InDepth: A Conversation with Southwest Fertility Center
InDepth is a new Arizona Physician section in both its print and digital formats highlighting medical practices across Arizona.
Meet both Sujatha Gunnala, MD, and Vinay Gunnala, MD, likely the only mother-son fertility doctors in the country. Arizona Physician recently sat down with them both to discuss how Southwest Fertility Center has evolved since its founding 42 years ago by Dr. Sujatha Gunnala and how the next generation is preparing for the future of fertility care.
Southwest Fertility Center by the Numbers:
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Founded in 1980
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2 Locations: (Phoenix & Glendale)
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2 Physicians
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1 Nurse Practitioner
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3 Registered Nurses
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1 Embryologist
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1 Lab Technician
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3 Medical Assistants
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4 Office Staff
Lets Discuss Fertility Treatment
AP: How has fertility treatment changed since 1980?
DR. SUJATHA GUNNALA: The world’s first test tube baby was born in 1978 in England, while I was in my fellowship training. I never would have imagined what would emerge from those early days. Back then, we had no formula for media to even grow the embryos. We would attend conferences, where researchers published their recipes. Back then an egg retrieval was a laparoscopic surgery done in the hospital under general anesthesia whereas now we can do perform the procedure under conscious sedation trans-vaginally in the office.
AP: As a younger doc in the field, what’s your take on recent advances?
DR. VINAY GUNNALA: The process for harvesting eggs takes only about 20 minutes with a vaginal procedure. So, there’s no scars in the belly, no incisions, much lower risk. The ability to fertilize eggs in a dish made huge advancements in the 90s as you can now inject one live sperm into each egg. ICSI has allowed millions of couples with a severe male factor to get pregnant with IVF. Other important advances have been the ability grow embryos in culture to a blastocyst (day 5 or 6) and to genetically test embryos with a biopsy. These advances allow us to select the best embryo for transfer, minimize risk of multiples.
AP: Have you seen growth in the number of patients seeking infertility treatment?
DR. VINAY GUNNALA: The incidence of infertility is increasing and now it affects one in eight couples or 12% of the general population. The reasons are multifactorial, but the biggest contributing factor is delaying pregnancy with more advanced female age. Like the national trends of infertility, our practice volume has increased about 15% per year for the last three or four years.
AP: What have been some of the biggest challenges over the past five or ten years?
DR. SUJATHA GUNNALA: Many of the insurance companies cover diagnostic tests and but most consider infertility as an elective treatment. Infertility is a symptom of underlying gynecological disorders and after completing the diagnosis, patients can have a very good chance of conceiving.
AP: Would you say your interactions with insurance carriers is generally positive or negative?
DR. VINAY GUNNALA: It's a benefit for the patient when it's done in the correct way but, by the same token, working with insurance carriers makes it more challenging to practice. But at the end of the day, if it gives the patient a benefit in terms of being able to afford treatment, then it's our job as an office to go through the hurdles. When I started four years ago, it was maybe 15% and today 30 to 35% of our patients have some fertility treatment coverage.
"We had to write a letter and fight to get paid! In this field, we're lucky to get 20 cents on the dollar."
- Sujatha Gunnala, MD
Insurance's Impact on SFC
AP: Would you say your interactions with insurance carriers is generally positive or negative?
DR. VINAY GUNNALA: It's a benefit for the patient when it's done in the correct way but, by the same token, working with insurance carriers makes it more challenging to practice. But at the end of the day, if it gives the patient a benefit in terms of being able to afford treatment, then it's our job as an office to go through the hurdles. When I started four years ago, it was maybe 15% and today 30 to 35% of our patients have some fertility treatment coverage.
AP: What role do you think insurance plays in today’s healthcare system?
DR. SUJATHA GUNNALA: Health care should be a human right. How it is distributed, how it is implemented, and practiced are very important. Even educated people without insurance neglect their health and by the time they come for care, diseases are very advanced. It is important for people to have insurance, but carriers should not have as much control as they do.
AP: Reimbursement rates. Do you think they're reasonable?
DR. SUJATHA GUNNALA: I did a surgery on a patient over five hours with severe endometriosis, pain, symptomatic and all that. We submitted to the carrier and our insurance person brings me the check. It was one cent. One cent because the insurance carrier didn’t know the codes. We had to write a letter and fight to get paid. In this field, we’re lucky to get $0.20 on the dollar. There is so much written off.
DR. VINAY GUNNALA: There is a trend of fertility doctors to not do as much surgery because they are not getting reimbursed as well. Referring those surgical cases out while staying in the office and doing their office-based procedures is reimbursed higher than a 5-hour surgery. No matter what I see on the operative report or what I see in the pictures and who I talked to, doing the actual surgery prevents some loss of information.
AP: How much is the burden of preauthorization on your practice?
DR. SUJATHA GUNNALA: Over eight hours a day. The repetition of paperwork for each treatment is not using our staff’s time efficiently.
DR. VINAY GUNNALA: The insurance side of fertility has been the biggest challenge for me. There are easily three to four employees who cover aspects of pre-authorization, but every employee must be aware of the process. If you miss one step there is a delay in getting authorization and these delays may seem like an eternity for a patient who must wait to start treatment.
AP: What are your suggestions to decrease the burden?
DR. VINAY GUNNALA: A big problem is the lack of bundling of treatment. When starting with less aggressive treatment like IUIs or ovulation induction medication, most couples conceive in the first three cycles or up to six. Insurance authorizes one cycle at a time and then our staff has to complete all of the paperwork again and that takes another 15 business days. I think if insurance carriers could see these inefficiencies in their process and trust our medical expertise, it would relieve a little bit of the workload.
DR. SUJATHA GUNNALA: Why do they have to make medical decisions? We submit everything with the diagnosis and treatment, and we know that the treatment works most of the time.
AP: We understand the practice lost a COE insurance contract. What impact will that have on Southwest Fertility?
DR. VINAY GUNNALA: COE, or center of excellence, sometimes called an institute of excellence (IOE), is a label given to a specific fertility practice by the insurance company. It limits where a patient can get fertility treatment as that patient will only have fertility coverage at a center with that label. One of the big negatives of the COEs and IOEs is they’re very subjective. Insurance companies will analyze the pregnancy rates of that fertility center annually, but each companies’ criteria are different. This past year, with the same annual dataset, we lost one COE label and got accepted with a different insurance company. Different goalposts.
AP: How are renovations in the Phoenix location a game changer?
DR. SUJATHA GUNNALA: With a higher volume of patients, we needed more space to do our procedures and recover multiple patients at a time. Before we scheduled procedures 1-2 hours apart and that was not efficient for our patient flow.
DR. VINAY GUNNALA: The air filtration system in our new IVF lab is 10 times purer than you would find in any standard hospital. We were always happy with our rates but, in the last year, the growth of embryos has had a significant change from prior, so there's no doubt that it made a difference.
AP: What’s it like working with your son?
DR. SUJATHA GUNNALA: When it comes to patient care, medical decisions, I don't interfere because he's very well trained. With my experience, I may see something and say, “That’s not going to work,” and he says, “Mom, you don’t know.” That happens.