Gender-Affirming Surgeries Increasingly Covered by Private Insurance, Medicare, Medicaid

Although the majority of patients receiving gender-affirming surgery are classified as self-pay, private payers, Medicare, and Medicaid are increasingly paying for these procedures for transgender patients, according to a new study in JAMA Surgery.¹

Joseph K. Canner, MHS, and colleagues analyzed data from the National Inpatient Sample for 4118 encounters involving gender-affirming surgery that took place between 2000 and 2014. Gender-affirming surgery only accounted for 11% of all encounters coded with transsexualism or gender identity disorder codes. The investigators compared the demographics, health insurance plan, and type of surgery between 2000-2005 and 2006-2011, as well as annually from 2012 to 2014.

They found that the incidence of genital surgery increased from 72% of patients undergoing gender-affirming surgery in 2000-2005 to 83.9% of patients in 2006-2011. More than half of these patients (56.3%) were not covered by health insurance. However, the percentage of patients identifying as self-payers declined over time. By 2014, only 39.4% of patients were self-payers.

Meanwhile, coverage by Medicare or Medicaid increased 3-fold from 2012-2013 to 2014. The findings suggest that after CMS began covering transition-related services, more transgender individuals enrolled in these health plans, according to the researchers. The analysis also found that coverage of gender-affirming surgery by private insurance increased from 25.6% during the period between 2000 and 2011, to 45.2% in 2014.

“Policies banning discrimination based on gender identity among third-party payers are essential to engage transgender patients in care and ensure coverage of these medically necessary procedures,” the authors concluded.

The authors identified several limitations, such as the process of identifying transgender patients, which relied on diagnosis codes for transsexualism or gender identity disorder. Those codes estimated the proportion of transgender patients seeking care at just 14 per 100,000 patients, which is much lower than national estimates. The de-identified data could also have caught instances where the same patient was hospitalized 2 times and estimates of hospitalizations and procedures could have been inflated.

Since efforts to estimate patients seeking gender-affirming surgery suffers from the absence of routine, standardized collection and reporting in healthcare settings, the authors suggest future efforts to improve this data collection and mandate reporting.

An accompanying commentary² highlighted the future areas of study that the Canner et al article suggests. These areas include the surgical challenges and costs when a patient regrets the gender-affirmation procedure, the cost-effectiveness and cost burdens given public funding is increasingly being used for these surgeries, and the psychiatric outcomes.

“Following psychiatric outcomes is especially important, as surgery may relieve gender dysphoria but may not suffice as treatment for transsexual individuals, given their higher rates of suicidality and psychiatric morbidity than the general population,” Marie Crandall, MD, MPH, of the Department of Surgery, University of Florida College of Medicine in Jacksonville, wrote in the commentary.

References

1. Canner JK, Harfouch O, Kodadek LM, Pelaez D, Coon D, Offodile AC, Haider AH, Lau BD. Temporal trends in gender-affirming surgery among transgender patients in the United States [published online February 28, 2018]. JAMA Surg. doi: 10.1001/jamasurg.2017.6231.

2. Crandall M. Trends of gender-affirming surgery among transgender patients in the United States [published online February 28, 2018] JAMA Surg. doi: 10.1001/jamasurg.2017.6232.