This cross-sectional study assesses whether undergoing genital gender-affirming surgery outside the patient’s state of residence is associated with higher out-of-pocket costs than undergoing surgery in the state of residence.
Key Points
Question
Is traveling out of state to undergo a genital gender-affirming surgery associated with higher out-of-pocket costs for patients compared with undergoing surgery in the state of residence?
Findings
In this cross-sectional study of 771 patients who underwent vaginoplasty or phalloplasty, undergoing surgery outside the patient’s state of residence was associated with significantly higher out-of-pocket costs compared with undergoing surgery in their state of residence.
Meaning
The findings suggest that health care practitioners should be aware of out-of-pocket expenses and the association of the location where surgery is performed with patients’ costs when possible.
Abstract
Importance
Genital gender-affirming surgery (GAS) is safe and offers substantial benefits to patients. Geographic accessibility and high out-of-pocket (OOP) costs reportedly hinder access; however, to date, this has not been thoroughly investigated at the national level.
Objective
To estimate OOP and total costs for GAS among commercially insured beneficiaries and assess whether costs differed between surgical procedures conducted in and outside the patient’s state of residence.
Design, Setting, and Participants
This cross-sectional study used previously collected insurance data from the MarketScan Commercial Database (129 million patients) from January 1, 2007, to December 31, 2019. Vaginoplasties and phalloplasties were identified using diagnosis and procedure codes among patients aged 18 to 64 years. Out-of-state surgical procedures were identified based on residence at enrollment and place of service of the surgery. Data analysis took place from July 1 to September 31, 2021.
Exposures
Vaginoplasty and phalloplasty.
Main Outcomes and Measures
The main outcomes were differences in OOP and total costs by out-of-state designation, census region, age, and insurance type for surgical procedures, estimated using multivariable linear regression models.
Results
The study included 771 patients who underwent GAS. A total of 609 underwent vaginoplasty, of whom 249 (41%) underwent surgery in their state of residence (mean [SD] age, 38.7 [13.1] years) and 340 (56%) underwent surgery outside their state (mean [SD] age, 38.1 [13.0] years), and 162 underwent phalloplasty, of whom 66 (41%) underwent surgery in their state of residence (mean [SD] age, of 39.7 [11.6] years) and 81 (50%) underwent surgery outside their state (mean [SD] age, 35.8 [10.9] years); 20 vaginoplasties (3%) and 15 phalloplasties (9%) could not be classified as in or out of state owing to missing data about the facility or residence. Procedures outside the state were associated with 49% (95% CI, 19%-85%) higher OOP costs compared with procedures done in the state of residence.
Conclusions and Relevance
In this cross-sectional study, 56% of patients who underwent vaginoplasty and 50% of patients who underwent phalloplasty underwent the procedure outside their state of residence. Patients who underwent these procedures outside their state also experienced higher OOP costs than did those who underwent these procedures in their state. Improving geographic access and understanding patient preferences for surgical care may help reduce the cost burden for those planning to undergo GAS.
Introduction
Genital gender-affirming surgery (GAS; eg, vaginoplasty and phalloplasty) is a critical part of gender affirmation for some transgender and gender-diverse (TGD) patients. Access to gender-affirming care has been associated with better mental health outcomes,1 yet the limited availability of national data on TGD surgical procedures and patient care has left many research questions unanswered.2
Genital gender-affirming surgical procedures are highly specialized and are often centralized in high-volume centers in urban areas.3 Patients seeking GAS may be required to travel long distances to access care.4 However, postoperative travel can disrupt continuity of care and social support and can be cost prohibitive for those who are unable to pay for transportation and lodging.5 Furthermore, readmissions may be higher if patients do not receive the appropriate postoperative support and recovery.6
Recent work found that 61 surgeons across 38 locations within only 20 states confirmed offering GAS.3 This suggests that geographic accessibility is likely to be a concern for patients seeking GAS in the 30 states without a surgeon, yet it is unknown how frequently patients travel to other states for GAS for which they must pay out of pocket (OOP). We examined the prevalence of patients who underwent GAS outside their state of residence and compared their characteristics with those of patients who underwent GAS in their state of residence. We hypothesized that younger patients and those with less restrictive insurance plans would travel out of state most frequently.
Reducing unwanted variations in surgical costs has been an important avenue for cost containment. Understanding the variability in costs of GAS can help identify factors associated with increased costs. As payers continue to expand coverage of GAS, it is critical to understand the costs to the payer and the patient to inform budgeting. Thus, the primary objectives of this study were to estimate total medical and OOP costs in a national cohort of commercially insured individuals and to examine whether these costs varied across characteristics such as location of surgery and restrictiveness of insurance plan.
Methods
Data Source
We conducted a cross-sectional study using the IBM MarketScan Commercial Database.7 MarketScan is a nationally representative data set of individuals covered by employer-sponsored health insurance in the US and includes information on insurance enrollment along with medical and drug claims for individuals who receive health insurance coverage from their employers. We analyzed data collected from January 1, 2007, to December 31, 2019, that contained deidentified claims for 129 million enrollees from approximately 350 payers in the US. The study period was selected because the number of patients with a gender identity diagnosis code increased during that time.8 Data analysis was performed from July 1 to September 31, 2021. This study followed the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.9 The study was deemed exempt from human participants review and informed consent by the Oregon Health & Science institutional review board because data were deidentified.
Study Population
Consistent with a modified approach,10 we used International Classification of Diseases, Ninth Revision; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Current Procedural Terminology codes to identify a cohort of adults aged 18 to 64 years who underwent either vaginoplasty or phalloplasty. These GAS procedures were selected because they are the most common and consistently coded in claims data. During the study period, there were no Current Procedural Terminology codes dedicated specifically to vulvoplasty and metoidioplasty alone. Adults older than 64 years were excluded because they are eligible for Medicare. The index surgery date was assigned as the earliest date of record when multiple claims were available (eg, revisions). Patients with a diagnosis of congenital malformations of genital organs anywhere in their record were also excluded. Patient gender is not available in MarketScan and thus is not reported. Details on the selection of the cohort are available in the eMethods, eFigures 1 and 2, and eTables 3 to 9 in the Supplement.
Outcomes
The primary outcome of interest was OOP costs associated with vaginoplasty and phalloplasty; the secondary outcome of interest was total costs for patients for these same procedures. In accordance with published literature,11 we created 3 periods a priori in reference to the index surgery date: baseline (−365 to −15 days), perioperative (−14 to 28 days), and postoperative (29-365 days) periods. Out-of-pocket costs were calculated by adding the coinsurance, copayment, and deductible amounts for all inpatient, outpatient, and outpatient pharmacy claims during the perioperative and postoperative periods. Negative OOP costs were recoded as 0. Total costs were calculated by adding gross payments of all inpatient, outpatient, and outpatient pharmacy claims in the perioperative and postoperative periods. All costs were converted to 2019 US dollars using the US Bureau of Labor Statistics’ Consumer Price Index for all Urban Consumers Retroactive Series.12
Variables of Interest
The primary variable of interest was whether the surgery occurred outside a patient’s state of residence. We used the state of residence of the primary beneficiary and the state where the hospital was located to assess whether a procedure occurred in or outside the state of residence. Patient covariates included age, US census region of residence, year of surgery, relationship to beneficiary (self, spouse, dependent), and health plan type (less restrictive and more restrictive). Less restrictive plans included comprehensive and preferred provider organization plans. All other plans (basic or major medical, exclusive provider organization, health maintenance organization, point of service, point of service with capitation, consumer-directed health plan, and high-deductible health care plan) were categorized as more restrictive.
Statistical Analysis
Descriptive Statistics
First, to understand how patients who underwent vaginoplasty or phalloplasty compared with the overall population of beneficiaries, we compared baseline characteristics of the patients who underwent GAS with a random sample of 1 million patients, weighted to reflect the year distribution of the years during which patients underwent GAS. Second, to assess how rates of GAS changed over time, we divided the number of vaginoplasties and phalloplasties by the number of beneficiaries aged 18 to 64 years who were enrolled in each year. Third, to describe how patients who underwent GAS in their state of residence and outside their state of residence differed, we compared baseline characteristics between these 2 groups for each surgery type. For these descriptive comparisons, t tests were used for continuous variables and χ2 tests were used for categorical variables.
OOP and Total Costs
To compare OOP and total costs for each surgery type, we further restricted the cohort to patients who had complete baseline, perioperative, and postoperative costs (ie, enrolled at least 1 year before and after the index surgery date). First, we compared differences in OOP and total costs (median and IQR) by patient characteristics in each surgery group using Kruskal-Wallis tests. Next, we built 2 multivariable linear regression models to describe the characteristics associated with OOP and total costs. By examination of the residual plots, we found the assumption of homoskedasticity to be satisfied by both models. For this analysis, the patients who underwent vaginoplasty and those who underwent phalloplasty were combined into a single group. The dependent variable was log-transformed cost, and the independent variables were out-of-state designation, census region, age, insurance type, year of surgery, and surgery type. In addition, the first model (with OOP as the dependent variable) included the log of baseline OOP cost as an independent variable. Similarly, the second model (with total cost as the dependent variable) included the log of baseline total cost. Baseline costs were included to account for differences in utilization patterns among patients. To address the possibility that the complete-enrollment cohort may have differed from the incomplete-enrollment cohort (and therefore the results would not be generalizable to both groups), we compared baseline characteristics and perioperative costs between the 2 groups (eMethods in the Supplement). Statistical analysis was performed using R, version 4.2.0 (R Project for Statistical Computing) and SAS, version 9.4 (SAS Institute Inc). A 2-tailed P < .05 was considered statistically significant.
Results
Descriptive
The study included 771 patients who underwent GAS. Compared with a random sample of MarketScan patients, a higher proportion of MarketScan patients who had vaginoplasty or phalloplasty were ages 18 to 34 years, the primary beneficiary on the insurance plan, and living in the West (eTable 1 in the Supplement). The rate of vaginoplasty and phalloplasty in the population of MarketScan enrollees aged 18 to 64 increased from 0.02 per 100 000 beneficiaries and 0.01 per 100 000 beneficiaries, respectively, in 2007 to 0.81 per 100 000 beneficiaries and 0.17 per 100 000 beneficiaries, respectively, in 2019 (Figure). A total of 0.98 per 100 000 beneficiaries had GAS paid for by commercial insurance in 2019.
Figure. Trends in Rates of Vaginoplasty and Phalloplasty Among US Patients Aged 18 to 64 Years With Employer-Sponsored Health Insurance From 2007 to 2019.
Differences Between Patients Who Underwent Surgery In and Outside Their State of Residence
A total of 609 patients underwent vaginoplasty, of whom 249 (41%) underwent surgery in their state of residence (mean [SD] age, 38.7 [13.1] years) and 340 (56%) underwent surgery outside the state (mean [SD] age, 38.1 [13.0] years), and 162 underwent phalloplasty, of whom 66 (41%) underwent surgery in their state of residence (mean [SD] age, 39.7 [11.6] years) and 81 (50%) underwent surgery outside the state (mean [SD] age, 35.8 [10.9] years) (Table 1). Twenty vaginoplasties (3%) and 15 phalloplasties (9%) could not be classified as in state or out of state owing to missing data about the facility or residence. A higher proportion of patients who underwent surgery outside their state resided in the South, and a lower proportion resided in the West compared with those who underwent surgery in their state of residence. A higher proportion of patients who underwent vaginoplasty outside their state of residence were the primary employee beneficiary compared with those who underwent vaginoplasty in their state of residence. Patients who underwent phalloplasty outside their state of residence were younger compared with those who underwent phalloplasty in their state of residence. No differences in insurance type, enrollment patterns, or year of surgery were observed.
Table 1. Baseline Characteristics of Patients Who Underwent Vaginoplasty or Phalloplasty in Their State of Residence and Outside Their State of Residence.
| Characteristic | Vaginoplasty, No. (%)a | Phalloplasty, No. (%)a | ||||
|---|---|---|---|---|---|---|
| In state (n = 249) | Outside state (n = 340) | P valueb | In state (n = 66) | Outside state (n = 81) | P valueb | |
| Age, mean (SD), y | 38.7 (13.1) | 38.1 (13.0) | .63 | 39.7 (11.6) | 35.8 (10.9) | .04 |
| Age category, y | ||||||
| 18-34 | 115 (46) | 169 (50) | .54 | 23 (35) | 42 (52) | .18 |
| 35-44 | 46 (18) | 62 (18) | 19 (29) | 18 (22) | ||
| 45-54 | 50 (20) | 53 (16) | 17 (26) | 17 (21) | ||
| 55-64 | 38 (15) | 56 (16) | 7 (11) | 4 (5) | ||
| Relationship status | ||||||
| Self | 181 (73) | 269 (79) | .008 | 52 (79) | 64 (79) | .68 |
| Spouse | 31 (12) | 18 (5) | 8 (12) | 7 (9) | ||
| Dependent | 37 (15) | 53 (16) | 6 (9) | 10 (12) | ||
| Census region | ||||||
| South | 33 (13) | 113 (33) | <.001 | 13 (20) | 28 (35) | <.001 |
| West | 107 (43) | 79 (23) | 38 (58) | 17 (21) | ||
| Midwest | 61 (24) | 82 (24) | 9 (14) | 18 (22) | ||
| Northeast | 48 (19) | 66 (19) | 6 (9) | 18 (22) | ||
| Insurance plan type | ||||||
| Less restrictive | 125 (50) | 188 (55) | .29 | 29 (44) | 46 (57) | .19 |
| More restrictive | 118 (47) | 148 (44) | 36 (55) | 35 (43) | ||
| Unknown | 6 (2) | 4 (1) | 1 (2) | 0 | ||
| Enrollment | ||||||
| Complete | 69 (28) | 103 (30) | .56 | 35 (53) | 31 (38) | .11 |
| Incomplete | 180 (72) | 237 (70) | 31 (47) | 50 (62) | ||
| Years | ||||||
| 2007-2014 | 51 (20) | 91 (27) | .10 | 16 (24) | 13 (16) | .30 |
| 2015-2019 | 198 (80) | 249 (73) | 50 (76) | 68 (84) | ||
Percentages may not add to 100% because of rounding.
The P values for age were calculated using a 2-sided t test. P values for categorical variables were calculated using a χ2 test.
OOP and Total Costs of Vaginoplasties
Among 176 vaginoplasties, the median OOP cost was $2953 (IQR, $1657-$4437) and the median total cost was $59 673 (IQR, $40 169-$81 770) (Table 2). Out-of-pocket costs were significantly higher for patients who underwent vaginoplasty outside their state of residence and for patients residing in the South. No differences in OOP costs were observed by age, plan type, or year. Total costs for vaginoplasties were higher in recent years compared with earlier years.
Table 2. Median OOP and Total Costs for Vaginoplasty by Patient Characteristics.
| Characteristic | Patients, No. (%)a | OOP cost, median (IQR), $ | P valueb | Total cost, median (IQR), $ | P valueb |
|---|---|---|---|---|---|
| All | 176 (100) | 2953 (1657-4437) | NA | 59 673 (40 169-81 770) | NA |
| Location | |||||
| In state of residence | 69 (39) | 2079 (1104-3811) | .002 | 64 309 (38 756-83 076) | .84 |
| Outside state of residence | 103 (59) | 3336 (1987-4817) | 57 976 (41 398-80 164) | ||
| Unknown | 4 (2) | 3912 (2613-5404) | 78 106 (49 756-116 512) | ||
| Census region | |||||
| South | 50 (28) | 3780 (2566-5366) | .005 | 56 507 (40 024-70 709) | .07 |
| West | 49 (28) | 2838 (1602-3755) | 56 761 (41 859-75 276) | ||
| Midwest | 47 (27) | 2544 (1443-3793) | 64 165 (30 186-78 677) | ||
| Northeast | 30 (17) | 2121 (1401-5078) | 79 279 (57 886-100 027) | ||
| Age category, y | |||||
| 18-34 | 83 (47) | 2724 (1645-4275) | .86 | 58 783 (44 224-76 815) | .13 |
| 35-44 | 32 (18) | 3203 (1795-4715) | 68 275 (55 862-83 414) | ||
| 45-54 | 30 (17) | 3345 (1634-4253) | 57 309 (40 147-88 676) | ||
| 55-64 | 31 (18) | 2838 (1777-4481) | 50 813 (25 853-82 335) | ||
| Insurance plan type | |||||
| Less restrictive | 98 (56) | 3207 (1870-4417) | .15 | 58 022 (41 410-75 921) | .20 |
| More restrictive | 76 (43) | 2657 (1352-4608) | 63 023 (38 712-92 506) | ||
| Unknown | 2 (1) | 1368 (1236-1500) | 111 116 (103 812-118 420) | ||
| Years | |||||
| 2007-2014 | 44 (25) | 2822 (1644-4228) | .65 | 41 560 (31 392-54 091) | <.001 |
| 2015-2019 | 132 (75) | 3017 (1657-4531) | 66 826 (50 021-91 206) |
Abbreviations: NA, not applicable; OOP, out-of-pocket.
Percentages may not add to 100% owing to rounding.
The P values were calculated using a Kruskal-Wallis test.
OOP and Total Costs of Phalloplasties
Among 72 phalloplasties, the median OOP cost was $2120 (IQR, $738-$4371) and the median total cost was $148 540 (IQR, $74 679-$240 844) (Table 3). Out-of-pocket costs were higher for patients residing in the South, patients with less restrictive health plans, and patients who underwent surgery in more recent years. No other differences in total costs were noted.
Table 3. Median OOP and Total Costs for Phalloplasty by Patient Characteristics.
| Characteristic | Patients, No. (%)a | OOP cost, median (IQR), $ | P valueb | Total cost, median (IQR), $ | P valueb |
|---|---|---|---|---|---|
| All | 72 (100) | 2120 (738-4371) | NA | 148 540 (74 679-240 844) | NA |
| Location | |||||
| In state of residence | 35 (49) | 854 (286-4734) | .15 | 192 539 (88 512-298 917) | .17 |
| Outside state of residence | 31 (43) | 2720 (1282-4469) | 130 247 (59 954-172 106) | ||
| Unknown | 6 (8) | 1654 (1081-2299) | 147 325 (75 162-231 484) | ||
| Census region | |||||
| South | 14 (19) | 4391 (2451-5519) | .006 | 122 732 (48 990-176 517) | .62 |
| West | 34 (47) | 1022 (292-3245) | 150 464 (87 570-275 647) | ||
| Midwest | 11 (15) | 2035 (635-4913) | 162 145 (80 462-231 730) | ||
| Northeast | 13 (18) | 2208 (977-4216) | 126 747 (71 622-200 505) | ||
| Age category, y | |||||
| 18-34 | 24 (33) | 3030 (765-4369) | .44 | 149 336 (79 037-192 646) | .91 |
| 35-44 | 18 (25) | 2198 (1086-5891) | 161 514 (66 336-232 089) | ||
| 45-54 | 22 (31) | 1192 (522-2397) | 119 433 (60 964-262 668) | ||
| 55-64 | 8 (11) | 2116 (851-4116) | 130 013 (97 506-291 438) | ||
| Insurance plan type | |||||
| Less restrictive | 37 (51) | 3666 (1281-5536) | .001 | 129 779 (76 840-215 464) | .80 |
| More restrictive | 35 (49) | 1023 (286-2312) | 150 777 (69 266-260 799) | ||
| Years | |||||
| 2007-2014 | 21 (29) | 977 (290-2314) | .02 | 75 850 (49 382-268 122) | .15 |
| 2015-2019 | 51 (71) | 2362 (937-4913) | 156 793 (94 783-238 327) |
Abbreviations: NA, not applicable; OOP, out-of-pocket.
Percentages may not add to 100% owing to rounding.
The P values were calculated using a Kruskal-Wallis test.
Adjusted Differences in OOP and Total Costs
After controlling for covariates, OOP costs were 49% (95% CI, 19%-85%) higher for patients who underwent surgery outside their state of residence compared with those who underwent surgery in their state of residence (Table 4). For the typical patient (setting all other covariates equal to their means), this translated to an expected increase of $864 (95% CI, $381-$1360) in OOP costs from the expected in-state OOP costs of $1781 (95% CI, $1516-$2091). Compared with OOP costs for patients residing in the South, OOP costs were 36% (95% CI, 15%-52%) lower for patients residing in the West and 31% (95% CI, 7%-49%) lower for patients residing in the Midwest. Total costs were 109% (95% CI, 75%-149%) higher for phalloplasty compared with vaginoplasty and 43% (95% CI, 20%-70%) higher for surgical procedures performed from 2015 to 2019 compared with those performed from 2007 to 2014.
Table 4. Percentage Change in Costs Among Patients Who Had Vaginoplasty or Phalloplasty .
| Variable | Model 1 OOP cost, % (95% CI)a,b | Model 2 total cost, % (95% CI)a,c |
|---|---|---|
| Location | ||
| In state of residence | Reference | Reference |
| Outside state of residence | 49 (19 to 85) | –1 (–16 to 17) |
| Census region | ||
| South | Reference | Reference |
| West | –36 (–52 to –15) | 12 (–10 to 39) |
| Midwest | –31 (–49 to –7) | –3 (–22 to 22) |
| Northeast | –25 (–46 to 4) | 16 (–10 to 49) |
| Age, y | –0.4 (–1.2 to 0.4) | –0.4 (–1 to 0.3) |
| Insurance plan type | ||
| Less restrictive | Reference | Reference |
| More restrictive | –18 (–34 to 1) | 2 (–13 to 20) |
| Years | ||
| 2007-2014 | Reference | Reference |
| 2015-2019 | 22 (–3 to 54) | 43 (20 to 70) |
| Surgery type | ||
| Vaginoplasty | Reference | Reference |
| Phalloplasty | –19 (–36 to 2) | 109 (75 to 149) |
Abbreviation: OOP, out-of-pocket.
95% CIs that do not include 0 correspond to P < .05.
Model 1 was a multivariable linear regression model with log-transformed OOP cost as the dependent variable. Estimates for unknown location (n = 10), unknown insurance plan type (n = 2), and log of baseline OOP cost are not shown.
Model 2 was a multivariable linear regression model with log-transformed total cost as the dependent variable. Estimates for log of baseline total cost are not shown.
Sensitivity Analysis Comparing Patients With Complete Insurance Enrollment vs Those With Incomplete Insurance Enrollment
No differences were observed between patients who underwent vaginoplasty who had complete insurance enrollment (n = 421) and those who had incomplete insurance enrollment (n = 248) (eTable 2 in the Supplement). Compared with patients who underwent phalloplasty and had complete insurance enrollment, those who had incomplete insurance enrollment tended to be younger, have higher OOP perioperative costs, and have their surgical procedures performed from 2015 to 2019 than from 2007 to 2014. This finding suggests that our estimates of OOP costs for phalloplasty using the patients with complete insurance enrollment may slightly underestimate the OOP costs of the entire cohort of patients who underwent phalloplasty.
Discussion
In this cross-sectional study, we found that 56% of vaginoplasties and 50% of phalloplasties took place outside the patient’s state of residence in a commercially insured population. Although this finding was expected given the specialization required to perform these surgical procedures, it highlights the potential access challenges experienced by TGD patients. Patients who travel long distances to access surgery often present later for readmission to a local hospital,6 where they may not receive optimal care.5 Research examining surgical outcomes in these populations should consider how geographic access impacts short- and long-term health outcomes.
Traveling a long distance for surgery may also be unaffordable for those who cannot afford to pay for transportation and lodging costs. Genital gender-affirming surgical procedures, such as vaginoplasty and phalloplasty, may involve intensive outpatient follow-up, requiring patients and their caregivers to stay within close range of their surgical team for weeks to months after discharge. Beyond the immediate perioperative period, routine postoperative care and management of complications also often includes in-person evaluation. These costs are in addition to lost wages from taking time off from work for recovery. We found that the medical OOP costs were higher for those who traveled out of state for their surgery. Out-of-pocket costs, in addition to the costs of transportation and lodging, are among the top concerns of people undergoing GAS.13 The higher OOP costs may be attributable to patients accessing health care practitioners outside their network or traveling to surgical centers in the West or Northeast, where costs are typically higher.
Patients residing in the South traveled out of state most often for their surgical procedures. This finding suggests that there may be a shortage of GAS surgeons in this region. A study in 2020 found that there were 11 surgeons in 7 practice locations in the South, 4 of which were located in Florida.3 It is unknown what factors beyond geographic access influence a patient’s selection of a surgical team. Some locations offer different types of surgery (eg, zero-depth vaginoplasty, penile inversion vaginoplasty), which may be associated with patient decision-making.3
Our study found that 0.98 per 100 000 beneficiaries had GAS paid for by commercial insurance in 2019. Application of this rate to the 183 million beneficiaries receiving employer-sponsored health insurance in 2019 in the US14 suggests that, nationwide, employers paid for an estimated 1800 GAS procedures that year. In comparison, the utilization rate of bariatric surgery, another procedure that is typically underinsured, was approximately 20 times higher.15
Of note, the rate of vaginoplasty increased faster than the rate of phalloplasty. Prior work using the National Inpatient Sample8 found that the rate of surgery for TGD patients increased over time; however, this was, to our knowledge, the first evidence of surgery-specific temporal trends. The difference in trends between these 2 surgery types may reflect demand, supply of surgeons, or other factors related to coverage of care.
Although an increasing number of surgical procedures are being covered by private insurance, evidence suggests that most are still self-pay.8 In 2020, 30 of 38 locations for GAS reported accepting any form of insurance.3 However, a study of 435 health insurance contracts from 40 self-insured Fortune 500 corporations in 2019 found that 25% of these companies had language that excluded transition-related care.16 Furthermore, only half of the companies with a perfect score from the Human Rights Campaign provided clear language in their insurance policy about accessing GAS.16,17 These findings suggest that utilization of GAS would likely be higher in plans offering clearer language in their insurance policies. Future work should examine the effects of insurance language on utilization of GAS.
Limitations
This study has limitations. Results are likely not generalizable to patients without insurance or those enrolled in Medicaid or Medicare. The number of GAS procedures performed in this population was likely undercounted because patients with both phalloplasty and vaginoplasty claims were excluded. Out-of-pocket costs did not include claims that were denied or costs not submitted for reimbursement, which may have led to underestimation of costs. For example, preoperative hair removal is often required for GAS but rarely covered by insurance; we observed only covered costs.18 Other sources of cost underestimation include a lack of inpatient prescription drug data and omission of planned surgical procedures that occurred more than 1 year after the index surgery date, which is more common for patients undergoing phalloplasty. We were unable to account for within-hospital or within-surgeon correlations in cost owing to missingness of data on provider and facility. Furthermore, we were unable to assess quality of surgical procedures, which is an important factor to consider beyond cost of care. This study also excluded other types of GAS, such as vulvoplasty and metoidioplasty, because of challenges in identifying these procedures in the data source; this limits the generalizability of these findings to vaginoplasty and phalloplasty.
Conclusions
In this cross-sectional study, we observed a frequent need for travel and substantial OOP and total costs for commercially insured patients undergoing vaginoplasty and phalloplasty in the US. Our study showed that 56% of patients who underwent vaginoplasty and 50% of patients who underwent phalloplasty traveled out of state to undergo the procedure. Patients in the South traveled more than those in other regions. Patients who traveled outside their state of residence for GAS had higher OOP costs. Future research should aim to understand patient preferences and constraints in selection of surgeons and how traveling out of state is associated with safety, quality, and effectiveness of GAS outcomes.
eTable 1. Baseline Characteristics of Surgery Patients Compared to Random Sample of Beneficiaries Aged 18-64
eTable 2. Perioperative Costs and Characteristics of Complete- vs Incomplete-Enrollment patients
eMethods. Identifying a Cohort of Patients Undergoing Genital Gender-Affirming Surgery
eFigure 1. Flow Diagram of Patient Selection in the Study
eFigure 2. Venn Diagram of Identification of Transgender and Non-binary Patients
eTable 3. Vaginoplasty Procedure Codes
eTable 4. Phalloplasty Procedure Codes
eTable 5. Non-specific Procedure Codes
eTable 6. Congenital Malformation of Genital Organs (CMGO) Diagnosis Codes
eTable 7. Gender Dysphoria Diagnosis Codes
eTable 8. Conclusive Gender-Affirming Procedure Codes
eTable 9. Endocrine NOS Disorder Diagnosis Codes and Specific Nondiabetes Endocrine Diagnosis Codes
eReference
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Baseline Characteristics of Surgery Patients Compared to Random Sample of Beneficiaries Aged 18-64
eTable 2. Perioperative Costs and Characteristics of Complete- vs Incomplete-Enrollment patients
eMethods. Identifying a Cohort of Patients Undergoing Genital Gender-Affirming Surgery
eFigure 1. Flow Diagram of Patient Selection in the Study
eFigure 2. Venn Diagram of Identification of Transgender and Non-binary Patients
eTable 3. Vaginoplasty Procedure Codes
eTable 4. Phalloplasty Procedure Codes
eTable 5. Non-specific Procedure Codes
eTable 6. Congenital Malformation of Genital Organs (CMGO) Diagnosis Codes
eTable 7. Gender Dysphoria Diagnosis Codes
eTable 8. Conclusive Gender-Affirming Procedure Codes
eTable 9. Endocrine NOS Disorder Diagnosis Codes and Specific Nondiabetes Endocrine Diagnosis Codes
eReference