Private vs. Public Insurance Delays in Gender Affirming Mastectomy Coverage
Elise Hogan, BS, Kiersten Woodyard, BS, Ermina Lee, BS, Douglas Dembinski, MD, Ryan Gobble, MD, FACS

Intro:
Gender affirming care is recognized by every major medical association in the US as medically necessary for the treatment of gender dysphoria1. However, a 2015 national survey of transgender individuals found that 25% of respondents were denied coverage for hormones and 55% were denied coverage for surgical care within that year2. Access to gender affirming care has been associated with improved health outcomes in the transgender population, but there is a paucity of literature characterizing wait time from initial surgical consult to gender-affirming mastectomy. The purpose of this study was to investigate insurer coverage practices for transgender patients seeking gender-affirming mastectomy at the University of Cincinnati Medical Center to better inform surgical providers and their patients.

Methods:
A retrospective review of patients presenting to our institution interested in gender-affirming mastectomies from July 2014 to January 2022 was conducted. Patients were sub-stratified into those with public insurance and private insurance providers. Patient demographic data was collected, including insurance type, race, ethnicity, age, BMI, and smoking status, with additional information such as time on hormone replacement therapy (HRT) and prior psychiatric involvement. Categorical variables were analyzed with t-tests, and continuous variables were examined via linear regression. 

Results:
90 patients were interested in gender-affirming mastectomies that presented to our institution; 67 were insured by public providers and 23 by private insurers. 51 patients went on to have surgery (56.67%); 38 patients with public insurance (74.51% of surgical patients; 56.72% of publicly insured) and 12 patients with private insurance (23.53% of surgical patients; 52.17% of privately insured). 77 of the original 90 new patient consults (85.56%) had previously documented psychiatric involvement; 49 of 51 surgical patients (96.08%) had documented psychiatric involvement. Surgical patients with public insurance were on HRT for an average of 21 months compared to 30 months for private insurance. Average time from initial consultation to surgery was significantly longer for public insurers, with an average of 280 days, compared to private insurers, with an average of 186 days. For both public and private insurance, there was no association between months on HRT and time to surgery. 

Conclusion: There is a delay in time to surgery associated with patients who have public insurance when compared to private insurance that is unassociated with time on hormone replacement therapy. Awareness of a patient’s insurance status allows providers to provide realistic surgical timelines more accurately for patients interested in gender affirming mastectomy. 





References
1. Baker, K. E. (2017). The Future of Transgender Coverage. The New England Journal of
Medicine, 376(19), 1801-1804. https://doi.org/10.1056/NEJMp1702427 
2. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report
of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender 
Equality. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf


Private vs. Public Insurance Delays in Gender Affirming Mastectomy Coverage

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