SOCIETAL AND POLICY IMPLICATIONS FOR MEDICALLY NECESSARY SERVICES AND PREVENTIVE CARE IN THE U.S. TRANSGENDER POPULATION: A COST-EFFECTIVENESS ANALYSIS

Purpose: To analyze the cost-effectiveness of provider coverage for medically necessary services in the U.S. Transgender population. Currently, many health insurers deny coverage to transgender individuals for transgender-related care and services. In 2013, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of an expressed clause prohibiting coverage for transgender-related services, and whether the cost-effectiveness of coverage for enrollees would support removing the exclusion.

Method: A Markov model simulated transgender patients' utilization of health services based on provider coverage, including surgical treatments (e.g. bilateral mastectomy, hysterectomy), non-surgical treatments (e.g. hormone replacement therapy), primary care (e.g. OB/GYN), and preventive care (e.g. mammograms). The 10-year model included endpoints of treatment success or negative outcomes (e.g. HIV/AIDS, depression, suicidality, drug abuse, mortality) dependent on provider coverage.

The model took the U.S. commercial payor perspective. Probabilities, quality-adjusted life years (QALYs), and costs were included in the model based on a systematic review of literature. Costs and QALYs were discounted at 3% ($US; 2013 values). We conducted univariate sensitivity analyses of parameters with the greatest impact on results. A Bayesian multivariate probablistic sensitivity analysis using 10,000 Monte Carlo simulations was also conducted. Findings were interpretted from a willingness-to-pay of $100,000/QALY.

Results: Compared to no health benefits for transgender patients ($24,029; 6.63 QALYs), provider coverage for medically necessary services came at a greater cost and effectiveness ($31,758; 8.31 QALYs). Overall, provider coverage was cost-effective, with an incremental cost-effectiveness ratio (ICER) of $4,600/QALY. Although surgery costs $10,000-22,000 and provider coverage costs $2175, these additional expenses hold good value for medically necessary care and reducing the risk of negative endpoints – HIV, depression, suicidality, and drug abuse.

The results were robust to change based on several univariate sensitivity analyses, although the model was sensitive to the average health utility of the transgender population (0.867 QALYs). The multivariate probabilistic sensitivity analysis showed that provider coverage was cost-effective in 9,994 out of 10,000 simulations.

Conclusion: Provider coverage is a cost-effective policy for the U.S. transgender population from a commercial payor perspective. This analysis implicates the downstream effects of lacking provider coverage for services based on increased rates of negative endpoints. Organizations such as the Massachusetts GIC should heed to these cost-effectiveness results of exclusions that prevent coverage for transgender health benefits.