Gender-affirming Chest Reconstruction: Does Hospital Volume Influence Admission Charges?

PURPOSE: While several national databases are well equipped to analyze postoperative outcomes, there has been a paucity of research with nationally representative datasets analyzing the evolving landscape of insurance coverage and admission cost for gender-affirming surgery. The purpose of this study was to provide a descriptive analysis of the financial implications of undergoing gender-affirming top surgery. METHOD: Retrospective cohort study was conducted of gender-affirming chest reconstruction performed between 2016 and 2019 using the Nationwide Ambulatory Surgery Sample. This is the largest all-payer surgery database of outpatient procedures performed in the United States. Financial data was adjusted for inflation and represented in 2020 US Dollars. High volume hospitals were defined as the 90th percentile of cases performed during the study interval, and highest volume hospitals were defined as the 95th percentile of cases performed during the study interval. Patients concurrently undergoing both top and bottom surgery were excluded. RESULTS: During the study interval, 15272 patients underwent gender-affirming top surgery, of which 82.7% (n=12634) were transmale and 17.3% (n=2638) were transfemale. There were 691 hospitals performing gender-affirming top surgery over the last four years, with a median case volume of only 3 procedures. High volume hospitals at the 90th percentile performed 59 procedures over the study interval, and highest volume hospitals at the 95th percentile performed 104 procedures over the study interval. Hospital admission charges for top surgery have been slightly increasing over the years (p<.001, ρ=+0.165). High-volume hospitals (p<.001, $28304 vs $26458) and highest-volume hospitals (p<.001, $28476 vs $26836) charged significantly more than lower volume hospitals, however this trend has reversed in the last fiscal year. There is significant difference in charges between regions of the country (p<.001), with the Midwest having the lowest (median $24918) and the West having the highest (median $29679). Transmale procedures were charged significantly higher admission charges than transfemale procedures (p<.001, $28311 vs $25718). While we are uncertain why this might be the case, this trend was seen in all four regions of the United States. Academic hospitals charge significantly more than nonacademic hospitals (p<.001, $27946 vs $23007). Urban hospitals charged over twice as much as rural hospitals for gender-affirming top surgery (p<.001, $27953 vs $10755). Over the last four years, the percentage of self-pay patients significantly decreased from 9.1% to 4.3% (p<.001). Despite recent updates to CMS coverage guidelines, the percentage of patients utilizing government insurance for gender-affirming top surgery has been decreasing from 35.0% to 29.9% (p<.001), while the percentage of patients with commercial insurance coverage has significantly increased from 52.5% to 63.4% (p<.001). Patients with commercial insurance were billed significantly more for gender-affirming top surgery than patients with government insurance (p<.001, $29593 vs $26319). CONCLUSION: High-volume and highest-volume hospitals charged patients significantly more than lower volume hospitals for gender-affirming chest surgery, however this trend has reversed in the last fiscal year. Rural hospitals charged patients significantly less than urban hospitals. Patients are increasingly seeking commercial insurance to undergo gender-affirming top surgery rather than government insurance.