PC25. Out-of-Pocket Costs and Probability of Gender Affirming Surgery

PURPOSE: Insurance coverage has expanded for gender affirming surgery (GAS), yet the impact and quality of coverage remain unclear. We sought to explore the variation in out of pocket (OOP) costs associated with surgery and the probability of undergoing surgery by plan type. METHODS: Using the Truven Marketscan database, we identified individuals from 2010-2019 using gender dysphoria diagnosis codes linked with procedure codes for masculinizing and feminizing GAS. Procedures were categorized as: masculinizing chest surgery (MCS), feminizing chest surgery (FCS), masculinizing genital surgery (MGS), and feminizing genital surgery (FGS). Variation in OOP costs and probability of surgery were examined using generalized linear and logistic regression models adjusting for age, region, and year. RESULTS: Of the 22,491 individuals in the cohort, 8.1% underwent GAS. There was large variation in cost for all procedures (MCS IQR $103.19-2,732.66, FCS IQR $101.42-2,681.28, MGS IQR $40.57-1,807.55, FGS IQR $117.11-2,577.99). Adjusting for covariates, OOP cost in HMO plans were 6.9, 14.9, 7.4, and 5.9 times lower compared to PPO or high-deductible health plans for MCS, FCS, MGS, and FGS respectively. Individuals with HMO coverage were more likely to undergo surgery compared with those covered by any other plan type (10.8% vs. 7.8%, p<0.001). CONCLUSION: In this cohort of insured individuals, we observed substantial variation in OOP costs associated with GAS. Individuals with HMO plans had the lowest OOP costs and highest probability of surgery. Efforts should be made to reduce the financial burden associated with gender affirming surgery due to insurance plan design.