In 1965, Medicare and Medicaid were established in the U.S. to assist elderly and low-income citizens with healthcare costs. Medicare then expanded to cover more groups like disabled individuals and those needing hospice care.

Presently, Medicare pays physicians based on relative value units (RVUs) assigned to medical services. These values are updated annually considering factors like economic conditions such as inflation. Predicting changes in Medicare reimbursement, especially for surgeries, is challenging due to aging demographics, rising healthcare costs, and regulatory changes, including those prompted by the COVID-19 pandemic.

Approximately 0.5% of the U.S. population reports experiencing gender dysphoria, which is distress caused by an incongruence between one’s gender identity and the sex they were assigned at birth. About one-fourth of these individuals will undergo at least one gender-affirming surgery in their lifetime.

A new study aimed to analyze trends in Medicare reimbursement for gender-affirming surgeries in the U.S. from 2014 to 2021. For the study, researchers examined gender-affirming surgical procedures performed at a single urban academic medical center, including facial feminization surgery, chest/breast surgery (mastectomy and breast augmentation), and genital surgery (vaginoplasty, metoidioplasty, penile prostheses, etc.). They also included five common non-gender-affirming procedures for reference.

Data was collected from the Centers for Medicare and Medicaid Services (CMS) using Current Procedural Terminology (CPT) codes. The researchers then analyzed these codes alongside national RVUs and conversion factors, calculating changes in RVUs and monetary values from 2014 to 2021 while adjusting for inflation. Additionally, changes in reimbursement before the COVID-19 pandemic were assessed. The purpose of this analysis was to see how Medicare reimbursement rates for gender-affirming surgeries have changed over time, relative to inflation.

In the end, the researchers found that Medicare reimbursement for gender-affirming procedures showed minimal average change before adjusting for inflation between 2014 and 2021. However, after accounting for inflation, there was a notable decrease in reimbursement for these procedures. In fact, Medicare reimbursement for gender-affirming surgery decreased by 0.09% on average before adjusting for inflation, but after adjusting, it dropped by 10.03%.

All categories of gender-affirming surgery saw decreased reimbursement, notably feminizing top surgery (15.69%) and masculinizing bottom surgery (13.27%). Despite a general rise in prices (11.83%), reimbursement for these surgeries fell. Even before the COVID-19 pandemic, reimbursement decreased by 8.08%.

This trend is not unique to gender-affirming surgery; other procedures have experienced similar decreases. The variation in reimbursement changes among different gender-affirming surgeries could be linked to different motivators of dysphoria among transgender individuals. For example, the main motivators of gender dysphoria in transgender women include the genitals and face, while the chest and trunk are the main motivators for transgender men. This may be why facial feminization and transmasculine mastectomy retained more value than other forms of gender-affirming surgery.

This study only reflects Medicare reimbursement, not private insurers or out-of-pocket payments, limiting its scope. Nevertheless, the results of this study revealed that Medicare reimbursement of gender-affirming surgeries has not kept pace with inflation. Gender-affirmation surgeons should be aware of these trends to ensure access to necessary care for transgender patients.

References:

• Siotos, C., Underhill, J. M., Sykes, J., Jones, K. B., Schechter, L., Dorafshar, A. H., & Hamidian Jahromi, A. (2024). Trends of Medicare reimbursement rates for gender affirmation procedures. The Journal of Sexual Medicine, 21(2), 181–191. https://doi.org/10.1093/jsxmed/qdad160Top of Form