Padula W V, Heru S, Campbell JD. Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis. J. Gen. Intern. Med. 2015. [Accessed November 1, 2015].
When someone (a physician) tells me that they believe that providing medically supervised care for people who are transgender is “expensive,” I worry that they are not up to date on the latest science for this population, or for all of LGBTQ people.
It’s been a while (well, a microsecond in terms of health care innovation – 3 years) since the State of California’s Department of Insurance deemed that health insurance coverage for transition related medical care was “immaterial” – “insignificant” – “de minimis” in their actuarial analysis (which you can find here). Those are pretty definitive actuarial-sounding words.
Now, a team from Johns Hopkins led by William Padula, PhD (@DrWmPadula) has found essentially the same, using a cost-effectiveness analysis model (Study: Paying for Transgender Health Care Cost-Effective – 2015 – News Releases – News – Johns Hopkins Bloomberg School of Public Health).
In the language of health economists, here’s what they found:
While justice, legality, and a desire to avoid discrimination should drive decisions about benefit coverage, this case for the transgender population also appears economically attractive.
And the numbers:
- $0.016 per member per month, averaged over the population, over a 5 year time horizon
- $9300 per Quality Adjusted Life Year, over a 10 year time horizon
Two good comparisons:
- Most medical treatments considered cost-effective are rated at $100,000 per Quality Adjusted Life Year
- Another widely recommended preventive service, Pre-Exposure Prophylaxis to prevent HIV transmission is rated at $54,443 per Quality Adjusted Life Year, over a 20 year time horizon if all of the people who are recommended to get this treatment get it (see: The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in Men Who Have Sex with Men in the United States )
….and Pre-Exposure Prophylaxis (PrEP) is usually fully covered. While medically supervised transition related care is usually not covered. But that’s changing. Rapidly.
In other words, comparing to other widely accepted covered treatments in health care: de minimis, immaterial, insignificant.
This is one of the reasons why my home city, Washington, DC, is a leader in eliminating the coverage gap. Since 2014, coverage for this care is the law.
The study itself
The usefulness of cost-effectiveness analysis in medicine is great. It allows physicians and health systems to compare treatments side by side by their overall health profile. So you can say, treatment X, extends your life by y number of years multiplied by the quality of those extended years, or as it is written “Quality Adjusted Life Years.”
The paper, published this month, was mentioned by the editors of the New York Times in this article ( No Reason to Exclude Transgender Medical Care – The New York Times ) who have come to the same conclusion.
You have to know what you’re looking for when you’re reviewing one of these, and what to compare it to.
In this case, the authors did a very good job of culling the medical literature for both the costs of medically supervised transition, and the costs of not covering medically supervised transition.
The literature shows that properly administered medical care results in longer, healthier, lives. As I posted recently, this is true for adolescents as well. See: Just Read: Transgender Adolescents develop into well adults with comprehensive care (“The Dutch Model”)
What else? Nothing else, really. Just another confirmation that this health care is life prolonging and quality enhancing for society. As colleague Gary Cohen from Health Care Without Harm likes to say, what else is health care here for.
I’m embedding one of the presentations I’ve given on this topic which has links to the earlier studies mentioned here plus ideas on eliminating conscious and unconscious bias against transgender people in health care.
Because the 20th century ended a long time ago, we can, and we’re going to 🙂 .