The Cost-Effectiveness and Cost Savings of Gender-Affirming Mastectomy

Purpose: Gender-affirming surgery (GAS) improves both physical and mental health in transgender and gender-diverse individuals. However, access to GAS in the United States is hindered by unreliable insurance coverage and the geographically limited availability of gender-affirming surgeons. This study aimed to demonstrate the cost-effectiveness of gender-affirming mastectomy to encourage more routine insurance coverage. Methods: A cost-effectiveness analysis was performed using a Markov model with a willingness-to-pay threshold of $50,000/quality-adjusted life year (QALY). The two main arms of the Markov model were access to, or lack of access to, mastectomy followed by additional sub-arms for negative or positive health events. Data on health event probability, quality of life, and cost were extracted from the 2015 US Transgender Survey Report, a large Midwest academic health system, and published literature. Results: Compared with no mastectomy ($14,195, 1.13 QALYs), gender-affirming mastectomy resulted in a greater annual cost and effectiveness ($22,438, 1.46 QALYs) with an incremental cost-effectiveness ratio (ICER) of $24,979/QALY in the second year. By the seventh year of the model and beyond, mastectomy was less costly while still remaining more effective than lack of surgery (ICER $-85/QALY). Conclusions: Our findings indicate that gender-affirming mastectomy is cost-effective in the second-year post-surgery and modeled to save the health care system money seven years after surgery. These results imply that the provision of gender-affirming mastectomy services results in better outcomes at a lower cost, making the business case for public policymakers and private third-party payers to expand their coverage.