CLINICALLY DOCUMENTED SOCIAL RISK FACTORS, HEALTH SERVICES UTILIZATION, AND EXPENDITURES IN A PRIVATELY INSURED TRANSGENDER POPULATION

‘Transgender’ is an umbrella term for people who have a gender identity that is different from the sex they were assigned at birth. There were an estimated 1.4 million transgender people in the U.S. as of 2016, and the size of the transgender population is growing, particularly among younger age cohorts. Poorer health and other health disparities have been documented among transgender people compared to cisgender people. To help better understand these disparities, the National Institutes of Health have designated the transgender population a “health disparities population” for purposes of federally supported research. This dissertation sought to advance the field of transgender health research by assessing health, health care utilization, and associated expenditures among a privately insured transgender population. Aim 1 described temporal trends in coding for transgender status, as well as utilization and costs of gender-affirming hormone therapy and surgeries among the transgender population in a proprietary insurance claims database. The number of claims for gender-affirming care increased rapidly between 2011 and 2019, though the budget impact of this care remained small. Aim 2 quantified utilization and health plan paid and out-of-pocket expenditures incurred by transgender adults and compared them to a cisgender adult population drawn from the same database. This assessment encompassed a wide range of health services, including inpatient stays, emergency department visits, outpatient and office visits, and prescription drugs; transgender people had higher utilization and costs in several of these categories, which may point to the utility of risk adjustment for this population. Aim 3 used diagnostic codes to identify disparities in mental and behavioral health between the transgender and cisgender groups and investigated the relationship between mental and behavioral health diagnoses and social risk factors captured in the claims history. This assessment showed a strong dose-response relationship between social risk factors and mental and behavioral health diagnoses, which underscores the importance of policy and programmatic efforts to address discrimination and other risk factors for poor health in the transgender population