Cedars-Sinai Medical Center is part of a growing trend. By adding a transgender surgical program, the hospital now joins other academic medical centers, like UCSF, the Cleveland Clinic, Boston Medical Center, Oregon Health and Science University and Mount Sinai Hospital in New York.
And one advantage big academic medical centers have over smaller private clinics is the bureaucratic power they bring to bear on issues like health coverage. In addition to bringing gender confirmation surgery to Southern California, Cedars-Sinai’s program also accepts patients who are on Medi-Cal and Medicare, opening up access to crucial treatment that was generally available only from expensive private practice clinics. The hospital’s experience dealing with health insurance companies can also spare patients a lot of heartache and money.
Nikolai Miles, a 26-year-old security guard in Thousand Oaks, California, decided to get a double mastectomy back in 2014 — a standard part of the series of surgeries that transgender men can get to affirm their identity. He went to a private practice in San Francisco that required him to pay all the money ― $8,500 ― upfront, while assuring him that they were going to work with his insurance to get as much of the operation covered as possible.
When he was recovering from the procedure, he got the shocking news that his clinic hadn’t bothered getting prior authorization for the surgery from his health insurance company, and that not a single dollar of his deposit would be reimbursed. Miles said that if he had known that his surgery would not be partially reimbursed, he never would have gone through with it.
″It was pretty crazy, and there were unfortunately a lot of aggravating curse words,” Miles recalled. “I wasn’t as appropriate on the phone as I should have been. It was a stressful moment, but there was no going back from it.”
There are no hard numbers on how common Miles’ experience was. What we do know is transgender people are less likely to have health insurance than the general population, and gender affirmation surgeries can cost tens of thousands of dollars out of pocket. Despite the costs, those surgeries are up almost 20 percent since the American Society of Plastic Surgeons began counting them in 2015. The group estimated that transgender people had more than 3,200 surgeries of some kind in 2016 to help them transition.
Despite Miles’ financial setback, he continued to research clinics that could help him continue his transition, and in the beginning of 2017, a therapist suggested he contact Garcia at Cedars-Sinai. Garcia’s office worked with Miles for over six months to communicate with his health insurance company about the process, getting authorization for the surgeries beforehand and ensuring that they would be covered.
“I thought for so long that I was never going to have bottom surgery, because it was so expensive,” he said. “As soon as Dr. Garcia said he was going to work with insurance, I felt like I was going to fall off my chair.”
So far, Miles has had a scrotoplasty and a phalloplasty, and is recovering from his most recent surgery on Nov. 1. Because he just turned 26 and can no longer be on his grandmother’s insurance plan, he’s figuring out how to pay for his third and final surgery. While he’s stressed about it, he’s thankful that surgeries that could have cost him anywhere from $60,000 to $100,000 out of pocket — quotes from private practice clinics that all refused to work with insurance — have cost him only about $1,500.
“It’s enough, in itself, to give anybody goosebumps,” Miles said.
It’s this kind of comprehensive care that Garcia and his colleagues strive for at Cedars-Sinai. Whether it’s providing help navigating health insurance companies, connecting people with previous patients who have gone through similar procedures, or even offering a makeup session to transgender women before they return home, Garcia aims to offer patient-centered care that takes care of the whole person, not just their body.
“It’s about making people feel whole, and recognizing it’s a whole person we’re taking care of, not just the genital area.”