"Cost-Effectiveness and Budget Impact of Facial Feminization Surgery"

Facial feminization surgery (FFS) is an important aspect of gender affirming care and improves quality of life. However, FFS is sparsely covered by insurance and is the most commonly denied gender affirming procedure. We conducted, to our knowledge, the first cost-effectiveness and budget impact analysis of undergoing FFS.

We designed a Markov cohort model of 30-year-old transgender women to evaluate the cost effectiveness of FFS compared to no FFS, with 5- and 10-year time-horizons from a U.S. health system perspective, across all accepted willingness-to-pay thresholds (WTPs) in the U.S. ($50,000-$150,000/quality-adjusted life-years [QALYs]). The primary outcomes were the incremental cost-effectiveness ratio in U.S. Dollars (USD) per QALY and the per-member-per-month (PMPM) cost of covering FFS. Transition probabilities and utilities were population-specific and were sourced from published data. Our budget impact model considers projected trends in demand for FFS.

Compared to not receiving the surgery, FFS accrued $23,200 more dollars and 0.5 more QALYs across five years, with an ICER of $44,300 [95% CI: $32,200- $63,800]. FFS remained cost effective across all scenarios and sensitivity analyses, notably even with a diminishing mental health benefit of FFS across 10 years. FFS was favored in 100% of 10,000 probabilistic iterations at a WTP of $100,000/QALY. The budget impact of FFS was $0.049 in 2025 and is projected to decrease over the next five years despite a projected increase in demand for FFS.

Insurance coverage of FFS is cost-effective at a WTP of $100,000/QALY with a low budget impact.