Our health care quality measures are failing transgender patients

Many health care quality measures improperly include or exclude transgender people, limiting efforts to control costs and improve care

By Landon Hughes

Scholarship around transgender health–health care costs, access, and standards–is becoming more abundant. Recently, studies have revealed disparities faced by transgender patients in our health care system, specifically around access to care, mental health care, and mistreatment in health care settings. While estimates regarding the size of the transgender population in the US vary greatly across studies, one thing is for certain: this population is becoming increasingly visible, and ensuring their health care needs are met and recognized is essential.

Since the passage of the Affordable Care Act, our health care system has moved toward value-based delivery models, such as accountable care organizations and the Oncology Care Model. These models aim to reduce health care costs and improve health care quality. To this end, models assess the quality of care a doctor provides using measures. For example, a quality measure might calculate the percentage of patients who received a flu shot during the flu season.

Quality measures use specific criteria to determine which patients should be assessed. For instance, a flu shot measure will only evaluate patients who visited the doctor during a flu season.

Although time may be an appropriate criterion to determine which patients are assessed, in a recent journal article, I and other RTI researchers noted that using sex criteria in healthcare quality measures often improperly excludes or includes transgender patients, as their sex-identifier may not accurately represent their physiology. Furthermore, the quality measures may not align with the existing standards of care for transgender individuals.

Let’s look at two measures as examples:

(1) Breast Cancer Screening

This measure calculates the percentage of women between the ages of 50 and 74 who received a mammogram within 27 months. This measure:

i. improperly excludes transgender men who changed their sex identifier to male and haven’t undergone mastectomy

ii. doesn’t specify measurement for transgender women, which is recommended for transgender women 50 and older who have received hormones for more than 5 years

iii. improperly includes transgender women who changed their sex identifier to female and have not received hormones 

(2) Chlamydia Screening and Follow Up

This measure calculates the percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up. This measure:

i. improperly excludes transgender men who changed their sex identifier to male

ii. improperly excludes transgender women who have not changed their sex identifier to female 

We recommend that quality measurement organizations adapt their measures to transgender patients using existing clinical recommendations.

As the health care system moves toward value-based delivery models, we should ensure the quality measures used in them are inclusive of transgender patients. These models offer a mechanism to address transgender health disparities and hold providers accountable for the care of their transgender patients.

Creating an inclusive health care system will be essential to ensuring that all patients–regardless of their gender identity–are provided with high-quality care.   

As a researcher within our program on public health and well-being, Landon Hughes studied public health programs and policies, with a special focus on the social determinants of lesbian, gay, bisexual, and transgender health.