A Crucial Step Forward In Trans And Gender-Diverse Healthcare

By Dr. Antimony Deor

This year might be the year that new Medicare Item Numbers are created specifically for gender-affirming surgeries. This move would be a crucial step forward for both healthcare workers and trans and gender-diverse people across Australia.

Every medical service, procedure, treatment, and medication covered under the Medicare system has a unique five-digit number assigned to it. These are known as Medicare Item Numbers and are akin to a catchy nickname for a procedure. “Complex laparoscopic hysterectomy with bilateral salpingo-oophorectomy” becomes simply “35753”. Item numbers standardise terminology across Australia, allow easy identification, and facilitate the efficient collection and analysis of health data.

Everything with an item number also has a price set by Medicare. This is called the Medicare Benefit Schedule Fee (or MBS fee) and represents the standard payment a doctor will receive when they perform a particular procedure. MBS fees allow patients in the private system to compare doctors, and doctors to know exactly how much money they will receive from Medicare.

However, gender-affirming surgeries do not currently have their own unique item numbers. Instead, surgeons use numbers that are close enough or approximate to the kind of surgery they are actually doing. A surgeon performing top surgery might use the item number for a double mastectomy, for example, even though cis women who get mastectomies do not usually request their chest be contoured to a masculine shape. This means that doctors are not reporting the right data, are not receiving the right remuneration, and patients are picking up the fee.

Some procedures cannot be described by existing item numbers and fall outside the Medicare framework altogether. Neither Medicare nor private health insurance pays any benefits towards these surgeries, leaving the patient to cover the entire cost themselves. The resulting fee can be tens of thousands of dollars, which means trans people must save for years, forgo other financial goals, or go without healthcare.

The proposed additional item numbers would also cover some GP, sexual health, and psychiatric consultations specifically relating to gender-affirming care. A separate application has been made to the Pharmaceutical Benefits Scheme Committee to allow hormones to be prescribed in the case of gender incongruence.

The consultation process for this application gathered responses from trans people and health bodies citing the high costs of surgeries and the risks to practitioners in reporting inaccurate item numbers, as well as the effect this measure would have on reducing stigma associated with gender-affirming care. Opponents of the application argued that surgery can result in loss of sexual function and fertility, patients may feel regret, gender incongruence is not a genuine condition, and patients should be directed towards psychological therapy instead.

The proposed new Item Numbers would only be applicable to procedures performed on adults between the ages of 18 and 50. The application will be heard by several committees throughout 2024 before advice is finally presented to the government.