ROCHESTER — Rejecting the advice of diversity and clinical experts within its own system, Mayo Clinic declined in 2019 to offer expanded health insurance coverage for employees seeking treatment of gender dysphoria, a move resulting in its recent downgrading on a prized quality score.

The coverage gap in question could expose the clinic to more than just a missed opportunity for enhancing its brand. In a letter sent to Mayo CEO Gianrico Farrugia last July, LGBTQ advocates behind a successful legal challenge against Essentia Health in 2014 argued that the omission could expose Mayo to a lawsuit for discriminatory health care coverage under provisions of the Affordable Care Act.

The unusual turn of events stands in contrast to the clinic's otherwise robust efforts to establish itself as a leader in inclusive healthcare practices, initiatives which include efforts to educate staff on best practices in the care of transgender patients, development of a nine-page set of policies, procedures and guidelines for the care of transgender patients and treatment of transgender employees, and later this month, plans to host 100 clinicians for a three-day continuing medical education conference on the care of transgender and intersex patients.

The scoring downgrade emerged in the release last week of the 2019 Healthcare Equality Index, a closely-watched report by the Washington-based Human Rights Campaign Foundation. The survey scores medical centers across the country on a host of LGBTQ-friendly variables, including non-discrimination and staff training, patient visitation policies, community engagement, and employee benefits.

In 2018, Mayo Rochester scored a perfect 100 on the survey, earning the HRC designation as a Leader in LGBTQ Healthcare Equality. This year, hospitals faced an additional hurdle to reaching that status. Employers were required to "provide at least one health plan to all employees that affirmatively and explicitly covers medically necessary health services for transgender people, including gender transition-related treatment."

Because Mayo Rochester did not meet this standard, it scored a 95, with its only points lost thanks to its decision to forego coverage. The 95 still earned the clinic a "Top Performer" status, but fell short of the perfect score granted to a host of Mayo competitors large and small, including Rush University Hospital, Memorial Sloan Kettering, The Hospital for Special Surgery, all 39 Kaiser Permanente locations, and in Minnesota, St. Cloud Hospital and the VA Minneapolis. Cleveland Clinic scored 90, while Johns Hopkins declined to participate.

"We were disappointed," says Dr. Sharonne Hayes, director of Diversity and Inclusion at Mayo Clinic. "But we will continue to work towards having those benefits covered, because we think that is what's going to be best for our employees."

Hayes sat on the working group which argued for the new coverage, working alongside a LGBTQ Mayo Employee Resource Group in appealing unsuccessfully to an executive-level Salary and Benefits Committee at Mayo. The executives were given a seven-page briefing outlining the case for covering the procedures, a paper signed by three experts from its Transgender Intersex Specialty Care Clinic. The appeal warned the committee Mayo would lose its top score if it did not expand coverage, even adding that "the financial and personnel impact of changes to the plan are small, but would set an important tone for Mayo Clinic."

The gap in question is for employees requiring health care services drawn from a slate of lesser-known procedures accompanying full gender transition. Since 2014, Mayo employees have been offered health care coverage which pays for mental health, hormone therapy, and major gender affirmation surgeries, a period in which just five employees have transitioned medically according to the briefing. Mayo does not cover other gender dysphoria procedures, including hair removal, facial reconstruction, lipofilling, body implants and voice therapy or vocal surgery.

The refusal by Mayo to offer coverage for these treatments has forced employees who have transitioned to either pay out-of-pocket or exist in a kind of gender transition below the standard of care. The latter is at odds with the World Professional Association for Transgender Health, or WPATH, an advisory body Mayo accepts as the recognized authority on best practices in transgender medical care. On a web page for its care of gender dysphoria, the clinic states that "Mayo providers follow the standards of care established by the World Professional Association for Transgender Health."

Critics say Mayo executives are effectively playing the role of an unqualified insurer, one standing between doctors and patients.

"I think the best practice for health care organizations - and clearly the people who do the Human Rights Campaign index feel the same way — is to include the standards that are cited by the World Professional Association for Transgender Health," says Christy Hall, senior staff attorney for the St. Paul based legal advocacy organization Gender Justice. "Those folks are the experts."

Gender Justice wrote the aforementioned letter to Farrugia after having been contacted by a Mayo employee who had sought coverage for two of the WPATH procedures not included under the health Mayo plan. The letter noted that as a recipient of federal financial assistance in the form of Medicare and Medicaid, "Mayo Clinic is subject to the nondiscrimination provisions of the Affordable Care Act, both with respect to patients and employees."

It cited Tovar v. Essentia Health, a ruling it argued and one in which its client has prevailed, finding against "gender discrimination on the basis of gender identity."

"Failure to adhere to the WPATH standards and provide coverage for medically necessary care that disproportionately impacts transgender employees" it continued, "constitutes prohibited sex discrimination under Section 1557 of the Affordable Care Act." It added that "(f)ailure to provide coverage for some transition-related treatments could mean that the employees are unable to access them whatsoever, exacerbating the effects of gender dysphoria."

Gender Justice says they have not heard back from the clinic. In response to a query from Forum News Service about the letter, Mayo spokesperson Ginger Plumbo replied in an email that:

"The letter was received and reviewed by Mayo Clinic’s Legal Department. At that time, the decision for the 2020 benefits coverage had already been made. The information will be reviewed and considered as the 2021 benefits coverage is being discussed. We appreciate the perspective shared by Gender Justice but disagree with that organization’s legal interpretation. Mayo Clinic’s health plan covers many of the services recommended by WPATH and complies with all applicable laws regarding transgender coverage."

While it is not clear why Mayo rejected the coverage request, participants within the negotiation process have speculated that clinic leadership may have viewed the procedures an exception not granted to cisgender (non transgender) employees. "One of the things that was brought forward," says Hayes, "[is that] these are considered cosmetic procedures that are not covered for me if I wanted one ... So there were concerns about how we would navigate that. Obviously other organizations have managed to navigate it, and we’d like to help Mayo navigate that as well... I do wonder if they somehow thought that perhaps this would be a slippery slope, that now everyone who ever wanted liposuction and has always dreamed of having it for cosmetic reasons would be knocking at the door."

"I don't believe this is a slippery slope scenario or anything resembling that," says Jess Braverman, legal director for Gender Justice. "I think it's about the needs of the patients. I would hope they would step up and provide world class care to their own employees."

The rising profile of patients with gender dysphoria has undergone a rapid movement into the mainstream in the course of just a few years, one driven by popular culture, high-profile transgender public figures like Chelsea Manning and Caitlyn Jenner, the adoption of non gendered pronouns, and the LGBTQ social justice movement. Observers believe this rapid shuffling of the social order may have left some clinicians behind the curve.

"We offer training to different departments (within Mayo)," says Jimmy Luckey, chair of the Rochester LGBTI Mayo Employee Resource group and a participant in the negotiations with Mayo salary and benefits executives. "Some of the attendees don't understand this is not a cosmetic treatment, that this is something that is treating a gender dysphoria, and these procedures aren't done for cosmetic reasons. They're done to alleviate distress associated with gender dysphoria."

"It is new knowledge for many of our staff, I'll just say that," says Hayes. "It's something they didn't grow up with, something they weren't trained in in medical school. So we are trying to fulfill some of those gaps through a variety of training and online learning."As for the missing coverage, Hayes says, "the decision by the salary and benefits committee was not to cover it at this time. As with many other coverage issues, whether its health or otherwise, those are always up for reconsideration."

Forum News Service reporter Anne Halliwell contributed to this report.