Plume’s Dr. Jerrica Kirkley on Advancing Health Equity in the Arena of Transgender Care

Progress and change are evolving forward across healthcare, even as the subject of health equity is becoming ever more entrenched in the thinking of healthcare leaders about how to think about healthcare delivery. Now, reflecting a broader set of trends in the general society, consciousness about how to deliver optimal care to transgender patients, is evolving forward.

And even as the leaders of traditional hospitals, medical groups, and health systems are working to enhance the care environment for transgender patients, one specialty provider of care is focusing predominantly on the transgender patient population. Plume Healthcare, with more than 40 clinicians, the majority of them MDs, has been working to fill the gaps, particularly in the telehealth space. Initially founded as a pilot in 2019 in Denver, the organization has been expanding staff and services since then.

Indeed, as the staff of Tech Funding News reported on Aug. 24, “Denver-based Plume, which provides virtual healthcare services designed for the transgender community, has raised $24 million in Series B funding. The investment round was led by Transformation Capital with participation from General Catalyst and Town Hall Ventures. The proceeds of this round will support Plume in fulfilling its mission to transform healthcare for every trans life by creating access to high quality, safe gender-affirming care. The company will use these resources to expand coverage nationwide and into virtual primary care, ensure Plume is covered by insurance, and provide support that trans and gender diverse people and their families deserve.”

That article quoted Jerrica Kirkley, M.D., Plume’s cofounder and chief medical officer as saying that, “With today’s announcement, we are on track to reach our goal of increasing access to high-quality, gender-affirming care to patients across the U.S. in both urban areas and coverage deserts. Knowing the hurdles trans Americans face when accessing care, I’m encouraged to reach this benchmark and I look forward to Plume’s growth in the future. I want to thank Transformation Capital, General Catalyst, and Town Hall Ventures for their partnership in transforming health care for every trans life.”

And it quoted Matthew Wetschler, M.D., Plume’s cofounder and CEO, as stating that, “Since launching in 2019, Plume has strived to bring the trans community the deeply personalized health care they deserve. Amidst growing anti-trans rhetoric nationwide, Plume’s model offers unmatched access to health care for trans Americans. Today’s announcement only reinforces our goal of expanding that coverage and eliminating barriers to quality care,” Dr. Wetschler told Tech Funding News.

In addition to serving patients in Colorado, Plume clinicians care for patients in 41 states, and reaching 93 percent of the trans population, making it the largest provider of transgender healthcare in the country. At the core of the package of care available to patients through Plume is a subscription that covers gender-affirming hormone therapy and emotional support services; as the organization frames it, the package includes the following:

•             24/7 access to gender-affirming care

•             Personal consultations

•             Lab monitoring

•             Letters of support

Also this summer, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed Dr. Kirkley about Plume’s mission, services, and vision for the future. Below are excerpts from that interview.

When was Plume founded?

We started a pilot in August 2019, which was our incorporation of our practice. We went out to seek venture capital that fall after receiving great feedback from our pilot. And I received great feedback as a physician caring for many transgender patients and a transgender person myself; in early 2020, we officially started.

And getting into the ‘why’ of it—I went into medicine as a vehicle for social justice. So health equity has been my mantra since even before medical school. And the civil rights environment was an inspiration; also was Paul Farmer who wanted to care both for the individual patient while thinking about how to change the system so that all patients can have that experience. And so I first started provide gender-affirming care in my residency—2012-2015. And it was an incredibly powerful process, and I knew I wanted to be a part of providing gender-affirming care to the transgender community.

What’s more, race, ethnicity, age, physical status, all were elements in how I saw, and see, health equity. So, starting with building a curriculum and protocol for prescribing hormones, was a step. And at that point, it became an issue to create gender-affirming care to trans people. And my co-founder, who had been an ER physician, faced issues in his work as well. In that context, tlehealth can really support healthcare for trans people, because it affords physical safety and convenience; and doing it in a virtual, remote setting allows us to bring together clinicians from around the country. Because if you’re in a small town or rural area, it can be almost impossible to find gender-affirming care. This is care that you literally can’t find in a bricks-and-mortar site.

How many patients do you see?

We have over 10,000 active patients, and we’ve cared for over 15,000.

Do patients need formal referrals to access Plume’s services?

Hormone therapy is not a specialty service, it’s a primary care service; but most primary care providers are not trained, so it does require a referral. A lot of patients come to us through word of mouth or through online search, etc. But it’s not required. Insurance is another whole subject, because hormone therapy and gender-affirming surgery—it varies a lot, but more and more private insurance is covering both. Twelve states actively prohibit transgender-related services under Medicaid; Medicare covers them. The bigger element is finding access to care, and understanding that coverage doesn’t equal access to care.

What are some of the biggest challenges you’ve faced, and how are you overcoming them?

From a cost-access standpoint, that’s always a challenge. We’ve tried to create a price structure that’s accessible to many. We’ve even provided free care of up to a year for many people. But the next piece is really figuring out how to connect with insurance companies; that’s always a challenge. The other, from a policy side—there’s just a lot to navigate when it comes to telehealth navigation—pre-pandemic, pandemic, etc. And there can be variation on a state-by-state basis. There are changes in federal legislation; so, being able to adapt, while providing care in accordance with these rapidly changing standards, while also advocating for the trans community and other communities. It can mean even advocating for broadband access.

If Congress chooses to not extending telehealth flexibilities after the public health emergency ends, could that be devastating?

We actually started pre-pandemic. And it’s still complicated and difficult to navigate. If we were able to extend the public health emergency, that would help. We started as a cash-only practice. And we have to engage with insurance.

Have there been any other challenges?

I think there’s always the day-to-day challenge of simply providing the best care period, and then also, in a virtual environment. And the opportunities are endless, whether through the care teams, workflows, or product and platform we’re using; there’s so much room for improvement. There are a lot of things we can do inside our system at Plume; but we also have to work with pharmacies, lab companies, health insurers. And just by building this system at Plume, we’ve already seen care platforms, organizations, changing how they identify names, gender, etc., in their product, because of what we’ve requested. It’s wonderful to see organizations incorporating changes, and making substantive change. So how do we create from within as well as externally.

What about any challenges related to the electronic health record [EHR] and gender?

That involves a lot of workarounds and hacks; and some of those workarounds and hacks have also changed things. We have an EHR and a patient communication platform, off the shelf. We have purposely not used the patient portal built into the EHR, because the portal was gender-rigid. The EHR is systematically making changes that are great, but they have pieces of their system that have not been revised. So we looped in an entirely separate communication platform. They can put in any gender they want. And we’re always using that in our communication.

How are you and your colleagues addressing clinical issues in the EHR, some of which can be related not only to issues like pronouns, but also related to shifts of gender that could allow for missing conducting key diagnostic screenings and tests, for example?

Yes, there are now three fields: gender identity, sex assigned at birth, and legal gender, and that’s great to have. But there’s not necessarily a legal definition of gender in the EHR; in some states, it’s based on your Social Security name. But if you have all three fields, you can address issues. So regardless of your sex assigned at birth, if you have an organ that requires a cancer screening, you get that screen. And if a test or procedure that is done, it’s done in an empathetic way. But as clinicians, we always need to care for patients based on organs present. We call that an organ inventory. But clinicians oftentimes don’t think about that, and that’s the problem. That’s the cultural competency. You see the sex or gender or even name, and automatically make certain assumptions.

Does your work include the education of other clinicians?

Yes, that can certainly happen in day-to-day care, when a patient might want to reach out to their everyday physician. I do educate primary care providers in my work outside of Plume and hormone therapy. And getting back to the source, we need that education in medical schools and PA schools and nursing schools.

Is it starting to happen now in professional healthcare schools?

It’s starting to happen. You’re seeing it more.

Are you at all concerned about growing anti-trans sentiment in some areas of the country, sentiment that could lead to public policy changes that might affect Plume’s work?

Yes, we’re absolutely concerned. Of course, we as a trans community have been facing intense stigma for thousands of years. It’s very much intensified in the last few years, with over 200 bills proposed in the last few years, with the number for 2022 already pushing 300. And with the overturn of Roe v. Wade, and there’s a lot of uncertainty.

One of the elements in the Dobbs decision in June was the Supreme Court majority’s writing that both the privacy and the due process elements in Roe v. Wade were not legitimate. Are you at all concerned that some of that legal reasoning could be used against trans patients.

The short answer, again, is that it’s concerning. It is concerning, and something that we’re going to have to watch.

What is your vision for the future of Plume in the next few years?

We want to continue to expend our services, and branch into primary care and preventative health for our community, and finding different payment forms, focusing on insurance.