Reducing costs of referrals for non-neonatal circumcision in Florida Medicaid population

Florida Medicaid will only cover a non-neonatal circumcision if it meets the specified Medicaid medical indications or the patient is 3 years or older and has failed a 6-week trial of topical steroid therapy (TST). Referral of children who do not meet guideline criteria results in unnecessary costs.

We sought to evaluate the cost savings if the initial evaluation and management were performed by the primary care provider (PCP) with referral to a pediatric urologist of only those males meeting the guidelines.

An institutional review board-approved retrospective chart review of all male pediatric patients ≥3 years of age presenting for phimosis/circumcision from September 2016 to September 2019 at our institution was performed. Data extracted included (1) presence of phimosis, (2) presence of medical indication for circumcision on presentation, (3) circumcision performed without meeting criteria, (4) use of topical steroid therapy prior to referral. The population was stratified into 2 groups based on whether criteria were met at the time of referral. Those with a defined medical indication on presentation were excluded from cost analysis. Cost savings were based on costs incurred for PCP visit(s) versus initial referral to a urologist using estimated Medicaid reimbursement rates.

Of the 763 males, 76.1% (581) did not meet Medicaid criteria for circumcision on presentation. Of these, 67 had a retractable foreskin with no medical indication, 514 had phimosis with no documented topical steroid therapy (TST) failure. A savings of $95,704.16 would have been incurred if the PCP initiated the evaluation and management and referred only those who met the criteria (Table 2).

These savings would only be feasible if there were proper education of PCPs in the evaluation of phimosis and the role of TST. Limitations are assuming cost savings in the setting of well-educated pediatricians for clinical exam and believing they are aware of and comply with the guidelines.

Education of PCPs on the role of TST in phimosis and current Medicaid guidelines may reduce unnecessary office visits, health care costs, and family burden. The most impactful method to reduce the cost of non-neonatal circumcision would be for states that do not currently cover neonatal circumcision to acknowledge affirmative policies from the American Academy of Pediatrics regarding circumcision and realize the cost savings associated with providing coverage for neonatal circumcision and reducing significantly the number of more expensive non-neonatal circumcisions.