Allocation of Healthcare Dollars: Analysis of Nonneonatal Circumcisions in Florida

Circumcision remains a controversial operation. Most procedures are performed in the neonatal period and avoid general anesthesia. Legislation driven by policy statements from the American Academy of Pediatrics led to significant changes in circumcisions in Florida with a shiftto non-neonatal procedures as a result of costs. We sought to study the prevalence and financial implications of nonneonatal circumcisions in Florida. A retrospective population study was performed using the Florida Agency for Health Care Administration outpatient procedure database. We queried for patients 0 to 17 years of age undergoing circumcision between 2003 and 2008. Demographics, charges, and insurance status were analyzed. From 2003 to 2008, 31,741 outpatient circumcisions were performed. Publicly funded circumcisions accounted for 17,537 charging the state $6,263 on average for each circumcision at an expense of $111.8 million for the 5-year time period analyzed. Publicly funded circumcision procedures increased more than sixfold (P.0001) than those covered by private insurance. Black circumcision procedures increased 77.3 per cent, whereas white circumcisions increased 28.7 per cent. There has been a significant increase in the number of nonneonatal circumcisions performed. This has resulted in an increase in economic health care. Public funding of neonatal circumcision could result in significant cost savings and avoid potential complications of general anesthesia.

DESPITE ITS ANCIENT history, circumcision is today controversial in the United States. One side of the debate has those in favor citing health benefits that include reduced rates of infections of the urinary tract, sexually transmitted diseases including penile and cervical cancers, and human immunodeficiency virus.1 Those against the procedure counter that medical evidence of the benefits of circumcision is lacking.2 The low rate of circumcision in Europe is cited as a reason to avoid it in the United States.3 Since a consensus policy statement by the American Academy of Pediatrics (AAP) published in 1999 stated that routine neonatal circumcision is not warranted,4 the Canadian and British Academy of Pediatrics and the American Medical Association have taken the same position against the procedure.5 One consequence is that 18 state health agencies, including Florida, have decided against funding neonatal circumcision.6 In the 10 years since the 1999 AAP statement, national rates of neonatal circumcision decreased significantly.7 In states that retained funding of neonatal circumcisions, rates were 24 per cent higher.8, 9

In our clinical practice, we noted a recent increase in the numbers of referrals for circumcision among young boys, in particular those aged 2 to 5 years of age. Parents often explained that they were unable to pay for the procedure after the child was born. We hypothesized that neonatal circumcisions were deferred among families in lower socioeconomic classes because public funding was not available. Circumcisions would then be done when the child was older, a costlier procedure requiring general anesthesia in an outpatient surgical facility. To test this contention, we used state health agency databases to determine rates of circumcisions in the neonatal and nonneonatal age groups. We found that publicly funded nonneonatal circumcision has significantly increased in recent years.

Methods

The University of Florida Institutional Review Board approved all protocols.

In Florida, the Agency for Health Care Administration (AHCA) oversees the licensure of the state's 36,000 healthcare facilities. AHCA collects and shares data on all surgical operations and procedures, inpatient and outpatient, through the Florida Center for Health Information and Policy Analysis, data sets available to the public for a fee.10

The database identifies procedures by Current Procedural Terminology code (CPT; Table 1). All patients 0 to 17 years of age over a 5-year period (2003 to 2008) undergoing circumcision were identified, including their demographic characteristics, facility charges, and insurance status. Professional fees are not included in the reported charge data. Ages are reported as an integer (0, 1, 2, 3, etc.) and no dates of birth are given. We therefore chose to define nonneonatal circumcision as those occurring in patients aged 1 year old or older; neonatal circumcision occurring in patients here the age was reported as ''0.'' Imputation analysis was not required for this study.

Practice Review

We collected and analyzed patient information from our practice for 2010, including basic demographic data, insurance information, reason for the procedure, complications, and clinic and operative day show rates.

Statistical Analysis

Data were grouped into years and analyzed using Student's t tests and Fisher's exact test for proportions. Prevalence and incidence are estimated using the numerator only because total birth rates were not considered in the analyses. Minitab software (Minitab, Cary, NC) was used for statistical analysis. Significance was at P < 0.05.

Results

From AHCA data, 31,740 circumcisions were performed from 2003 to 2008 in the state. In each age group analyzed, circumcisions increased over the 5 years (Fig. 1). Total circumcisions increased 79.0 per cent over the period of study. Each year nonneonatal circumcisions (aged 1 year and older) were more common than neonatal circumcision (age 0). In subgroup analysis, the group aged 1 to 5 years had the highest number of circumcisions performed (P < 0.0001). CPT code 54161 was used 77.4 per cent of the time and CPT code 54150 the second most at 11.8 per cent (Table 1).

Payer Data

Public agencies covered payment for 55.3 per cent of circumcisions, 65.2 per cent of which were in patients aged 1 year and older. Numbers of publicly funded circumcisions more than doubled (114.7% increase) during the study period, a rate of increase 6.4 times the rate observed of private insurance-funded circumcisions (P < 0.0001). For both public and private payers, nonneonatal circumcisions were consistently more common each year compared with neonatal circumcision.

Procedural Charge Analysis

Average facility charges for public and privately funded circumcisions were $6263 and $4565, respectively (Fig. 2; Table 2). Average charges increased by 25 per cent from the first year of the study ($5467) to the last ($6848), charges to public funding more than doubling (to $33.6 million from $14.9 million; 126%). In contrast, total private charges only increased by 16 per cent (to $14.1 million from $9.3 million). Total charges for publicly funded circumcision were $111.8 million over the 5 years, the final year alone accounting for 30 per cent of the total.

Demographic Analysis

Circumcisions among blacks had the largest rate of increase among all racial groups, increasing by 77 per cent over the study period (P 4 0.003); Hispanics, 33 per cent (P 4 0.083); and whites, 29 per cent (P 4 0.021). By total number of procedures, whites ranked first in the total number of circumcisions performed for the first 4 years, but in the fifth year, blacks assumed the top spot. Half of the number of publicly funded nonneonatal circumcisions was in blacks, 50 per cent; whites, 34 per cent; and Hispanics, 15 per cent. Numbers of publically funded nonneonatal circumcisions among all racial groups showed relative increases greater than privately funded procedures (Fig. 3).

Practice Data

In a single year (2010), 311 nonneonatal circumcisions were performed: 83 per cent were publically funded, 78 per cent were black, and the most common age group was 1 to 5 years. There was a 24 per cent no show rate for the preoperative assessment and a 12 per cent absence on the operative day, excluding those who called to cancel a scheduled operation for a bona fide reason such as illness or missed transportation.

Discussion

Our data show the cost of nonneonatal circumcisions in Florida has more than doubled over the 5 years studied, the apparent result of defunding nonneonatal circumcisions. Our experience suggests that parents continue to want the procedure done in early childhood because of the availability of public financing. If public funding were available for the procedure in the neonatal period, they would have had the procedure done then.

The current neonatal circumcision rate in the United States is approximately 56 per cent7-9 with rates varying from 45 to 80 per cent depending on region and the availability of public funding.6, 11, 12 Midwestern states have the highest rate, 74 per cent, followed in order by the Northeast (67%), South (61%), and West (30%). States where Medicaid has defunded neonatal circumcision have lower rates of circumcision, thus creating a disparity along the lines of ability to pay for the procedure.6, 8, 9

As currently practiced, neonatal circumcision is a safe bedside procedure not needing general anesthesia. There is general agreement that newborns perceive pain and adequate regional anesthetic block is required for the procedure.13 Morris et al. supports infancy as the optimal time for neonatal circumcision under local anesthesia because of the low cost, quick healing, and a superior cosmetic result.14, 15 Reviews that compare complications from neonatal and nonneonatal circumcisions show a higher complication rate (0.2 to 0.6 vs 1.5 to 3.8%, respectively) with the older age group.16, 17 The cost of neonatal circumcisions ranges from $250 to $800 depending on who performs the procedure (obstetrician, pediatrician, surgeon) and where it is done (office, inpatient, neonatal intensive care unit).6, 18 Reviews using administrative databases note an overall increase in neonatal circumcisions in the United States in the past decade,3, 19 the causes of which are not well understood.

Our study is unique in that the database used captured outpatient circumcisions, a limitation of federal administrative databases such as the Kids' Inpatient Database that focus on inpatient procedures. Thus, we found increasing state expenditures for the procedures, the unintended result of state agencies deciding not to fund neonatal circumcisions. It is important to recall that our data only include the facility fee; therefore, the actual charge is significantly higher when one considers the provider fees for the surgeon and anesthesiologist. Publicly funded circumcisions increased, whereas the numbers for the procedure paid by private insurance stayed stable. We speculate the increase was among patients with lower socioeconomic status who depend on publically funded health care. The disparity in circumcisions among families below the poverty line has been shown by others.8, 9, 20 To our knowledge, the present study is the first to analyze the funding for and demographic distribution of nonneonatal circumcision on a statewide basis.

There are several limitations of our study. Administrative databases lack specific information so conclusions necessarily are general. The AHCA database is an outpatient procedural database and does not reflect inpatient procedures such as neonatal circumcision performed at the bedside during the initial birth hospitalization. The use of solely integers for patient age made distinguishing procedures done in the neonatal period (under 28 days) impossible. Including older infants younger than 1 year of age resulted in an underestimate of the numbers of circumcisions done among older infants and children, and any conclusions would therefore be conservative. Financial data also only captured facility charges and missed professional charges. Again, because nonneonatal circumcisions are uniformly performed under anesthesia, missing professional anesthesiologists' fees would make the increased financial burdens even more remarkable.

In August 2012, the AAP revised its 1999 position stating, ''the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it.''21 They further advocated for third-party payment for circumcision. Despite this change in position, the issue of circumcision remains controversial. Our economic analysis supports a change in the state's defunding decision of 2001, especially in a time of resource constraint in public health.

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LUKE G. GUTWEIN, M.D.,* JUAN F. ALVAREZ, M.D.,* JENNY L. GUTWEIN, M.S.N., A.R.N.P.,[dagger] DAVID W. KAYS, M.D.,* SALEEM ISLAM, M.D., M.P.H.,*

From the *Division of Pediatric Surgery, Department of Surgery, College of Medicine, and the [dagger]College of Nursing, University of Florida, Gainesville, Florida

Presented at the Southeastern Pediatric Surgical Congress at the Southeastern Surgical Congress Annual Meeting, Jacksonville, FL, February 9-12, 2013.

Address correspondence and reprint requests to Saleem Islam, M.D., M.P.H., Department of Surgery, University of Florida, P.O. Box 100286, 1600 SW Archer Road, Gainesville, FL 32610. E-mail: [email protected].