Impact of Florida Medicaid Guidelines on Frequency and Cost of Delayed Circumcision at a Children's Hospital
Susana Soto, BS1, Kailee Hernandez, BS1, Kaity Colon-Sanchez, MPAS, PA-C2, Pamela Ellsworth, MD2.
1University of Central Florida College of Medicine, orlando, FL, USA, 2Nemours Childrens' Hospital, orlando, FL, USA.
BACKGROUND - In 2003, Florida Medicaid discontinued coverage of routine neonatal circumcision (NC) resulting in an increase in nonneonatal circumcisions. Florida Medicaid is one of 18 state healthcare plans that do not cover NC. Florida Medicaid follows the MCG guidelines and will cover a male circumcision in a child ≥3 years for a defined medical indication or persistent phimosis refractory to topical steroid therapy (TST). We sought to assess the economic impact of the evaluation and management of phimosis/circumcision in Florida Medicaid males ≥3 years treated at a single children’s hospital.
METHODS - We performed an IRB approved retrospective chart review of all male Florida Medicaid patients ≥ 3 years seen at NCH for phimosis/circumcision from Sept. 2016 – Sept. 2019. Data extracted included demographics, age at presentation, prior treatment with TST, response to TST, surgical interventions, complications, and unexpected returns to clinic/ER/OR. The patients were stratified into three management groups (figure 1). Total costs for each group were based upon estimated medical reimbursement rates (Table 1). Data was analyzed using descriptive analysis on SPSS.
RESULTS - Three hundred and eighty-two males were evaluated. Age at presentation ranged from 3 years to 17 years, median age of 6 years. Sixty two percent of the children were 3 to 6 years of age at initial presentation. Two hundred and thirteen (55.8%) patients underwent circumcision. The total estimated cost of care for all patients was $825,854 (Table 2). This compares to an estimated cost of $86,000 if all individuals underwent NC at current cost.
CONCLUSIONS - The total estimated cost associated with the evaluation and management of 382 patients ≥ 3 years at NCH for phimosis/circumcision was $825,854. This is 9.6x the estimated cost of NC for all these patients. 17.8% of circumcisions met Florida Medicaid defined medical indications. The total estimated cost is an underestimation of the true cost given we did not factor in additional visits outside of the initial consultation and follow-up, post-operative visits outside of the global period, emergency room visits and returns to operating room. Success rates for TST range from 53.8-95%, however, our success rate was 26%. Caretakers desiring circumcision may be less compliant with TST use. Only 6.3% of patients had a documented failure of TST prior to initial presentation. Further education of PCPs on current Medicaid/MCG guidelines for the evaluation and management of phimosis, as well as PCP adoption of use of TST, could reduce the number of unnecessary office visits, healthcare costs and family burden. 
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