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Reducing Costs of Referrals for Non-neonatal Circumcision in Florida Medicaid Population
Kailee Hernandez, Medical student1, Susana Soto, Medical student1, pamela Ellsworth, MD2.
1University of Central Florida College of Medicine, Orlando, FL, USA, 2Nemours Children's Health Orlando, Orlando, FL, USA.

Background: Florida Medicaid guidelines for non-neonatal circumcision are consistent with commonly used guidelines, MCG guidelines. 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 was performed by the Primary Care Provider with referral to Pediatric Urologist of only those males meeting the guideline.Methods: An IRB approved retrospective chart review was performed of all male pediatric patients 3 years of age and older presenting for phimosis/circumcision from September 2016 to September 2019 at our institution. 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 or not criteria 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 primary care provider visit(s) versus initial referral to urologist using estimated Medicaid reimbursement rates.Results: Of the 763 males, 81.5% (621) 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 TST failure and 41 had other penile conditions. Only 6.6% had a documented failure of TST prior to initial presentation. A savings of $95,704.16 would have been incurred if the primary care provider initiated the evaluation and management and referred only those who met criteria.
Conclusions: In a prior study we demonstrated the high costs incurred by Florida Medicaid for non-neonatal circumcision related to lack of Florida Medicaid coverage of neonatal circumcision. Further analysis of this data demonstrates that the costs of non-neonatal circumcision can be reduced by having the initial evaluation and management be performed by the Primary Care Provider with referral of only those males meeting Medicaid criteria. Education of Primary Care Providers on the role of topical steroid therapy in phimosis and current Medicaid/MCG guidelines may reduce unnecessary office visits, health care costs and family burden.


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