Infant Male Circumcision
By Jane Lyons, MD, Pediatrician, Dignity Health - St Joseph's Hospital and Medical Center
February 2023
Medicine can be frustrating. Even with all of our training, medical technology, and good intentions, there may be a barrier to helping our patients that we just can’t fix. Our patients may live too far from a specialist and they don’t own a car. Their insurance is denying the prior authorization you submitted, or any number of little barriers we come across every day. But sometimes, there might be a way to fix it.
As a pediatrician, I offer families of infant males the option to circumcise their infant. For many families, this is a procedure they definitely want, whether it be for religious or cultural reasons, or medical ones. But sometimes, the $200 price tag within two weeks of an already expensive birth is too much. In all but four states, Medicaid does not cover infant male circumcision without prior authorization. This is where organized medicine comes in.
Organized medicine fights for the interests of physicians and our patients. A powerful tool in our toolbox is pushing for legislative changes. That path requires finding a champion.
Veteran lawmaker State Representative Dr. Amish Shah of District 5 agreed to be our champion. An emergency physician, he introduced HB2342 in the 56th Arizona Legislature that would amend Section 36-2907 of Arizona Revised Statutes and compel AHCCCS coverage without prior authorization. MCMS has been an integral part of making this bill a reality and continues to lobby for it. This is how medical societies respond to members and can help to make your ideas a reality.
MCMS reached out to foster connections and grow support for the bill. The medical society is incredibly thankful to organizations in favor of the change. These groups include Arizona Medical Association, Arizona Osteopathic Medical Association, Arizona Urological Society, Arizona Hospital and Healthcare Association, Arizona Section of the American College of Obstetricians and Gynecologists (AZ ACOG), March of Dimes, and Arizona Public Health Association.
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Evidence
Medical professionals and literature support infant male circumcisions. For example, in their 2012 Technical Report titled, “Male Circumcision,” The American Academy of Pediatrics stated, “Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it.”[1] The oft-used UpToDate states, “circumcision has been associated with a number of medical benefits, including lower rates of urinary tract infection (UTI), penile cancer, penile inflammation, penile dermatoses, and sexually transmitted infections.”[2] Significant complications are rare.
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AHCCCS Coverage
The state’s Medicaid program does not cover the procedure unless prior authorization is approved. However, this is an extended process only used and approved for older male infants or children with complications of being uncircumcised. Infant males may have multiple hospitalizations for urosepsis associated with pyelonephritis putting them at risk for renal damage, or repeated ER visits and urologic procedures for phimosis, before AHCCCS would cover the more risky and expensive procedure of male circumcision of an older infant/child under general anesthesia.
Cost
Evidence-based policy is one aspect of the advocacy battle. Another is cost. Assisting the legislature with analysis of the state budget, revenue and expenditures, and potential impacts of new bills is the Joint Legislative Budget Committee, a bipartisan group with 16 members from the legislature and full-time staff support.
According to the JLBC’s fiscal note for HB2342, “AHCCCS actuaries estimate the bill would increase AHCCCS costs by $1.9 million annually, of which $277,200 would be paid for via the General Fund, $148,000 via the Hospital Assessment Fund, and $1.4 million via federal Medicaid funds. This cost estimate assumes that the bill would result in an additional 12,372 infant males receiving the procedure annually at a cost of $151.40 per child.”
This is based on the assumption of a 50% male birth rate of 39,526 births in 2022, or 19,763 male births. Another assumption is a circumcision rate of 62.6%, which creates the final estimate of 12,372 new circumcisions stemming from HB2342.
JLBC staff concurred with the AHCCCS estimate of the bill’s fiscal impact.
Administrative Route
If the legislative route fails, then MCMS and our allies will approach the new leadership at AHCCCS about an administrative change to Chapter 400, Medical Policy for Maternal and Child Health of the Medical Policy Manual. We would also seek an update to the circumcision authorization guidelines last signed in 2017 by the AHCCCS Medical Director. The medical policy for MCH establishes requirements for AHCCCS contractors and fee-for-service providers regarding maternity care services. Chapter 400 of the medical policy states, “Pursuant to A.R.S. § 36-2907, routine circumcision for newborn males is not a covered service, and circumcision is a covered services under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) for males only when it is determined to be medically necessary. The procedure requires prior authorization by the Contractor Medical Director or designee for enrolled members, or the AHCCCS Chief Medical Officer or designee for FFS members.”
This is where you and organized medicine come into play. Physicians united are a strong force. Good bills with good intentions do pass through the Arizona House and Senate to become law and make positive changes in our community. I encourage you to become active in organized medicine and speak up for issues you believe are in the best interests of patients and our profession.
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Learn More About the Author:
Jane Lyons, MD, is currently a Pediatrician at Dignity Health - St Joseph's Hospital and Medical Center. Dr. Lyons earned her medical degree from University of California, San Diego and completed her residency at the UCSD Pediatric Residency Training Program in San Diego, CA.
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Citations:
[1] Male Circumcision. American Academy of Pediatrics. www.pediatrics.org/cgi/doi/10.1542/peds.2012-1990. doi:10.1542/peds.2012-1990
[2] Neonatal Circumcision: Risks and Benefits. https://www.uptodate.com/contents/neonatal-circumcision-risks-and-benefits
