Circumcision Procedure - Cost
Circumcision is amongst the 40 most frequently performed surgical procedures, occurring more commonly than tooth extraction [Australia's Health, 1992].
In the USA cost per newborn was typically $165 [Schoen et al., 2006]. Post-neonatal circumcision, however, was approx. 10 times more expensive [Schoen et al., 2006]. The total cost of newborn circumcisions in the USA was estimated as US$150–270 million.
In Australia, in the year to Feb 2004, 16,311 neonatal circumcisions were performed at a cost to Medicare of A$623,080. Interestingly, as an important historical anecdote, back in 1985 the Federal Minister for Health removed the rebate for newborn circumcision from the Medical Benefits Schedule in response to the (now outmoded) 1983 recommendations of the National Health & Medical Research Council (NHMRC) of Australia. It was then quickly restored after a public outcry. The NHMRC currently has no policy statement on circumcision.
The scheduled fee for a neonatal circumcision in Australia in 2004 was A$38.20 (~US$26) [Australian, 2004b]. The overall cost to Medicare for circumcisions in the year to Feb 2004 was thus A$623,080 + $275,210 + ($298,880 or $369,086) = $928,170 to 998,375.
In 2007 the scheduled fee in Australia was A$42.00, with a benefit of A$35.70 [Medicare, 2007b]. For circumcision of those aged 0.5–10 years the scheduled fee was A$97.65 and benefit A$83.05. For circumcisions in those over age 10 these figures were A$135.20 and A$114.95, respectively (if done by a general practitioner) and A$167.65 and A$142.55 (if done by a specialist).
In late 2009, the scheduled fee for a male under 6 months of age was A$43.95, with the Medicare benefit being A$37.40 (85%) or A$33.00 (75%) [Government A, 2009] (http://www9.health.gov.au/mbs/search.cfm?q=30653-30660&sopt=I). For 0.5-10 years the scheduled fee was A$102.20 and benefit A$86.90 (85%) or A$76.65 (75%). The general practitioner fee for males 10 and over was A$141.50 and the benefit A$120.30 (85%) or A$106.15 (75%). For a specialist the scheduled fee was A$175.45 and benefit A$149.15 (85%) or A$131.60 (75%).
The Australian Medicare Benefits Schedule for Circumcision was updated in 2020 [Australian Government Department of Health, 2020]. In 2024 the scheduled fee for a neonatal circumcision in Australia was A$52.95 and the benefit paid by Medicare was A$39.75.
In the years that have followed the schedules fee and rebate have changed little, but the amount actually charged by private medical practitioners has increased substantially. A likely reason is that elective circumcisions are no longer available in the public hospital system.
Many doctors consider that the scheduled fee and thus benefit in Australia should be higher, as such a low rebate has the potential to cause some doctors to discourage circumcision because of the low return relative to other procedures.
The average cost of an adult MC is £2,259 in the UK [Private Health Care UK, 2021], which most men would not be able to afford. The cost of a private practice circumcision for an infant in the UK is approx. 10-times lower [Integral Medical Co, 2022; Thornhill Circumcision Centre, 2022]. Other than circumcisions for medical need, most circumcisions in the UK are performed by doctors working in private practices. In the UK general practitioners rarely perform even minor surgery such as circumcision because no reimbursement is provided by the National Health Service (NHS). When a patient presents with a medical condition requiring circumcision, patients are referred to a hospital. In hospitals, even the most senior doctors, despite having the freedom to make their own decision to do a circumcision, are generally unable to avoid their decisions being scrutinized of their fellow doctors and other medical personnel, as well as it coming to the attention of hospital administrators. Every procedure is subject to the question "is it necessary", the reason being that every procedure increases the burden on the rest of the team of staff each doctor works with. Therefore, in most instances, non-surgical approaches are used, despite the often more arduous, time-consuming nature of some of these (e.g., twice-daily use of creams for an extended period to treat phimosis) as well as the slim chance of others being successful or as effective as circumcision. For elective and parent approved circumcision, the only option at present is using a private practitioner and paying their fee.
In the USA, a neonatal circumcision will generally cost US$89–204, being cheaper in the mid-west and more expensive on the east coast. A review in 1995 found that 61% of infant circumcisions were paid for by private insurance, 36% by Medicaid, and 3% were paid for by the parents [Mansfield et al., 1995]. From 1999 to 2007, of the 52 states in the USA, 16 had ceased to allow Medicaid payments for circumcisions other than for those needed to treat a medical condition [National Conference of State Legislators, 2006a]. As a result, circumcision rate, especially amongst the poor, has gone down in those states, and will have a devastating effect on public health [Leibowitz et al., 2009; Morris et al., 2009]. Such short-sighted policy, which would save money in the short term (but not the long term), has followed intense lobbying by anti-circumcision organizations. The devastating impact the latter extremists are having on gullible politicians is to be deplored.
The ensuing decrease in infant MC in the USA was estimated to have resulted in >100 additional HIV cases and $30M in net medical costs for treatment per year [Andrews et al., 2012]. The cost to circumcise males in that birth cohort was US$4,856,000, i.e., 6% of the cost of treating just HIV. A decline in infant male circumcision prevalence in the USA from 79% to a 10% level was estimated to result in a direct cost increase of US$4.4 billion for treatment of infections only (UTIs and STIs) spanning 10 annual birth cohorts [Kacker et al., 2012]. The increase in expenditure for every infant circumcision not undertaken was estimated as US$313. In addition, the authors (who were at the prestigious Johns Hopkins University) estimated that the resulting indirect costs associated with failure to prevent HIV alone would exceed the direct medical costs by > 4-fold. An evaluation by others estimated that there would be > 200,000 additional cases of STIs if prevalence of infant circumcision in the US decreased from 90% to 10% [Morris et a., 2022c] Modelling studies have, moreover, found cost savings initially generated by non-coverage of elective infant MC by Medicaid in Louisiana [Ortenberg & Roth, 2013] and Florida [Gutwein et al., 2013] were mitigated by increases in rate and expense of medically indicated MC. The Louisiana study only considered the costs of later MC for boys aged 0–5 years. Lifetime costs would therefore represent a far greater financial burden on healthcare systems. The Florida study found Medicaid defunding led to a 6-fold rise in publicly funded MCs at a cost of US$112M [Gutwein et al., 2013], leading Florida to restore Medicaid coverage for non-medical MC [Attorneys for the Rights of the Child, 2014]. It is possible that Colorado may have also restored Medicaid coverage.
Similar nonsense has seen governments in all states and territories of Australia from 2006 onwards exclude circumcisions, except for “medical need”, in the public hospital system, classing them as “social” or “cosmetic” procedures along with breast implants, tattoo removal, liposuction and reversal of sterilization. The Ministers for Health suggested circumcision be sourced in the private sector, failing to recognize any of the health benefits. Quite surprising is that the governments that made these decisions were of the Labor (socialist) party, meaning that the poor in society, who are usually more likely to be protected by Labor party policies and who rely on the public hospital system, are the ones now most adversely affected.
Failure to perform circumcision early in life has financial implications for health systems and individuals around the world. Notably, (i) the higher procedural cost of elective circumcision after infancy including adolescence and adulthood, (ii) more so, the cost of later circumcision to treat adverse medical conditions avoidable by newborn circumcision [Kacker et al., 2012], (iii) the higher (10-20-fold) risk, and therefore treatment costs, of procedural complications for elective circumcision after 12 months of age [El Bcheraoui et al., 2014]. In Australia, if newborn circumcision were to increase from what it was in 2019, namely 18.7%, to 85%, which was what it was in the 1950s [Qin et al., 2021] 77,000 cases of infections and other adverse medical conditions could be avoided over the lifetime for each annual birth cohort [Morris & Wodak, 2021]. As in the Johns Hopkins study above, the cost savings would likely be substantial. Clearly common sense and the application of evidence-based medicine to circumcision policy is needed in the public health system.
