Study Projects Declining Rates of Circumcision Will Up Costs

Steven Fox

August 20, 2012

August 20, 2012 — Continuing decreases in the prevalence of male circumcision (MC) are likely to increase long-term health costs for both men and women, according to new projections that are part of a study carried out at Johns Hopkins University in Baltimore, Maryland.

The study was published online August 20 in the Archives of Pediatric and Adolescent Medicine.

"There are an estimated 19 million new [sexually transmitted infections (STIs)] annually in the United States, which cost the health care system $17 billion each year in direct medical expenses," write Seema Kacker, BS, from the Department of Pathology at Johns Hopkins University, and colleagues. "Therefore, methods to curb STI incidence have both substantial health benefit and financial impact on a strained health care system."

"To our knowledge, this study is the first to comprehensively analyze the cost and health impact of MC," the researchers add.

Medicaid pays for more than a third of all in-hospital male circumcisions MC, but state governments are increasingly cutting Medicaid reimbursements for the procedure. So far, 18 states have eliminated coverage for MCs, and those cuts have been accompanied by decreases in rates of circumcision in those states. During the last 2 decades, the authors note, MC rates have declined from approximately 79% to 54.7%. That drop has closely corresponded to reductions in government-funded insurance coverage.

"Although there are multiple factors that contribute to a nation's MC rate, it is likely that reductions in insurance coverage play a role in lowered MC rates," the authors write. "Thus, the financial and health implications of policies that affect MC are substantial."

The researchers used a US population-based computer simulation (Markov-based Monte Carlo) to follow men throughout their lives to see how having undergone a MC or not having had the procedure would be likely to affect both their healthcare costs and the healthcare costs of their sexual partners and society overall.

In their simulation covering the US population, the researchers used a hypothetical MC rate of 10%, which reflects the overall circumcision rate in Europe, where insurance coverage for the procedure is limited.

On the basis of their simulation, they projected that a decrease to 10% in the rate of male circumcision will increase lifetime healthcare costs by about $407 per man and $43 per woman.

Those expenditures would balloon to nearly $916 million for every annual birth cohort, the researchers project.

Once the cost of the MC procedure is figured in, along with any potential complications that might be associated with it, net healthcare costs would be expected to go up about $505 million, the researchers say. That expenditure would reflect an increase of about $313 for every forgone MC procedure.

The authors also zeroed in on the anticipated increased costs per type of illness that a 10% MC rate in the US would trigger.

According to their computer simulation, the researchers say:

  • the lifetime prevalence of HIV among men would likely increase by 12.2%,

  • high- and low-risk human papillomavirus would increase by 29.1%,

  • herpes simplex virus type 2 would increase by 19.8%, and

  • infant urinary tract infections would increase by 211.8%.

Anticipated healthcare costs would also go up for women:

  • lifetime prevalence of bacterial vaginosis would be anticipated to increase by 51.2%,

  • trichomoniasis would increase by 51.2%,

  • high-risk human papillomavirus would increase by 18.3%, and

  • low-risk human papillomavirus by 12.9%.

Increased cases of HIV among men would fuel more than three quarters of the rise in costs, the researchers say. "Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses," they note.

In an accompanying editorial, Arleen Leibowitz, PhD, and Katherine Desmond, MS, from the Center for HIV Identification, Prevention, and Treatment Services, University of California, Los Angeles, make the case that MC should be included under Medicaid coverage.

"In view of the compelling evidence from randomized controlled trials about the lifelong health benefits of MC and the projections by Kacker et al on the cost reducing potential of MC," they write, "it is now time for the federal Medicaid program to consider reclassifying MC from an 'optional' service to one that all state Medicaid plans will cover for those parents who choose the procedure for their newborn sons."

They acknowledge that state budgets are tight, but say that making states offer MC as a prerequisite to get federal health dollars would prevent states from trading "long-term gains for near-term relief."

"Such a change would address 3 important health system goals: improving health by reducing future incidence of HIV and other STIs, reducing disparities in adult health, and lowering treatment costs for STIs in the long run," they conclude.

One coauthor was supported by the National Institutes of Health and a Doris Duke Charitable Foundation Clinician Scientist Development Award. One coauthor was supported by the National Institutes of Health. The authors of the editorial disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. Published online August 20, 2012. Article abstract, Editorial extract

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