Reducing costs of referrals for non-neonatal circumcision in Florida Medicaid population.

INTRODUCTION: Florida Medicaid will only cover a non-neonatal circumcision if it meets the specified Medicaid medical indications or the patient is 3 years or older and has failed a 6-week trial of topical steroid therapy (TST). Referral of children who do not meet guideline criteria results in unnecessary costs. OBJECTIVE: We sought to evaluate the cost savings if the initial evaluation and management were performed by the primary care provider (PCP) with referral to a pediatric urologist of only those males meeting the guidelines. STUDY DESIGN: An institutional review board-approved retrospective chart review of all male pediatric patients ≥3 years of age presenting for phimosis/circumcision from September 2016 to September 2019 at our institution was performed. 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 criteria were 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 PCP visit(s) versus initial referral to a urologist using estimated Medicaid reimbursement rates. RESULTS: Of the 763 males, 76.1% (581) 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 topical steroid therapy (TST) failure. A savings of $95,704.16 would have been incurred if the PCP initiated the evaluation and management and referred only those who met the criteria (Table 2). DISCUSSION: These savings would only be feasible if there were proper education of PCPs in the evaluation of phimosis and the role of TST. Limitations are assuming cost savings in the setting of well-educated pediatricians for clinical exam and believing they are aware of and comply with the guidelines. CONCLUSIONS: Education of PCPs on the role of TST in phimosis and current Medicaid guidelines may reduce unnecessary office visits, health care costs, and family burden. The most impactful method to reduce the cost of non-neonatal circumcision would be for states that do not currently cover neonatal circumcision to acknowledge affirmative policies from the American Academy of Pediatrics regarding circumcision and realize the cost savings associated with providing coverage for neonatal circumcision and reducing significantly the number of more expensive non-neonatal circumcisions.

Reported Beliefs About COVID-19 Vaccines Among Unvaccinated Hispanic Adults Utilizing a Free Clinic in Orlando, Florida.

BACKGROUND: Subgroups of the general population including Hispanic/Latinx individuals report higher rates of COVID-19 vaccine hesitancy than non-Hispanic White individuals. The purpose of this study was to identify factors that influence attitudes toward COVID-19 vaccines among unvaccinated Hispanic adults utilizing a free community clinic in Orlando, Florida, USA. METHODS: From May 2021 to July 2021, we used convenience sampling to recruit 20 self-identified Hispanic adults who were unvaccinated to complete an individual, semi-structured interview. Interview questions were derived from constructs from the Health Belief Model. Interviews were audio-recorded, transcribed, translated (when necessary), and qualitatively analyzed using inductive content analysis to identify recurring themes. RESULTS: Of the 20 participants in this study, 65% were female (n=13) and they ranged from 21 to 73 years of age (median age =42.5). We identified three primary themes in participant responses regarding their beliefs about COVID-19 vaccines. Primary theme 1: trust and clarity of COVID-19 vaccine information, with subthemes (1a) source trustworthiness, and (1b) clarity of COVID-19 vaccine information. Primary theme 2: personal contextual factors, with subthemes (2a) underlying health conditions, (2b) personal experiences with COVID-19, and (2c) immigration. Primary theme 3: lack of confidence, yet willingness to be vaccinated, with subthemes (3a) fear and distrust and (3b) willingness to be vaccinated. In summary, participants felt hesitant, although not completely opposed, to receiving COVID-19 vaccinations due to the information they gathered on vaccines from various sources received in the context of important personal factors (e.g., immigration, underlying health concerns, etc.). CONCLUSIONS: Overcoming vaccine hesitancy in vulnerable populations such as the Hispanic communities may require addressing issues of message clarity through trusted sources while considering personal contextual factors. Healthcare professionals can begin by initiating discussions with patients to understand individual circumstances and concerns and provide information on COVID-19 vaccines that clarify areas of confusion.

Impact of Florida Medicaid guidelines on frequency and cost of delayed circumcision at Nemours Children's hospital.

INTRODUCTION: In 2003, Florida Medicaid discontinued coverage of routine neonatal circumcision (NC) resulting in an increase in nonneonatal circumcisions. Florida Medicaid is one of 16 state healthcare plans that do not cover NC. Florida Medicaid covers 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 Nemours Children's Hospital. STUDY DESIGN: 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, and surgical interventions. The patients were stratified into three management groups. Total costs for each group were based upon estimated Medicaid reimbursement rates. Data were analyzed using descriptive analysis on SPSS. RESULTS: Seven hundred and sixty-three males were evaluated. Age at presentation ranged from 3 to 17 years and 59% of patients were 3-6 years at initial presentation. Three hundred and forty patients underwent circumcision. The total estimated cost of care for all patients was $1,345,533.90. This compares to an estimated cost of $171,675 if all individuals underwent NC at 2020 costs. CONCLUSIONS: The total estimated cost associated with the evaluation and management of 763 patients ≥3 years for phimosis/circumcision was 7.8 times the estimated cost of NC for all these patients and likely is an underestimation of the true difference in cost as we did not account for 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. Of the circumcisions performed, only 18.5% met Florida Medicaid defined medical indications. Success rates for TST range from 53.8 to 95% in the literature, however, our success rate was 34.3%. The reason for the variation in response rate between our results and the literature may reflect that caretakers desiring circumcision may be less compliant with TST use. Only 6.6% 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 TST, could reduce the number of unnecessary office visits, healthcare costs, and family burden.