Despite a series of reviews over the past few years aimed at containing costs and simplifying the system, there have been no significant changes to Medicare coverage of circumcision. The only changes have been to reduce the number codes (from four to two) and to make them unisex. This had had the unfortunate effect of making it impossible to calculate the number of circumcision procedures by age (thus obscuring the fact that the vast majority are of infants and young boys) and allowing circumcision of girls, as previously documented on this site. The latest report from one of the working groups, the Urology Clinical Committee, has proposed no changes to the circumcision codes at all, except for the requirement for analgesia (pain control). This is a desirable reform, but a less important issue than the fact that Medicare will continue to fund non-therapeutic (medically unnecessary) circumcision, including circumcision desired for religious, cultural and other social/cosmetic reasons. This is contrary to the provisions of the Health Insurance Act and the Medicare guidelines, which state clearly that benefits are payable only for “clinically relevant” services – i.e. procedures for which there is a demonstrated medical need. The Committee report is available here; the section relating to circumcision are on pages 68-70.
For some years the Commonwealth Government has been concerned at the ever-rising costs of the ever-expanding health budget, particularly the cost of Medicare. In 2015 it resolved to establish a reform process, the aim of which was to simplify the system and reduce costs by eliminating services of low medical value. Non-therapeutic circumcision was identified as an example of such a low-value service, giving rise to the expectation that it would be dropped from the Medicare Benefits Schedule. This has not happened.
In the first round of reforms all that happened is that the codes for circumcision were reduce from four (distinguished by age) to two (distinguished by type of anaesthesia) – thus making it impossible to determine how many infants and boys were being circumcised. In addition, the codes were made gender-neutral, allowing them to be used for circumcision of females – as is apparently happening.
In a further round of reforms the Urology Clinical Committee tackled the circumcision codes and managed to produce a very small mouse. Of nearly 6000 items on the MBS, it managed to eliminate 18, of which circumcision was not one. The Committee’s sole recommendation was to require analgesia (pain control) for circumcision procedures, “thus ensuring patient wellbeing.” This is certainly a welcome move in the right direction, but it is not the main issue. More significantly, the Committee made no attempt to limit the availability of the circumcision rebate; on the contrary, it accepted the prevailing situation in which it is readily available for procedures carried out for religious or cultural reasons:
The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions.
While this does not appear to be a formal recommendation, it presumably has the force of one.
It is difficult to see how subsidising religious or cultural practices could be a legitimate use of the health budget, particularly as the Health Insurance Act and the Medicare guidelines state clearly that the rebate is available only for “clinically relevant” services – i.e. medical treatment that is actually needed for medical reasons. The policy is certainly in contradiction to the fundamental objective of the reform process: to rein in and control costs. The stated objectives of the reviews were to achieve:
An open-ended subsidy (essentially a blank cheque) for procedures of zero clinical relevance makes no contribution to achieving these objectives, and is in fact in complete contradiction to them, especially the last.
Examining the Urology Clinical Committee’s recommendations and observations on circumcision in more detail, it is possible to raise six major objections to them, as set out below.
Further information on this site
Medicare Circumcision Review details
Medicare coverage of non-therapeutic circumcision criticised in submission
Medicare coverage of female circumcision?
This response is directed at the recommendations relating to circumcision, at pages 68-70.
5.5.1 Recommendation 14
Amend the item descriptor to mandate the use of analgesia for this procedure.
5.5.2. Rationale for Recommendation 14
The item descriptor has been amended to mandate the use of analgesia, which ensures patient wellbeing.
Comment
While this is a progressive and desirable reform, it should be noted that analgesia does not necessarily “ensure patient wellbeing”, only that he is given a painless operation.
The Committee noted that item 30654 should continue to include circumcisions conducted for religious and cultural reasons, reflecting both current practice and the need to ensure safe circumcisions.
Comments
1. This proposal is regressive and inappropriate in that it is essentially offering a blank cheque to all parents who desire to have their boys circumcised, whatever their reason, as well as to those rare individuals who desire circumcision for themselves. The specification “religious and cultural” is meaningless and ineffective in the absence of a verification mechanism by which the religious/cultural credentials of the parents can be checked. Such a system is not proposed, and it would be complex to administer, and expensive even if the obvious difficulties could be overcome. In effect, the Committee has legitimised the existing open slather by which any individual who desires circumcision for himself or any parent who wishes to get a boy circumcised for any reason can require the public purse to meet part of the cost.
Considering that the original objective of the various Medicare reviews was to rein in costs by eliminating procedures of low medical value, this seems highly counter-productive.
2. The argument about past practice is feeble and unacceptable. Merely because a certain policy has been followed in the past does not mean that it is desirable in or appropriate to current conditions; past practice is not best practice. The objective of reform exercises is to eliminate bad policies and replace them with good policies. Historical longevity is no basis for approving any practice in the contemporary world. As a matter of historical record, the government attempted to remove circumcision from the MBS in 1985, suggesting that in its original conception, Medicare was not intended to cover non-therapeutic circumcision at all. [1]
3. Related to (2), it is likely that payments for religious/cultural circumcision under Medicare are unlawful because the relevant act and associated guidelines provide that benefits are payable only for clinically needed procedures. As Michael Ryan, Assistant Secretary, MBS Policy and Specialist Services Branch, Department of Health, explains to Mr Peter Khalil MP (letter dated 6 November 2017, copy held by author):
“The Medicare Benefits Schedule (MBS) provides benefits (or rebates) for a range of professional medical services, including circumcision. The Health Insurance Act 1973 stipulates that Medicare benefits are only payable for clinically relevant services provided by health practitioners. A clinically relevant service is one that is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.
“On 1 November 2016 the MBS items for circumcision were restructured from four items to two items to separate them by the type of anaesthesia used, rather than by patient age. However, there have been no changes to the legal requirement that services must be clinically relevant, and there are no benefits available for non-therapeutic procedures.”
In its current policy statement on circumcision the Royal Australasian College of Physicians concluded: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.”
That being the case, non-therapeutic circumcision (including circumcision procedures desired for religious/cultural reasons), must be regarded as clinically not-relevant, and hence ineligible for a Medicare rebate.
4. The argument about the need to avoid the risk of additional harms or complications that might arise if needy parents (those who claim to be unable to meet the full cost) would resort to less expensive unqualified operators (as in the backyard abortions and kitchen-table surgery of infamous memory) fails for 2 reasons. First, the argument about avoiding the risk of additional harm is not a reply to the proposal that parents etc should meet the full costs of medically unnecessary procedures, but to the proposition that such procedures should be legally prohibited. The Royal Dutch Medical Association, which would like to see non-therapeutic circumcision of minors banned, raised this point as the only consideration which deterred the from making such a recommendation in their 2010 circumcision policy statement. [2] But the current proposal is not that circumcision should be prohibited or restricted in any way at all, merely that individuals or parents who desire a medically unnecessary circumcision should meet the full costs.
The mere fact that the procedure is covered by Medicare does not guarantee “safe circumcisions”. Complications and “botches” are still common in clinical settings, and at the hands of fully credentialed operators, often requiring expensive surgical repairs and sudden appearances in hospital emergency departments. [3] Ensuring patient safety is not the task of the MBS, but of the medical regulatory authorities.
Further evidence for this point is provided by the two Medicare items for “arrest of haemorrhage following circumcision”, items 30649 and 30663; from a policy perspective the risks and complications of circumcision are real enough and recognised. There is thus a question as to whether these circumcision-related MBS benefits encourage unnecessary risk-taking behaviour on the part of parents and compliant practitioners. But what level of complications is acceptable in a clinically-unnecessary procedure?
Second, the test of whether a person really values a good or service is how much he is willing to pay for it. Members of the religious/cultural groups that traditionally practise circumcision may be insistent that it is vitally necessary, but if they are not willing to put a price on it – if they do not wish to meet the actual costs involved – it suggests that they do not really regard it as necessary at all. To allow the rebate in this situation would be like allowing low-income families to drive a car without paying the full costs of vehicle registration because the expense is a strain on their resources. And here the full cost includes the insurance component, to cover the cost of accidents etc; the parallel with surgical complications of circumcision and the cost of repairing “botches” is quite exact. Most people regard the ability to drive as so vital that they are willing to meet whatever costs are involved.
Moreover, some religious groups celebrate the circumcision with a lavish family party. If they are willing to pay for that, they should also be willing to meet the full costs of the surgery that is the occasion for the event. One assumes that they do not expect the taxpayer to subsidise the party.
5. Now that the Medicare circumcision codes have been made unisex or gender neutral, there is the danger that retaining coverage of religious/cultural circumcision will lead to Medicare providing a rebate for circumcision or other forms of genital cutting on girls. There is in fact evidence that this is already happening. [4] The religious/cultural groups that practise circumcision or other forms of genital cutting on girls regard the procedures as just as important and meaningful as circumcision of boys; if they see the rebate available for circumcision of the latter, they are likely to expect or even demand it for the former as well. And if cultural/religious affiliation is to be the deciding factor, how can their request be denied? [5]
6. While some defenders of circumcision have begun to advocate toleration of “mild” forms of female genital cutting, partly as a way of reducing the blatancy of the double standard (FGM legally prohibited, with heavy criminal penalties, circumcision of boys legal and generally unregulated), a stronger current of opinion stresses the importance of “genital autonomy” and the need to protect all children – male, female, intersex – from any form of non-therapeutic genital cutting. [6-10]
It is puzzling and disappointing that the Committee displayed no awareness of these developments.
References
1. Robert Darby. Scientific advice, traditional practices and the politics of health-care: The Australian debate over public funding of non-therapeutic circumcision, 1985. Hygiea Internationalis: An Interdisciplinary Journal for the History of Public Health, Vol. 10, December 2011. Available at https://www.academia.edu/7028494/Scientific_advice_traditional_practices_and_the_politics_of_health-care_The_Australian_debate_over_public_funding_of_non-therapeutic_circumcision_1985
2. Details at http://www.circinfo.org/Dutch_circumcision_policy.html
3. Gold, G. et al. Complications following circumcision: Presentations to the emergency department. Journal of Paediatrics and Child Health 51 (12) 2015: 1158-63; Jacques Gallant. Secrecy questioned about baby’s death after circumcision. The Star (Toronto), 26 October 2015. https://www.thestar.com/news/gta/2015/10/26/secrecy-questioned-about-babys-death-after-circumcision.html
4. See for example http://www.circinfo.org/Medicare_Coverage_Female_Circumcision.html
5. Brian Earp. Between moral relativism and moral hypocrisy: Reframing the debate on FGM. Kennedy Institute of Ethics Journal 26 (2) 2016: 105-144. Available at: https://www.academia.edu/10197867/Between_moral_relativism_and_moral_hypocrisy_reframing_the_debate_on_FGM_
6. Brian Earp and Rebecca Steinfeld. Gender and genital cutting: A new paradigm. Euromind Global, 6 April 2017. Available at: http://euromind.global/en/brian-d-earp-and-rebecca-steinfeld/?lang=en
7. Robert Darby. The child’s right to an open future: Is the principle applicable to non-therapeutic circumcision?” Journal of Medical Ethics 39 (2013): 463-468. Available at: https://www.academia.edu/17264543/The_childs_right_to_an_open_future_Is_the_principle_applicable_to_non-therapeutic_circumcision
8. Eldar Sarajlic. Can Culture Justify Infant Circumcision? Res Publica 20 (4) 2014: 327-343.
9. Steven Munzer. Examining non-therapeutic circumcision. Health-Matrix: The Journal of Law Medicine 28 (2018). Available at: https://scholarlycommons.law.case.edu/healthmatrix/vol28/iss1/5/
10. Kai Möller. Ritual male circumcision and parental authority. Jurisprudence 8 (3) 2017: 461–79.