Despite several reviews and inquiries into medically unnecessary and low-value procedures, Medicare continues to provide a rebate for non-therapeutic circumcision of male infants and boys. Under changes to the codes that became effective in June 2016, however, it is now impossible find out how many circumcision procedures are performed on boys aged under 6 months. Even more alarming, it appears that Medicare is also paying for circumcision of girls – otherwise known as female genital mutilation (FGM).
A report to the Minister for Health arising from these inquiries did not pay much attention to circumcision (one of the low-value procedures identified in the reviews), but it did contain the following paragraph:
“Less commonly mentioned was unnecessary surgical intervention. However, when this issue did arise, the implications in terms of unnecessary patient risk were often more serious. Commonly cited examples included inductions of labour and caesareans for no medical reason, knee arthroscopy for patients with osteoarthritis, and circumcision in healthy male infants. A number of respondents to the survey indicated that surgery should not be considered unless conservative treatments had been undertaken — for example, physiotherapy for incontinence or prolapse, or physiotherapy for back pain rather than spinal surgery.”
Although several public submissions urged that the rebate for non-therapeutic circumcision be entirely scrapped (as the government intended when Medicare was introduced in 1985), the only major change arising from the inquiries was the replacement of the relevant codes. The old codes were:
30653: Circumcision of a male under 6 months of age
30656: Circumcision of a male under 10 years of age but not less than 6 months of age
30659: Circumcision of a male 10 years of age or over by a GP
30660: Circumcision of a male 10 years of age or over by a specialist
30663: Haemorrhage, arrest of, following circumcision requiring general anaesthesia
The new codes, operative since June 2016, are as follows:
30649 HAEMORRHAGE, arrest of, following circumcision requiring general anaesthesia on a person under 10 years of age
30654 Circumcision of the penis (other than a service to which item 30658 applies)
30658 Circumcision of the penis, when performed in conjunction with a service to which an item in Group T7 or Group T10 applies
30663 HAEMORRHAGE, arrest of, following circumcision requiring general anaesthesia on a person 10 years of age or over.
Medicare codes may be searched here.
As a Department of Health news item (November 2016) stated: “The four circumcision items (30653, 30656, 30659 and 30660) have been removed and replaced with two new items (30654 and 30658). Item 30658 is for circumcision procedures performed under anaesthesia and item 30654 is for all other circumcision procedures.”
It is not clear from the information readily available whether “under anaesthesia” means with a general anaesthetic (not possible with young babies), or whether “all other circumcision procedures” are performed without any anaesthetic at all.
According to figures that can be searched at the Medicare statistics portal of the Department of Health, the number of circumcisions performed under item 30654 (all other procedures) in June 2017 was 854. Following the link to find the ages of these patients reveals the astonishing information that 15 of these procedures were performed on females, with an age breakdown as follows:
0-4 years 5
25-34 years 6
35-44 years 4
Of the 839 males circumcised:
0-4 years 798
5-14 years 20
15-24 years 6
– and the remainder at older ages.
Figures for item 30658 (circumcision with anaesthesia) are even more alarming. In the second quarter of 2017 (March-May) 2328 circumcision procedures were performed, including 21 on females and 2307 on males. The age break down for the females was:
1-4 years 7
5-14 years 2
25-34 1
Of the 2307 males circumcised:
0-4 years 1262
5-14 years 399
15-24 years 185
Until 1995 the Medicare circumcision codes were unisex and read “circumcision of a person”, thus authorising a benefit for circumcision of females as well as of males. In order to protect girls from genital mutilation as part of the general development of laws and policies against FGM that followed the passage of the UN Convention on the Rights of the Child “person” was changed to “male”. At the same time the Crimes Acts of all states were amended to make female genital cutting a criminal offence. The new provisions made no exception for culturally or religiously motivated circumcision, but they do allow a defence of medical necessity – that is, if the operation is judged to be necessary for the girl’s or woman’s health, it is then permissible. It is certainly possible that the procedures recorded here were deemed to be medically necessary, and thus not illegal, but it is still surprising to see female infants exhibiting such serious genital pathologies as would require circumcision. On top of that, we wonder who is making the judgement about medical need, and whether there is any safeguard against spurious or fraudulent claims. It also seems rather bizarre that a code described as “circumcision of the penis” can be used to fund circumcision of girls.
A similar comment about medical need applies to the large number of baby boys still being circumcised and attracting a Medicare rebate. It does not seem credible that so many boys aged 1 to 4 years (over 1200 in only 3 months) had such serious foreskin problems that circumcision was really necessary, and one suspects that the real reason was cultural or religious, dressed up as medical need for the purpose of attracting the rebate.
The report to the Minister noted that people were questioning why healthy boys should be circumcised at the expense of Medicare. In response, it would appear that the Government has changed the presentation of statistics in a way that makes it more difficult to work out how many juvenile circumcisions are taking place and impossible to determine how many neonatal circumcisions (i.e., circumcisions under the age of 6 months or one year) are being performed. Even more surprising, despite the new wording of the codes specifically referring to penises, it appears that little girls are also being subjected to circumcision procedures.
Further investigations by Mr Michael Glass, of Sydney, and Circumcision Information Australia have revealed the astonishing fact that Medicare began to provide a rebate for circumcision of females in 2013, wen the relevant codes were defined as “circumcision of a male”– a phenomenon that continued and increased when the new codes were introduced in 2016.
Over the 20 years since Medicare statistics became available (1993-2003) there were more than 450,000 rebates for male circumcision. Although there were some cases where the gender of the patient was not specified, no case was recorded where Medicare paid for the circumcision of a patient classed as female. Starting in July 2013, Medicare began to subsidise the circumcision of women and girls.
4 years of female circumcision under Medicare
In the 4 years from 1 July 2013 to 30 June 2017 Medicare paid for the circumcision of 256 girls under the age of 6 months. In the same period, Medicare also paid for the circumcision of 72 girls over the age of 6 months but less than 10 years. From 1 July 2013 to 30 June 2017, Medicare paid General Practitioners for the circumcision of 26 women and girls. 9 of these were girls from 5 to 14 years of age and a further 7 were between the ages of 15 and 24. (The rest were older.) From 1 July 2013 to 30 June 2017, Medicare paid specialists for the circumcision of 38 women and girls. 9 of these were girls from 5 to 14 years of age and a further 5 were between the ages of 15 and 24. (The rest were older.)
Female circumcision under the new item numbers
From 1 November 2016, the Medicare announced the removal of item numbers 30653, 30656, 30659 and 30660 and their replacement by two new item numbers, 30654 (all other circumcision procedures) and 30658 (circumcision with anaesthesia).
In 8 months, Medicare Item number 30654 subsidised the circumcision of 158 women and girls, 44 of whom were under the age of 5 and 5 of whom were between the ages of 5 and 14. In 8 months, Medicare item number 30658, subsidised the circumcision of 53 women and girls, 18 of whom were below the age of 5 and 5 of whom were between the ages of 5 and 14. Altogether, in the 4 years since 1 July 2013, Medicare subsidised the circumcision of 603 women and girls, 272 of them (just over 45%) in the most recent financial year.
Cost of the Medicare payments for circumcising females
The total cost of the Medicare payments for circumcising females in the 4 years from 1 July 2013 to 30 June 2017 is $59,424. The total cost for circumcising females in the most recent financial year (2016/2017) is $29,347. It cost more than 49% of the total cost for the four years to circumcise just over 45% of the total number of females, so the cost to Medicare had risen even faster than the number of females who were circumcised.
For the last four years, Medicare appears to have been subsidising the circumcision of hundreds of women, girls and baby girls. Whether this is lawful or criminal depends on whether the operations can validly be judged to be medically necessary for the health of the patient. (This was Dr Graeme Reeves' defence and the reason the jury at his first trial was unable to reach a verdict.) While it is plausible that operations on adult women who have given informed consent is lawful, a big question mark hangs over the operations of female minors: is it really likely that hundreds of baby girls suffer from such severe genital pathologies that something called circumcision is required? It seems especially unlikely that the 256 girls below the age of 6 months circumcised between July 2013 and June 2017 really needed the operation for medical reasons.
At a time when the government is desperate to save money, the cost of these procedures is also a matter for concern. The Medicare subsidy for this has cost the taxpayer $60,000. The Government and the taxpayer appears to have been defrauded this amount because the item numbers were supposed to be for the circumcision of males. The latest figures show that under the new Medicare numbers, the number of females circumcised has risen dramatically, but the cost to Medicare has risen even faster.
In response to inquiries from Mr Michael Glass, a Sydney human rights advocate, the Medicare statistics section has explained that the changes to the schedule were made in response to a directive from the Attorney General’s Department following amendments to the Sex Discrimination Act in 2013: According to Carla Cook, “The Department of Human Services complies with the 2013 direction of the Attorney-General’s department that introduced new protections from discrimination** on the grounds of sexual orientation, gender identity and intersex status in many areas of public life. As such, there are no gender based restrictions on accessing Medicare items.”
In other words, the 1995 restriction on Medicare providing a rebate for female genital cutting has been removed in the name of non-discrimination.
In response to questions about the legality of genital cutting procedures on women and girls Ms Cook further explained that all procedures under Medicare had to be clinically relevant in order to qualify for a rebate: “Medicare benefits are claimable only for ‘clinically relevant’ services rendered by an appropriate health practitioner. A ‘clinically relevant’ service is one which is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.”
She added that “Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, State and Territory laws.”
** This refers to a document called Australian Government Guidelines on the Recognition of Sex and Gender (July 2013), published by Attorney General’s Department
Mr Glass’s email and reply from Medicare statistics are below.
It does seem extraordinary that such startling changes to Medicare procedures should have occurred so quietly, without any comment in the media (so far as we are aware) and no alarm from women’s and human rights groups that it now covers circumcision of girls and women as well as boys and men. The rules state that all benefits (for males as much as females) are payable only for services that are clinically necessary for the person’s health; but the question is whether these rules are being observed and what safeguards are in place to ensure that they are observed and to prevent unscrupulous practitioners from rorting the system, defrauding the government and taxpayer, and (in the case of FGM) performing an illegal operation.
We have always argued that the principles of gender equity and non-discrimination require that boys and girls enjoy equal protection under the law; but our position is that this should be achieved by raising the level of protection available to boys, not by reducing the level of protection for girls. If it is a crime to cut a female’s genitals without her informed consent, it should be a crime to cut a male’s genitals without his informed consent – allowing for genuine medical necessity in both cases. It is reasonable that women and girls should be able to receive a rebate for genital cutting operations that are genuinely medically necessary for their health, along with boys and men; it is unreasonable and unacceptable that any person, male or female, should receive a rebate in cases where the cutting is performed for cultural, religious, cosmetic, social or other non-medical reasons.
We address the following questions to the Minister for Health:
1. Under the new Medicare codes, circumcision is classified as a therapeutic procedure, i.e. necessary to address a pathological problem that is not susceptible to conservative treatment. Furthermore, the rules state that a Medicare benefit is payable “only for ‘clinically relevant’ services rendered by an appropriate health practitioner”, i.e. a service “generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.” What safeguards are in place to ensure that rebates provided under the new codes are in fact confined to therapeutic procedures, i.e. procedures that are clinically necessary to address a pathological condition?
2. Is the Minister confident that these codes are not being used to provide a rebate for circumcision performed for cultural, religious, social, cosmetic or other non-therapeutic reasons?
3. What safeguards are in place to ensure that the above rules are complied with and that the codes are not misapplied?
4. Information from a report to the Minister on the Department of Health website states that item 30658 is for circumcision performed under anaesthesia, and that item 30654 is for all other circumcision procedures. Does this mean that circumcision under item 30654 is performed without anaesthesia?
5. Is the Minister aware that the current policy of the Royal Australasian College of Physicians is that routine (non-therapeutic) circumcision of male minors is not warranted in Australia or New Zealand? Is she also aware that in 2012 the Tasmania Law Reform Institute, in an exhaustive analysis of the medical, legal and ethical status of non-therapeutic circumcision, concluded that it was medically unnecessary and ethically objectionable, and that it ought to be legally regulated and restricted to certain specified situations?
If you look at Medicare statistics, here:
http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp
A wealth of information can open up.
You can find the number of services and the Medicare contribution to the benefit.
The following questions were sent by Michael Glass to the Medicare statistics inquiry address. They are reproduced below, with the replies from Carla Cook, Information Strategy, Governance and Release Section, Information Services Branch, Department of Human Services. (Links to web pages have been deleted.)
Thank you for your patience with this one, we have now received a response from the business area with relevant advice (please see below) relating to your queries. Please note that the questions highlighted in yellow have been directed to the Department of Health as it best sits with them for response. I hope the information provided is of assistance to you. I will be in contact with you shortly once a response is received from Health.
I have some questions about the recent changes in the item numbers regarding circumcision. According to this document some circumcision item numbers have been abolished and replaced with other item numbers.
1. Why were changes made to some of the circumcision-related item numbers?
2 The four circumcision items (30653, 30656, 30659 and 30660) have been removed and replaced with two new items (30654 and 30658). However, as late as July 2017 the older items were still in the Medicare statistical reports. Why is this so?
“Medicare statistical reporting captures all claims processed by the Department of Human Services within the specified period. This is not the same as the date the service was originally provided. For example, an item 30653 may have been performed on 15 October 2016 but the claim was not submitted to Medicare until July 2017. In this instance the item 30653 would appear in a statistical report of claims processed in July 2017.”
3. Item numbers 30654 and 30658 include “circumcision procedures” on females. 62 of these were under the age of 5, A further 10 of them were between 5 and 14. However, the descriptions of the item number state that they both were about the circumcision of the penis. What is going on?
“The Department of Human Services complies with the 2013 direction of the Attorney-General’s department** that introduced new protections from discrimination on the grounds of sexual orientation, gender identity and intersex status in many areas of public life. As such, there are no gender based restrictions on accessing Medicare items. The Department of Human Services does note that it is the responsibility of the servicing practitioner to ensure that the services are billed against the correct patient on the Medicare card.”
** https://www.ag.gov.au/Publications/Pages/AustralianGovernmentGuidelinesontheRecognitionofSexandGender.aspx
Under item 30654, 158 women and girls underwent a “circumcision procedure” up until the end of June, 2017. 44 of these females were aged from 0 to 4 and 5 were aged 5 to 14.
Under item number 30658, 53 females underwent a “circumcision procedure up until the end of 2017.18 of these females were aged from 0 to 4 and 5 were aged 5 to 14.
(a) How can funding for the circumcision of boys be used to fund “circumcision procedures” on women and girls?
“As outlined above, the Department of Human Services complies with the 2013 direction of the Attorney-General’s department that introduced new protection from discrimination on the grounds of sexual orientation, gender identity and intersex status.”
(b) Was it the intent of Medicare to also fund the sexual cutting of girls? If so, why?
“Health will be able to provide a details answer to this question. However, Medicare benefits are claimable only for ‘clinically relevant’ services rendered by an appropriate health practitioner. A ‘clinically relevant’ service is one which is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient. Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, State and Territory laws.”
4. Isn’t the genital cutting of underage girls against the law? If so, why is Medicare funding it?
“As outlined above.”
5. According to this web page: https://www.researchgate.net/figure/278675359_tbl2_Table-6-MBS-item-numbers-and-descriptors-for-male-circumcision [See note below] the fee for item number 30653 (circumcision of a child under 6 months) was $46.50; the fee for item number 30656 (circumcision of a child from 6 months but under 10 years) the fee was $108.15; for item number 30659 (circumcision of a male 10 years of age or over by a GP) the fee was $127.30; for item number 30660 (circumcision of a male 10 years of age or over by a specialist) the fee was $139.20
Were these fees still current in October 2016?
“The table provided in your email outlines the Fee, in-hospital benefit payable (75%) and out of hospital benefit amount payable (85%) for the item. The fees for these items in October 2016 were as follows:
30653 $46.50
30656 $108.15
30659 $149.75
30660 $185.60
As indicated above, the benefit payable for the service is determined by the hospital status of the patient. Services provided to an admitted patient receive benefits at 75% of the fee for the item. Non-admitted patients receive benefits at 85% of the fee for the item.”
6. According to the latest schedule of fees, there are now only two items for circumcision (a) for item number 30654 (circumcision of the penis) when a nerve block or anaesthetic is NOT being used) the fee is $46.50; (b) for item number 30658 (circumcision of the penis, when performed in conjunction with a regional or field nerve block or anaesthetics) the fee is $142.
Does this mean that males can be circumcised without any form of pain relief?
Does this mean that general practitioners are now being paid a lot more for circumcisions when pain relief is used?
7. Does this web page mean that item 30654 cost the taxpayer over half a million dollars in 2016-17?
“Correct, this report does indicate that the total amount of benefits assigned for item 30654 in the 2016-17 financial year was $525,877.”
8. Does this web page mean that item 30658 cost the taxpayer almost $700,000 in 2016-17?
“Correct, this report does indicate that the total amount of benefits assigned for item 30658 in the 2016-17 financial year was $697,927.”
The page referred to is a table from a longer document, MBS Reviews Paediatric Services Male Circumcision Services: Review Report, by Robyn Lambert, Yasoba Atukorale, Alun Cameron, David Tivey, published by the Department of Health in July 2014. This appears to be a review of circumcision practices in Australia, with particular reference to the rebates available from Medicare; but it confesses that it was not able to find much information about Australian circumcision practices, and it has a very limited bibliography that contains nothing on the bioethical, human rights and legal aspects of the question. The paper makes no recommendations, except that “further study needed”.
The paper does, however, contain much useful factual information on the number of boys being circumcised up until 2012, the identity of the operators (GPs, ObGyns, surgeons etc) and the associated costs to the public. Full text available here.
Medicare must not pay for medically unnecessary circumcision
Medicare should not cover non-therapeutic circumcision: Submission to Medical Services Review, 2015
[ Back to Top ]