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Mayo Clinic Health System Franciscan Healthcare

Amid the universal demand to cut health care costs, a La Crosse pediatrician advocates a baby step that would trim more than $1 million a year: train nurse practitioners to do circumcisions.

The change wouldn’t lower patient bills immediately but would improve efficiency in other hospital departments as well, said Dr. Dennis Costakos, neonatology chairman at Mayo Clinic Health System-Franciscan Healthcare.

“This is a free-market solution,” Costakos said in an interview. “When we increase the numbers doing it, the costs accelerate slower.”

Costakos’ conclusions emerge from an unprecedented 10-month study he conducted with a registered nurse and several neonatal nurse practitioners, or NNPs, in which physicians trained the NNPs to do circumcisions and the practitioners performed the surgery on 198 babies born at Mayo-Franciscan during that period.

Mayo-Franciscan became perhaps the only place in the country where nurse practitioners do the procedure. The protocol at Gundersen Health System enlists pediatricians for the procedure, according to a Gundersen official

Mayo-Franciscan’s duty-shuffling carries a couple of advantages, Costakos said:

  • At Mayo-Franciscan, NNPs are on duty 24 hours a day, so they are readily available to do circumcisions any time of the day or night, as opposed to the extra expense of calling in or waiting for a physician to do the procedure. That sometimes can result in earlier releases, which could lower a patient’s charge.
  • When nurse practitioners circumcise baby boys, doctors are freed up to care for other patients — boosting a hospital’s efficiency through better use of personnel.

The study, published in the November issue of Neonatology Today, lists the charge for a circumcision — regardless of whether insurance or another source pays — as $1,035.75, broken down as $340 for the hospital and $695.75 in professional fees.

It cites hourly compensation for each health care specialty as:

  • $53.74 for a neonatal nurse practitioner.
  • $94.41 for a pediatrician.
  • $115.65 for a family practitioner.
  • $140.38 for a neonatologist.
  • $167.16 for an obstetrician.
  • $247.96 for a urologist.

Thus, enlisting nurse practitioners to do circumcisions would reduce professional salary expenses for the procedure two to nine times, according to Costakos’ findings.

Circumcision is a high-demand surgery in the Coulee Region, running at about 80 percent, while studies indicate that it dips as low as 30 percent in some regions. Globally, infants in some countries, such as Denmark and Brazil, rarely are circumcised, while others, such as South Korea, have shifted from a rate of 85 percent uncircumcised to 85 percent circumcised.

In the United States, the circumcision rate for newborns dipped from 83 percent in the 1960s to 77 percent in 2010, according to the federal Centers for Disease Control and Prevention, which also reports that the overall rate for U.S. males ages 14 to 59 is 81 percent.

Meanwhile, groups such as Mothers Against Circumcision insist that the rate is declining and now is around 33 percent.

If every hospital in the United States switched to using NNPs instead of other professionals, professional fees could be reduced by $105 million over a decade, assuming 1.1 million newborn circumcisions a year, said Costakos, who also is an assistant professor at the Mayo Clinic College of Medicine in Rochester, Minn.

Although a layman logically might expect the bills for parents of newborn boys to drop overnight with such reductions in overhead, that wouldn’t be the case, Costakos said.

Rather, at least initially, the savings would result in slower price increases and spreading the savings to other departments and/or procedures, he said.

“The market catches up eventually, and it would be a free market solution,” Costakos said. “It’s like the big, expensive TVs that are cheaper now — eventually, the savings spread.”

The personnel shift also has health implications in areas where risk rates for contracting the human immunodeficiency virus, as well as other sexually transmitted diseases, are higher, he said, adding that that is not a major concern in the Coulee Region.

Studies indicate that the lifetime risk of HIV among circumcised heterosexual males decreased by 16 percent, and two trials found that contraction of herpes simplex virus type 2 and the human papillomavirus dropped by one-third.

“This may be the first surgery to decrease infection,” Costakos said. “If you could discover a vaccine that could do the same thing with infection as circumcision, you would be a rich person.”

In the long run, curbing infection also helps the bottom line, with Costakos observing, “You get more bang out of the buck,” reducing infections as well as health care costs.

Circumcision also is known to lower the risk of penile cancer, decrease the possibility of urinary tract infections during the first year of life and prevention of foreskin infections, Costakos said.

Circumcision, which is not considered a necessary surgery, although some religions such as Judaism and Islam traditionally require it, has its detractors — some of whom dismiss it as cosmetic.

The cosmetic contention is one reason some insurers and even Medicaid don’t cover the procedure, Costakos said.

His study cites a review that found private insurance paid for 61 percent, Medicaid covered 36 percent and parents, 3 percent. Medicaid in Wisconsin covers the procedure, while Medicaid programs in 18 states, including Minnesota, do not cover it.

Circumcision rates in states where Medicaid covers the procedure are nearly 70 percent, compared with 31 percent in states where Medicaid doesn’t cover it, Costakos’ study found.

The CDC, reflecting on the fact that such restrictions make the procedure unaffordable to many low-income families, contends that populations that might benefit the most are denied access. Although the procedure carries risks in a very low percentage of cases, the American Academy of Pediatrics’ most recent policy statement on the issue, in 2012, states: “Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweighs the risks and the procedure’s benefits justify access to this procedure for families who choose it.”

The CDC echoes that sentiment in guidelines published in 2014.

Groups such as Intact America and Mothers Against Circumcision reject the procedure as not only unnecessary but also one that is barbaric and inflicted upon someone too young to grant consent.

On the other hand, postponing it until teen years or adulthood has the disadvantage of making it more complicated.

Costakos has high hopes for training neonatal nurse practitioners to perform the procedure, saying, “We hope to be a model for the nation. This is a very Franciscan change.”



Mike Tighe is the Tribune newsroom's senior citizen. That said, he don't get no respect from the cub reporters as he goes about his duly-appointed rounds on the health, religion and whatever-else-lands-in-his-inbox beats. Call him at 608-791-8446.

(28) comments


Save even more money: Have the nurse-practioners work for tips.


This article failed to consider using zero-based budgeting for assessing the costs of continuing an unnecessary surgery. All costs for doing infant circumcisions and all the additional and substantial costs of treating circumcision complications and botches can be eliminated entirely by simply leaving boys intact and allowing them to decide for themselves how much of their male members they want to keep when they reach the age of majority.

Deferring until the boy can decide for himself is not only the most cost effective choice, it’s the only ethical choice. It’s the boy’s body after all and the right to decide about unnecessary alteration to it belongs to entirely and solely to him.

US healthcare outcome statistics[1] show that very few (


(continued from above)
US healthcare outcome statistics[1] show that very few (


[resubmitted after replacing apparently problematic less-than sign character]

This article failed to consider using zero-based budgeting for assessing the costs of continuing an unnecessary surgery. All costs for doing infant circumcisions and all the additional and substantial costs of treating circumcision complications and botches can be eliminated entirely by simply leaving boys intact and allowing them to decide for themselves how much of their male members they want to keep when they reach the age of majority.

Deferring until the boy can decide for himself is not only the most cost effective choice, it’s the only ethical choice. It’s the boy’s body after all and the right to decide about unnecessary alteration to it belongs to entirely and solely to him.

US healthcare outcome statistics[1] show that very few (less than 1%) of circumcisions are done to people who are able to refuse. Nearly all circumcisions are forced amputations inflicted on someone too young say the word no. It should not come as a surprise that when given the choice, men almost always choose to keep their entire male member. It’s unethical and grotesque to unnecessarily alter someone’s body knowing they he almost certainly would not choose such alteration for himself.

This article also failed to note that the claims of health benefits are contested and insufficient in any case to warrant surgery. This is especially true since the person affected is healthy, non-consenting, and unable to voice a complaint. This is the assessment of the world’s leading pediatricians as published in the April 2013 issue of the American Academy of Pediatrics journal, Pediatrics.[2]

This article also failed to note the glaring conflict of interest for hospitals and physicians who to stand to gain both from soliciting unnecessary surgery on non-consenting minors and selling the tissue removed from them, while overstating the benefits, failing to disclose the harms, and failing to disclose to parents that their son would almost certainly not choose this surgery for himself.

Finally, this article failed to note that this hospital is associated with a Catholic order and Catholic thinkers are increasingly finding infant circumcision to be morally unacceptable.[3] The imperative for Mayo-Franciscan isn’t to make the mutilation of infant genitals more available, it’s to banish it.

[1] Source: Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality: Outcomes for CCS principle procedure category: 115 Circumcision.


Circumcision alters sex dramatically. Informed adults can decide for themselves.


Childhood circumcision already has unacceptably haphazard outcomes. Cosmetic surgery on the genitals of a person too young to give informed consent or fight back is obscenely unethical.


quit doing them. problem solved. duh.


Couldn't care less about this subject, as long as it's left to parents to decide. The day the government has a say in this is the day I might lead a revolution, however.


The government already made it illegal even to make a pinprick on a girl's genitals. Why don't boys get the same protection? Why shouldn't a male be able to decide for themselves whether or not they have irreversible surgery on their genitals. His body, his decision.


Why the parents? They don't get to use the part in question. Why not the owner, who does, when he is old enough to decide for himself? If he's allowed to, he'll almost always choose to keep it all, which ought to tell you something.

There are plenty of other cases where the law ("the government") protects children from parents who want to treat their bodies as property. The most obvious analogy is female genital cutting (regardless of severity, motivation, hygiene or anything else, it's outlawed outright, so don't say it's "completely different").

Grand Dad's Bluff

Thanks for the tip.....


Think of how much money would be saved by eliminating this genital mutilation altogether!


I thought liberal extremists were all for genital mutilation and alterations? Seriously. Sex changes are encouraged but circumcisions should be outlawed? Taking the hypocrisy to all new heights.


You can get your breasts enhanced, your labia pierced or transition to a man and I wouldn't care in the least. But genital mutilation of children who have no choice in the matter is immoral and medically pointless.


It's about people being allowed to decide for themselves about their own body. Nothing hypocritical about that.


only yours

Union Man

I think Costakos has been getting a cheap trim job by a practitioner, 10 bucks he's republicon


It is an unnatural, unnecessary and expensive mutilation. Stop it. Some countries even do this to females.


First off, circumcisions need to die the way of the lobotomy, and secondly, if there is a true medical need for the procedure, you want the most trained person there is to perform it. 100 baby boys die every single year from doctors botching this unnecessary procedure. Absolutely should not have nurses doing it.

Women have a higher risk of mastitis and cancer yet we don't routinely cut out the offending tissue of newborn babies to try to prevent those infections. That's just crazy! Yet we are applying that very logic to boys body parts.


"...the savings would result in slower price increases and spreading the savings to other departments and/or procedures, he said." What a crock...


cut the thing...looks like an eelpout otherwise


Yeah? Sounds like you have a lot of experience.


You have a vivid imagination. Who cares what it looks like? When it's doing its job you can't see it.
And the only person with any right to change its appearance or its function is its owner, when he's old enough to decide for himself.


This is what some national medical organizations say about infant male circumcision:

Canadian Paediatric Society
"OTTAWA— In an updated statement released today, the Canadian Paediatric Society (CPS) continues to recommend against the routine circumcision of newborn males."

Royal Australasian College of Physicians
"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."
(almost all the men responsible for this statement will be circumcised themselves, as the male circumcision rate in Australia in 1950 was about 90%. "Routine" circumcision is now *banned* in public hospitals in Australia.)

British Medical Association
"to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate."
"The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."

Danish Medical Association
"The Danish Medical Association (Lægeforeningen) has recommended that no boys under the age of 18 be circumcised in Denmark.
The association released its recommendation on Friday, saying that circumcision should be “an informed, personal choice” that young men should make for themselves."

The Royal Dutch Medical Association
"The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children's rights to autonomy and physical integrity."

Swedish Paediatric Society
"Circumcision of young boys for religious and non-medical reasons ought to be banned in Sweden, urged the Swedish Paediatric Society (Svenska barnläkarföreningen, BLF)."

Mexican Secretariat of the Interior
"Evitar como práctica rutinaria la circuncisión, toda vez que no existe evidencia científica que compruebe un beneficio directo a la persona recién nacida."
Sec 5.7.13 "Avoid circumcision as a routine practice, since there is no scientific evidence to prove a direct benefit to the newborn person."
"[30 September 2013] - At a meeting today in Oslo, the children's ombudspersons from the five Nordic countries (Sweden, Norway, Finland, Denmark, and Iceland), and the children's spokesperson from Greenland, in addition to representatives of associations of Nordic paediatricians and pediatric surgeons, have agreed to work with their respective national governments to achieve a ban on non-therapeutic circumcision of underage boys."

German Pediatric Association
(very long, but very much against circumcision, and includes the following)
"Therefore it is not understandable that circumcision of boys should be allowed but that of girls prohibited worldwide. Male circumcision is basically comparable with FGM types Ia and Ib that the Schafi Islamic school of law supports"


How about we stop doing it altogether? Research, people. This is a cruel way to welcome newborns into the world. Let them decide for themselves. If your excuse is to "so it when they don't remember", don't you dare think infants don't feel pain. This puts a shock on their system and the babies are often too stunned to cry. It is not common in many other countries and we need to stop making money off this unnecessary cosmetic surgery. Yes, cosmetic. Whether you believe in God or not, babies are not born with "an extra part they don't need". PLEASE do your research before you remove those most sensitive areas from your perfect baby boy. 117 annual deaths in the United States each year from this surgery. That is way too many, folks!


It has been my experience that appointments or procedures with a Nurse Practitioner is not reflected in the billing. I understand that the medical facility saves money by paying the practitioner less than a MD but the patient is charged as if they were seen by an MD.

If the cost saving argument is that the facility can cut down operating costs using a trickle down model, they are still charginng the patient for services not rendered. This article would have more meat, pun not intended, if the doctor would have given us a cost comparison between procedure done by an MD versus a NP.


I like your trickle down part.


I agree, my grandkids see a Nurse Practitioner, yet his parents are still billed the same rate as a pediatrician.

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