Access Consequences of Restricting Mohs Micrographic Surgery to Fellowship-Trained Surgeons: A National Workforce, Board-Certification, and Drive-Time Simulation Study
Year: 2026
Type: preprint
Study design: Observational Study
Abstract: ABSTRACT Background Policies restricting Mohs micrographic surgery (MMS) to only fellowship-trained (FT) surgeons, whether through privileging standards, laboratory-director qualifications, or payer credentialing, would bar residency/practice-trained (R/P-trained) surgeons from MMS. The access consequences have not been quantified. Objective To quantify the access consequences of restricting MMS to only FT surgeons. Methods Cross-sectional analysis of all Medicare MMS billers (2020-2024), classified FT or R/P-trained by audited American College of Mohs Surgery directory linkage and linked to Micrographic Dermatologic Surgery (MDS) certification; drive-time simulation of R/P-trained exclusion against the Centers for Medicare & Medicaid Services (CMS) dermatology access standard; fellowship-pipeline replacement modeling; and projection of rural Mohs capacity needed through 2041. Results R/P-trained surgeons were 45.3% of the 2024 workforce (55.6% MDS-certified), supplied 52.1% of nonmetropolitan MMS volume, and were the only Mohs surgeons in 223 counties. On the specialty’s quality measure, stages per case, the pathways were indistinguishable (median 1.5 in both). Excluding R/P-trained surgeons would put 23.1 million people newly outside the CMS dermatology access standard, with nonmetropolitan drive times rising by 3.2 times the metropolitan increase. R/P-trained surgeons perform 353,736 Medicare cases a year, and the remaining surgeons could not care for all of the displaced patients even at 50% higher caseloads. With R/P-trained surgeons grandfathered, 114 counties would still lose in-county access by 2041. At present, rural access falls 323 surgeons short of the CMS standard. Closing that shortfall by 2041 would take about 77 new rural Mohs surgeons a year, four times today’s entry rate. Limitations Fee-for-service claims; directory-based classification, audited and adjusted; no clinical outcomes. Conclusion A fellowship-only restriction would produce large access losses, geographically concentrated and disproportionately rural, and the fellowship pipeline could not replace the excluded surgeons in the counties that would lose them. The workforce loss would affect both metropolitan and nonmetropolitan patients, but with far more severe consequences for nonmetropolitan residents. Access to Mohs surgery rests on both training pathways. Policy should expand every route into Mohs surgery, through more fellowship positions, stronger Mohs training within dermatology residency, and a reopened practice pathway to MDS certification, and should keep laboratory-director and network eligibility keyed to the primary dermatology board certification common to both pathways. CAPSULE SUMMARY Privileging, CLIA laboratory-directorship, and payer credentialing policies could restrict Mohs surgery to only fellowship-trained surgeons; the workforce literature had not quantified the access consequences. Excluding residency/practice-trained surgeons would disproportionately affect nonmetropolitan patients, leave 223 counties without in-county Mohs access, push 23 million people outside the Centers for Medicare & Medicaid Services’ dermatology access standards, and displace roughly 212,000 cases per year that the remaining workforce could not absorb, lengthening waits in urban and rural areas alike; access policy should treat the two pathways as coequal routes into Mohs surgery, as Medicare coverage policy already does.
Source: medRxiv
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7213307016