Access Consequences of Restricting Mohs Micrographic Surgery to Fellowship-Trained Surgeons: A National Workforce, Board-Certification, and Drive-Time Simulation Study

Background

Policies restricting Mohs micrographic surgery (MMS) to only fellowship-trained (FT) surgeons — 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 workforce, board-certification, geographic, and patient-access consequences of restricting MMS to only fellowship-trained surgeons.

Methods

Cross-sectional analysis of all Medicare MMS billers (2020-2024; n=3,451), classified FT versus R/P-trained by complete ACMS directory linkage (the definition of prior national analyses; audited); linkage to American Board of Dermatology Micrographic Dermatologic Surgery (MDS) certification records; county/market access classes; road-network drive-time simulation of R/P-trained exclusion against CMS network-adequacy standards; fellowship-pipeline replacement modeling.

Results

R/P-trained surgeons were 45.3% of the 2024 workforce, 55.6% held MDS certification, and they supplied 52.1% of nonmetropolitan MMS volume. In 223 counties (23.4 million residents) they were the only Mohs surgeons. Simulated exclusion pushed 15.6 million more people beyond 60 minutes’ drive and 23.1 million out of CMS dermatology time-and-distance standards, disproportionately rural (3.2×). Pipeline replacement of rural capacity would require approximately 21 years. Absorbing the displaced volume (353,736 Medicare cases/year, 88% metropolitan) would require surviving surgeons to raise volume by 45.5%; even if every surviving surgeon took on 20% more cases, 211,848 cases/year would have no slot, and at 50% more, when national capacity would suffice, 94,982 would still remain beyond the reach of any surgeon with room because of the workforce’s geographic distribution — implying longer waits and stranded patients in metropolitan and rural areas alike. All findings were robust to the audited misclassification error of the training-pathway definition.

Limitations

Medicare fee-for-service claims; directory-based training-pathway classification, audited and adjusted.

Conclusion

A fellowship-only restriction — for example, a fellowship-gated qualification for directing the laboratories in which Mohs frozen sections are examined — would bar R/P-trained surgeons from directing the Mohs laboratories where they operate and would produce large, geographically concentrated access losses, borne disproportionately by rural America, without demonstrated quality benefit. Workforce policy should instead expand every route into Mohs surgery — more fellowship positions, stronger Mohs training within dermatology residency, practice-based training that certifying boards and payers continue to recognize, and a reopened practice pathway to MDS certification — while keeping regulatory eligibility keyed to primary dermatology board certification, which both pathways share.

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’ own 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’s own coverage policy already does.