Bae, Gordon Hyeonjin

Abstract Mohs Surgery from 2016 to 2022: Declining Medicaid Reimbursement and ACA Expansion Impact Mohs micrographic surgery (MMS) is the standard of care for many nonmelanoma skin cancers, yet access remains highly variable due to low reimbursement rates. Only 39.5% of Mohs surgeons nationally accept Medicaid. While the Affordable Care Act (ACA) Medicaid expansion improved coverage for low-income adults, its effects on dermatologic reimbursement remain unclear. This study provides the first comprehensive analysis of inflation-adjusted Medicaid reimbursement trends for MMS and determines whether ACA Medicaid expansion translated into improved payment rates. Average physician reimbursement per patient for MMS procedures (CPT codes 17311–17314) from 2016 to 2022 was extracted from a large insurance claims database and adjusted for inflation to 2022 U.S. dollars. States were categorized by Medicaid expansion status, and linear regression assessed reimbursement trends. Between 2016 and 2022, national weighted average reimbursement for MMS first stage (CPT 17311) declined 18.33%, while MMS additional stages (CPT 17312) decreased 25.52% (p = 0.0182). When stratified by expansion status, CPT 17311 reimbursement declined − 5.71% in expansion states versus increasing + 5.80% in non-expansion states (p = 0.00121). Reimbursement for non-high-risk anatomic areas declined 26.10% and 32.6%, respectively. Inflation-adjusted Medicaid payments for MMS declined substantially from 2016 to 2022, with greater reductions in Medicaid expansion states. While ACA expansion increased coverage, it introduced financial pressures through lower fee schedules, potentially threatening physician participation and access to essential dermatologic surgery for vulnerable populations.

Importance: Dermoscopy is increasingly recognized by skin cancer experts and professional leaders as an essential skill for physicians in dermatology and primary care. A substantial number of patients in both settings also receive care from physician assistants (PAs), who provide additional opportunities to evaluate patients with concerning skin lesions. Earning dermatology-specific credentials from the National Commission on Certification for PAs requires passing a written exam with dermoscopic content, and 77% of practicing PAs (all specialties) believe dermoscopy should be a standard element of their formal education. No published studies have identified precise learning objectives that would represent appropriate foundational proficiency in dermoscopy for PAs. Objective: We sought to identify common diagnoses with distinct dermoscopic features and delineate which of these represent appropriate proficiency expectations for early-career PAs in primary care and dermatology. Design, setting, and participants: A panel of 14 dermoscopists was assembled (8 dermatologists; 6 PAs), reflecting contributors to existing consensus statements on physician dermoscopy proficiency benchmarks, dermatologist-recommended competencies for PAs, and/or standardized test content for dermatology PAs. Panelists completed a modified Delphi consensus process involving electronic surveys and roundtable discussions. Main outcomes and measures: Consensus on which specific dermoscopic diagnoses reflect appropriate foundational proficiency expectations for PAs in both primary care and dermatology. Results: Twelve of 14 panelists (86%) reported using dermoscopy for over 12 years (mean: 15.5 y). All panelists completed 2 iterations of an electronic survey regarding 54 diagnoses, with 39 (72%) reaching a final consensus for inclusion in PA curricula and 15 (28%) being identified as non-priority items for early-career PAs. Panelists recommended 14 conditions for primary care PAs and 25 conditions for dermatology PAs. Conclusions and Relevance: Consensus achieved in this modified Delphi process identified diagnoses that represent pragmatic learning objectives to achieve foundational proficiency in dermoscopy for PAs in both primary care and dermatology. This list of validated objectives provides a consensus-based guide to help educators, supervising physicians, and professional leaders to cultivate specialty-appropriate dermoscopic proficiency among early-career PAs.