Mohs surgeons wrestle with increasing skin cancer rates, scrutiny by insurers

Key Points

National report - Mohs surgeons are facing rising skin cancer rates, along with concerns about healthcare reform and controversial changes in credentialing, sources say.

The American Cancer Society estimates that U.S. physicians diagnose more than 1 million basal cell and squamous cell carcinomas yearly.

However, a recent study combined multiple government databases to estimate the total number of nonmelanoma skin cancers (NMSCs) diagnosed in the U.S. population in 2006 at 3.5 million, prompting its authors to declare skin cancer an "under-recognized epidemic (Rogers HW, Weinstock MA, Harris AR, et al. Arch Dermatol. 2010;146(3):283-287)."

"Every Mohs surgeon I know is busy," Dr. Portnoff says.

With a 99 percent cure rate for new NMSCs, he adds, Mohs surgery is the best treatment for these cancers. "But the more Mohs surgery we do, the more scrutiny we get from Medicare and other insurers" concerned about overutilization.

That has brought increased scrutiny.

As in any field, Dr. Dzubow says, "There's a group of people who perhaps inappropriately utilize the procedure when it isn't necessary. This excessive utilization will eventually attract attention from the powers that be."

Accreditation, certification

Meanwhile, the American Board of Dermatology (ABD) continues to wrestle with a possible sub-certification exam for procedural dermatology that the organization proposed in 2008.

Organizations that have publicly opposed the proposal include the ASMS, the American Academy of Dermatology and the American Society for Dermatologic Surgery. The ACMS, which requires members to complete a one- to two-year fellowship, supports the plan.

Based on ABD criteria, Dr. Portnoff says, "Most dermatology residents are supposed to be proficient in the very things that are in this new certification. It's unnecessary, and it will create an extra certification that insurers or others may use to discriminate among providers."

The ABD held a retreat in June to seek input from state, national and other dermatologic societies, but declined to comment on the meeting's results until publication of its October newsletter.

Meanwhile, the credentialing path for Mohs surgery is changing. Until June, the ACMS oversaw 41 Mohs fellowships it had approved, Dr. Dzubow says. However, "Over the last year, we have relinquished control of the fellowship programs to the American College of Graduate Medical Education (ACGME)," which now accredits these fellowships, he says.

The ACGME also accredits 44 procedural dermatology fellowships it has approved. These are one-year programs that build on the experience gained in a two-year dermatology residency and provide additional surgical training, according to the ABD.

As an alternative to the ACGME path, physicians can still become ASMS members without completing formal fellowships.