Gaps in phototherapy and Mohs surgery access: A cross-sectional survey of dermatology residency programs in the United States

To the Editor: Access to dermatologic care remains challenging, with essential therapies like phototherapy and Mohs surgery (Mohs) inaccessible for some.¹ Our study examined the availability of these services across County/Federally Qualified Health Centers (FQHCs), Veterans Affairs (VAs) hospitals, and Flagship/Faculty clinics within dermatology residency programs.

Following IRB approval, we distributed a REDCap survey to faculty at 143 ACGME-accredited dermatology residency programs using the Association of Professors of Dermatology listserv and publicly available emails. Using JMP software (JMP Statistical Discovery LLC), logistic regression was performed to compare therapy availability and Medicaid acceptance.

Eighty-eight programs responded (62% response rate); 32%, 61%, and 93% reported County/FQHC, VA, and Flagship/Faculty sites, respectively.

Phototherapy was available at 99% of Flagship/Faculty sites, compared to 65% of VA and 61% of County/FQHC (P < .001, Table I). All County/FQHC sites offering phototherapy accepted Medicaid, whereas 5 Flagship/Faculty sites (6%) did not—four of which had no Medicaid-accepting sites (P = .16). When phototherapy was unavailable, 55% of sites referred patients to another residency clinic, while 60% of County/FQHCs modified treatment to include topical or systemic agents. Barriers included financial constraints (27%), space limitations (26%), insufficient faculty (15%), and patient travel distance (8%).

Table I.

Phototherapy survey results from 88 ACGME^∗-accredited dermatology residency programs

	County/FQHC† (N (%))	VA‡ (N (%))	Flagship/faculty (N (%))	P value
# of hospitals (MS§)	28 (32)	54 (61)	82 (93)	N/A‖
Offers phototherapy
Yes	17 (61)	35 (65)	81 (99)	<.001
No	10 (36)	11 (20)	1 (1)
I don’t know	1 (4)	8 (15)	0 (0)	N/A
If phototherapy is offered, accepts Medicaid?
Yes	17 (100)	N/A	76 (94)	.16
No	0 (0)	N/A	5 (6)
I don’t know	0 (0)	N/A	0 (0)	N/A
If no phototherapy, next step? (MS)
Redirect to a site within residency program	5 (50)	7 (64)	0 (0)	N/A
Redirect to site outside residency program	1 (10)	1 (9)	1 (100)	N/A
Alter therapy in other ways (free response)	6 (60)	3 (27)	0 (0)	N/A
	Topical (1) Systemic (2) Other (3)	Topical (1) Systemic (1)	N/A	N/A
I don’t know	0 (0)	3 (27)	0 (0)	N/A
Barriers in offering phototherapy (MS)
Room/Space availability	23 (26)			N/A
Financial (ie lack of Medicaid contract, low reimbursement rates, start-up costs)	24 (27)
Lack of support from leadership	5 (6)
Lack of faculty or support staff to oversee or administer treatments	13 (15)
N/A as all of my practice settings offer phototherapy	54 (61)
Free response (number of responses denoted adjacently)	Barriers to phototherapy: Space (7), Staffing (7), Patient distance (7), Broken phototherapy machine/no machine (2), Insurance co-pays (2), Not having complementary photosensitizer (1) How to overcome: Overcoming by referrals (5), Overall trying to improve access (2), Forming formal business plan that includes referral for biologics or other 340b drugs (1), Having insurance contracts to waive copays (1), Overcoming by having better home phototherapy options (1)			N/A

^∗Accreditation Council for Graduate Medical Education.

^†Federally Qualified Health Centers.

^‡Veterans Affairs Hospital.

^§Multiple selection.

^‖Not applicable.

Similar gaps were observed for Mohs access, with availabilities of 91%, 53%, and 43% at Flagship/Faculty, VA, and County/FQHC sites, respectively (P < .001, Table II). All County/FQHC sites with Mohs accepted Medicaid, while 6 Flagship/Faculty sites (8%) did not—4 of those lacked any Medicaid-accepting sites (P = .17). Respondents were allowed to select multiple options to reflect real-world practice of offering several therapies. When first-line Mohs was unavailable, 25% of responders at County/FQHC sites and 36% responders at VA sites offered excisions. Among County/FQHC responders who offered excision, 2 did not select either internal or external referrals as alternatives, whereas all VA responders who offered excision also provided referrals. Reported barriers included space limitations (30%) and limited faculty (26%).

Table II.

Mohs surgery survey results from 88 ACGME^∗-accredited dermatology residency programs

	County/FQHC† (N (%))	VA‡ (N (%))	Flagship (N (%))	P value
# of hospitals (MS§)	28 (32)	54 (61)	82 (93)	N/A‖
Offers Mohs surgery
Yes	12 (43)	29 (54)	75 (91)	<.001
No	16 (57)	25 (46)	7 (9)
I don’t know	0 (0)	0 (0)	0 (0)	N/A
If Mohs surgery is offered, accepts Medicaid?
Yes	12 (100)	N/A	69 (92)	.17
No	0 (0)	N/A	6 (8)
I don’t know	0 (0)	N/A	0 (0)	N/A
If no Mohs surgery, next step? (MS)
Redirect to a site within residency program	10 (63)	23 (92)	5 (71)	N/A
Redirect to site outside residency program	4 (25)	16 (64)	4 (57)	N/A
Offer excision	4 (25)	9 (36)	1 (1)	N/A
Alter therapy in other ways (free response)	0 (0)	2 (8)	1	N/A
	N/A	Slow Mohs (1) Other (1)	N/A	N/A
I don’t know	0 (0)	0 (0)	0 (0)	N/A
Barriers in offering Mohs surgery (MS)
Room/Space availability	26 (30)			N/A
Financial (ie lack of Medicaid contract, low reimbursement rates, start-up costs)	16 (18)
Lack of support from leadership	8 (9)
Lack of certified Mohs lab	16 (18)
Lack of faculty to support Mohs services	23 (26)
N/A as all of my practice settings offer Mohs surgery	43 (49)
Free response (number of responses denoted adjacently)	Barriers to Mohs surgery: Lack of staff (histotech (2), surgeons (7)), Hiring surgeons to academic practices vs private is challenging due to salary differences (1), Salary is not competitive enough for surgeons (1), Rely on voluntary faculty (1), Cost (3), Limited space (2), Equipment, no lab (2), Lack of leadership support (1), Hospital compliance rules that render workflow too inefficient (1) How to overcome: Overcoming by referrals (6), Overall trying to improve access (4), and Overcoming by hiring surgeons (1)			N/A

^∗Accreditation Council for Graduate Medical Education.

^†Federally Qualified Health Centers.

^‡Veterans Affairs Hospital.

^§Multiple selection.

^‖Not applicable.

These findings highlight gaps in phototherapy and Mohs access at County/FQHC and VA hospitals. Notably, substituting Mohs with excision for high-risk keratinocyte carcinomas may be suboptimal given Mohs reduces recurrences and disease-specific mortality, particularly in high-risk sites.² Furthermore, substituting phototherapy with systemic agents may increase adverse effects. Beyond patient care, these access gaps may also impact resident training by reducing exposure to therapies. However, despite differences in site availability of phototherapy and Mohs, it is encouraging that Medicaid was widely accepted (>92%) at sites offering these therapies.

Addressing barriers and identifying effective alternatives are important for optimizing care and residency education. While space limitations may be challenging to overcome, other barriers, including faculty recruitment and improved referral systems, may be modifiable.³ While home phototherapy and, less commonly, commercial tanning beds have been explored as alternatives to in-office phototherapy, limited insurance coverage for home devices and safety concerns regarding tanning beds necessitate cautious consideration.^4,5 Phototherapy and Mohs, essential treatments, may not be readily accessible to all; therefore, continuing to maintain high Medicaid acceptance rates, alongside further research to address these structural barriers, will be critical to optimizing access to these therapies.

Conflicts of interest

None disclosed.