Association between state-specific reimbursement and Medicaid acceptance for Mohs micrographic surgery

Abstract

To the Editor: Medicaid patients face considerable barriers to dermatologic care and suffer worse outcomes.1Mazmudar R.S. Gupta N. Desai B.J. Bordeaux J.S. Scott J.F. Dermatologist appointment access and waiting times: A comparative study of insurance types.J Am Acad Dermatol. 2020; 83: 1468-1470Google Scholar, 2Creadore A. Desai S. Li S.J. et al.Insurance acceptance, appointment wait time, and dermatologist access across practice types in the US.JAMA Dermatol. 2021; 157: 181-188Google Scholar, 3Alghothani L. Jacks S.K. Vander Horst A. Zirwas M.J. Disparities in access to dermatologic care according to insurance type.Arch Dermatol. 2012; 148: 956-957Google Scholar, 4Abdel-Rahman O. Prognostic impact of socioeconomic status among patients with malignant melanoma of the skin: a population-based study.J Dermatolog Treat. 2020; 31: 571-575Google Scholar Mohs micrographic surgery (MMS) is the preferred treatment for many skin cancers, and its demand in the Medicaid population has increased alongside the incidence of skin cancers. Understanding the factors that influence Medicaid acceptance among Mohs surgeons is important to improve access and minimize health disparities in this population. In this cross-sectional analysis of Mohs surgeons in the United States, we sought to determine if state-specific Medicaid reimbursement for MMS was associated with Medicaid acceptance. Physicians billing more than 10 MMS procedures based on the 2017 Medicare Provider Utilization Data, as well as MMS fellowship graduates from 2017 to 2020, were included. We determined Medicaid acceptance status by utilizing state-specific Medicaid directories and calling physician practices to verify acceptance. State-specific Medicaid and Medicare reimbursement rates for MMS Current Procedural Terminology (CPT) codes 17311-17314 were compiled from publicly-available fee schedules. Medicaid-to-Medicare ratios for each CPT code were used to enable relative comparisons across fees.5Zuckerman S. Laura S. Marni E. Medicaid physician fees after the ACA primary care fee bump. Urban Institute, 2017https://www.urban.org/sites/default/files/publication/88836/2001180-medicaid-physician-fees-after-the-aca-primary-care-fee-bump_0.pdfDate accessed: December 20, 2021Google Scholar Linear regressions were performed to assess the relationship between fee ratios and the proportion of Medicaid acceptance in each state. Medicaid acceptance by Mohs surgeons varied considerably between states. Many states in the Mountain and West North Central divisions had high Medicaid-to-Medicare fee ratios and Medicaid acceptance rates. However, several East South Central, and South Atlantic states had lower Medicaid acceptance rates despite having high fee ratios (Fig 1). Across all states, the correlation between fee ratios for all MMS procedures (CPT 17311–17314) and Medicaid acceptance was weak (r2 = 0.087) but significant (P = .036). The specific correlation between MMS of the trunk and extremities (CPT 17313–17314) and Medicaid acceptance reached significance (P = .029), whereas that for MMS of the head and neck (CPT 17311–17312) did not (P = .054) (Fig 2).Fig 2Linear regressions of state-specific Medicaid-to-Medicare fee ratios and statewide Medicaid acceptance rates. Linear regressions were generated using (A) mean fee ratio for Current Procedural Terminology (CPT) codes 17311–17312, (B) mean fee ratio for CPT codes 17313–17314, and (C) mean fee ratio of CPT codes 17311–17314. States are represented by individual points.View Large Image Figure ViewerDownload Hi-res image Download (PPT) These results suggest that reimbursement is not overall a reliable predictor of Medicaid acceptance and poorly explains the variation in Medicaid acceptance among Mohs surgeons. However, the significant relationship between reimbursement and Medicaid acceptance in certain MMS code combinations, including all codes combined, suggests that reimbursement may influence acceptance in certain scenarios. Such weak correlations could be explained by the various factors impacting Medicaid acceptance, including physician and practice characteristics and state Medicaid expansion. High Medicaid acceptance may exist in areas with relatively modest reimbursement, such as academic medical centers and hospitals requiring Medicaid acceptance. Enrollment in Medicaid may be avoided by Mohs surgeons and practices concerned about higher administrative burdens, delayed remuneration, and lower reimbursement rates for non-MMS CPT codes. Medicaid acceptance is critical to fill care gaps, and higher reimbursement, among other factors, may incentivize participation, especially in states with fewer Mohs surgeons.3Alghothani L. Jacks S.K. Vander Horst A. Zirwas M.J. Disparities in access to dermatologic care according to insurance type.Arch Dermatol. 2012; 148: 956-957Google Scholar This study is limited by potentially inaccurate capture of Medicaid acceptance status, use of fee-for-service rates in states with managed care plans, and lack of longitudinal trends. Despite these limitations, this study highlights the correlation between remuneration and Medicaid acceptance for MMS. Future research is needed to contextualize these findings with additional factors influencing Medicaid acceptance among Mohs surgeons. Author Feng has consulted for Cytrellis Biosystems, Inc and Soliton, Inc. Authors Beltrami, Hooper, Kodumudi, and Gronbeck have no conflicts of interest to declare.