Mohs Surgery?! Why NOT?!?!

[imtheman25]

Can anyone please explain to me why in the world do Mohs derm surgeons get paid close to 1 million dollars a year??! In my rudimentary medical experience, mohs surgery requires much less skill than so many other surgical subspecialties like ortho, optho, ENT, vascular surgery....etc.

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[imtheman25]

(Most) don't

Can you explain to me why they are one the highest paid sub specialties?

 

[drstranger]

I shadowed a Physician that does mohs. He had 4 rooms going at the same time 10+ each morning with help of a PA and medical assistants. He was telling me the insurance reimbursement is more then delivering a baby because insurance companies like MOhs a lot more then having to pay for cancer treatment when it has spread. But good gig for a 1-year fellowship he was even saying that there are even weekend course for mohs popping up which he was not happy about.

 

[Dermbattle2018]

Can anyone please explain to me why in the world do Mohs derm surgeons get paid close to 1 million dollars a year??! In my rudimentary medical experience, mohs surgery requires much less skill than so many other surgical subspecialties like ortho, optho, ENT, vascular surgery....etc.

From whatever silly compensation survey you found, that data from is pretty off in real life. from what i learned, it's quite difficult to even pick up a full-time mohs job these days.

Also, not sure how much you know about how compensation works in real life. Subjective statements like "requires much less skill" arn't worth much. The people who make that kind of money are well established and work pretty rough hours, as well as running their own histopath lab, employing many nurses/path techs/PAs. They often even do their own complex reconstructions and closures. Mohs also works extremely well (99%) cure rate, which makes it a great option. I'd say it's actually quite a cheap option in comparison to other fields for the healthare system when you consider one person does the removal, path, reconstruction, closure, and it works very well while preventing the progression of several aggressive cancers like squamous cells and MMis. Not to mention, good luck getting one of 50 total acgme spots.

 

[LoGo]

Can anyone please explain to me why in the world do Mohs derm surgeons get paid close to 1 million dollars a year??! In my rudimentary medical experience, mohs surgery requires much less skill than so many other surgical subspecialties like ortho, optho, ENT, vascular surgery....etc.

Get over yourself, skill is irrelevant across specialties. Never in a million years would I let an orthopod touch my face. Similarly I would not want a urologist doing a craniotomy. Mohs surgeons are highly skilled at identifying what is cancer and what is not on the skin and on histology, and skilled in reconstructing a surgically mangled face into something that is socially presentable, and doing so efficiently. They are a form of surgical oncologist, but also manage a massive team of techs and a private clinic plus get all the cash/cosmetic benefits of Derm if they choose. As to why they get paid so much, as someone else said, you have one person acting as the dermatologist, pathologist and surgeon all in an outpatient clinic. So instead of paying 3 people, it goes to one person at an overall reduced cost. Win for healthcare cost, win for the Mohs surgeon. Could plastics do the reconstruction? Certainly. But they can’t read the histo and would rather do boobs.

 

[JP2740]

Who cares? I hope their salary goes up as well as all specialties. People act like bringing down one specialty will boost up others. I think a loss for one specialty is a loss for all of medicine.

 

[IRorBustguy]

(Most) don't

MOHS don't (ftfy)

 

[SunsFun]

Get over yourself, skill is irrelevant across specialties. Never in a million years would I let an orthopod touch my face. Similarly I would not want a urologist doing a craniotomy. Mohs surgeons are highly skilled at identifying what is cancer and what is not on the skin and on histology, and skilled in reconstructing a surgically mangled face into something that is socially presentable, and doing so efficiently. They are a form of surgical oncologist, but also manage a massive team of techs and a private clinic plus get all the cash/cosmetic benefits of Derm if they choose. As to why they get paid so much, as someone else said, you have one person acting as the dermatologist, pathologist and surgeon all in an outpatient clinic. So instead of paying 3 people, it goes to one person at an overall reduced cost. Win for healthcare cost, win for the Mohs surgeon. Could plastics do the reconstruction? Certainly. But they can’t read the histo and would rather do boobs.

Not exactly. I wouldn’t wish on anyone to go to a Mohs surgeon who doesn’t refer more complex recons to plastics or ENT.

 

[LoGo]

Not exactly. I wouldn’t wish on anyone to go to a Mohs surgeon who doesn’t refer more complex recons to plastics or ENT.

Many will, even for more simple closures, because they’d rather move on to the next case. But it is rare where there is something that can’t be handled easily by Mohs. Most closures are simple local Skin flaps. Rarely there will be a cartilage graft, a forehead flap or a free flap from somewhere. Even more rare is muscle involvement. And extremely rarely will there be skeletal infiltration. So sure, send those facial cases to plastics or ent. But it’s often not necessary.

 

[Barrel Proof]

Because they can bill for general derm, derm path and surgical closure all in one day's visit

 

[anbuitachi]

Couple of reasons, one it bills reasonably well. Two they are short procedures.. If you work in a hospital you see that the best paid procedures (with a few exceptions) are the short quick ones. As a surgeon/proceduralist you'd make more money doing 20 endoscopy a day since they are like 15 minutes each, than several longer procedures.

 

[OrbitalOverload]

Because you bill as a separate procedure for each layer. Simple.
Sauce: My friends doing a derm residency now and this is what he told me.

 

[username456789]

Because you bill as a separate procedure for each layer. Simple.
Sauce: My friends doing a derm residency now and this is what he told me.

It’s a lot more lucrative to only have to do 1 or 2 layers and see more patients than it is to have to do 5-10 layers on fewer, more complicated cancers.

The reimbursement for subsequent takes declines fairly precipitously.

 

[itisallrelative]

Mohs surgeons are compensated very well, but to think the average Mohs surgeon is making anywhere near $1 million is absurd. I have no doubt some approach that or exceed that in a busy well run practice, but that's not the norm.

That being said, yeah the compensation isn't bad, at all. At the end of the day it's a surgical specialty and we all know that surgery reimburses well in general. It's also much easier for Mohs to run a PP than a lot of other surgeons which means less gets skimmed by the hospital.

Couple of cons,
-full time mohs is apparently hard to come by, the market is relatively saturated from what I've seen. Many split their time between Mohs and gen derm
-Most competitive specialty out there, need to match derm, then be good enough to get a fellowship (50% match rate)
-Lifestyle is worse than gen derm. As a surgeon you will get called for all the complications that go along with your patients when they happen.
-Potential for large government cuts (I've already heard new rules where they get paid less if they do 2 surgeries on the same patient on the same day, I think it's like buy 1 get 1 half off)

So while yes it's a great job, no it's not some chill job where everyone makes 1 mil per year.

Yes, they make a lot of money because most of the non-academic Derm Mohs guys are brilliantly skilled surgeons. They have such amazing dexterity.

 

[imtheman25]

Yes, they make a lot of money because most of the non-academic Derm Mohs guys are brilliantly skilled surgeons. They have such amazing dexterity.

Troll alert..

 

[itisallrelative]

Troll alert..

You know, there's a nice truth to that statement (Mohs is not restricted to Derm). Well, maybe apart from the "most."

 

[abefromann]

I'm a clinical dermatologist who over time frankly got good at surgery - never thought I would, but I do flaps on the face etc with great results. That being said - Mohs is often overutilized (this is another topic) and definitely over-reimbursed. Sorry, but the skill set is almost identical to mine (I was trained in residency by Plastics and Mohs), and reading slides for tiny remnants of BCC/SCC (98% of the time) isn't that difficult (is this follicle?). There's basically zero reason a standard excision should reimburse at a very small multiple of Mohs. Any argument against it is just an attempt to perpetuate the Emporer's New Clothes and the greed that is so evident among many Mohs 'surgeons.'

 

[Anti-PD1]

I'm a clinical dermatologist who over time frankly got good at surgery - never thought I would, but I do flaps on the face etc with great results. That being said - Mohs is often overutilized (this is another topic) and definitely over-reimbursed. Sorry, but the skill set is almost identical to mine (I was trained in residency by Plastics and Mohs), and reading slides for tiny remnants of BCC/SCC (98% of the time) isn't that difficult (is this follicle?). There's basically zero reason a standard excision should reimburse at a very small multiple of Mohs. Any argument against it is just an attempt to perpetuate the Emporer's New Clothes and the greed that is so evident among many Mohs 'surgeons.'

Nice to see some perspective.

 

[Xorthos]

I worked in a clinic with a dermatologist who focused on Mohs surgeries. He ONLY did Mohs on Tuesday/Thursdays. But on those days, he literally pumped out 30-40 Mohs per day by himself. He had a tech (who was a FMG plastic surgeon) suturing up afterwards while he moved on. And had a sick lab with two techs and about 3-4 microscopes.

The whole place ran like a well-oiled machine, and he was pumping them out in ridiculous amounts.

He was kind of a jackass though.

 

[Decicco]

Most mohs surgeons do not get paid 1 million dollars and there is a tremendous amount of skill. Taking layers if difficult. You have to read the slides under the microscope yourself. Complex facial flap/graft reconstruction is the norm. Just because it doesn't take place in an OR does not mean it doesn't require skill.

 

[MOHS_01]

I'm a clinical dermatologist who over time frankly got good at surgery - never thought I would, but I do flaps on the face etc with great results. That being said - Mohs is often overutilized (this is another topic) and definitely over-reimbursed. Sorry, but the skill set is almost identical to mine (I was trained in residency by Plastics and Mohs), and reading slides for tiny remnants of BCC/SCC (98% of the time) isn't that difficult (is this follicle?). There's basically zero reason a standard excision should reimburse at a very small multiple of Mohs. Any argument against it is just an attempt to perpetuate the Emporer's New Clothes and the greed that is so evident among many Mohs 'surgeons.'

Huh. First of all, very small multiple? It's not. Let's look at the math and the time requirements, and I'll even use frozen section pathology as it is billed at a lower rate than permanents and thus makes the comparison more favorable to standard excision.


11642 278
11643 328
17311 677
13132 488
14060 797
88331 100
88332 54
15260 1040

Let's say you have a 1.2cm BCC on the nose. You clear it with one stage leaving a 1.5cm defect. Standard excision, if done appropriately, is going to leave a bigger defect -- and you have less certain margins. Giving the benefit of doubt, however, let's say you can close it with a local tissue rearrangement. For Mohs, that's 797 + .5(677) for 1135. For the standard excision, and assuming that you want to increase your QC to reasonable levels and divide the specimen into three blocks, it's 797 + .5(278) + 100 +2(54) for 1144. Huh. Let's say that your contract with your carrier does not recognize the multiple procedure reduction exemption for pathology; that will bring that number down to 1094. Same cancer, inferior treatment, equal money. That's not what we call "value". I'm sure you're going to say "but what if it takes multiple stages?" Glad you brought that up -- because if it is going to take multiple stages, you likely would have positive margins on your excision. Unless you are doing intraoperative frozen sections, you will be reconstructing and calling the patient back in a week to deliver the bad news. Hopefully, at that point, you will send them on... but if you do not, you'll be doing the whole damn surgery again, and it will not be free. There is no version of this story that ends with you looking good.

As for the time / revenue efficiency -- it's not even close. I could do 20-30 excisions reconstructions a day. Easy. I could do 15-20 complicated ones. Intraoperative time simply is not the largest time consuming factor, neither for RVU calculation nor in practice. If they banned Mohs tomorrow for anything other than recurrent tumors and I had to switch to standard excision and pathology, I would actually make more money. I could accomplish more per unit time and free up time for additional services.

When Mohs lost the multiple procedure reduction exemption, all financial arguments against it (for appropriately selected tumors) went out the window. Shot. For appropriately selected tumors, it is the most effective -- not just by cure rate but by value -- treatment there is.

It's not that the emperor has no clothes... it's that those grapes are so damn sour. Why, I don't know -- the highest compensated derms in most states are not Mohs trained. Do yourself a favor and pull up MC's data release. It's eye opening.

Can you explain to me why they are one the highest paid sub specialties?

That 1m mark is somewhere between the 85 and 90th percentile mark for the specialty, so you can say 9 out of 10 do not earn that. As for the why -- it's a production issue. The ones who are busy -- the super minority -- do a high volume and most of the cost is relatively inelastic. It's more of a matter of total productivity density than compensation per unit.

I worked in a clinic with a dermatologist who focused on Mohs surgeries. He ONLY did Mohs on Tuesday/Thursdays. But on those days, he literally pumped out 30-40 Mohs per day by himself. He had a tech (who was a FMG plastic surgeon) suturing up afterwards while he moved on. And had a sick lab with two techs and about 3-4 microscopes.

The whole place ran like a well-oiled machine, and he was pumping them out in ridiculous amounts.

He was kind of a jackass though.

He is literally begging for an audit; that does not even sound reasonable. I hope he gets it. I hope his MC reviewer starts looking at dates of service... and how many microscopes can one man look at once?

 

[Skindoc83]

Not many mohs surgeons can churn out 15+ patients a day, more like 6-10. Unless they are referring out closures or doing some morally dubious things...

 

[MOHS_01]

Not many mohs surgeons can churn out 15+ patients a day, more like 6-10. Unless they are referring out closures or doing some morally dubious things...

I agree; I could do 10 a day on an average day, problem is not all days are average and I’m not going to cut corners because someone is unlucky enough to land on a bad day. I used to schedule 8 a day before people got “more selective” with their referrals, preferring to give it a try or 3 themselves before referring - now I do 7 and some days it’s still a full load. I do almost all of my own reconstructions, though... got burned with a few forehead flaps for things I could have easily reconstructed with a modified linear repair / crescentic advancement and said “no more”.

 

[W19]

An average of 7 mohs per day can land someone how much in term of compensation...

 

[MOHS_01]

An average of 7 mohs per day can land someone how much in term of compensation...

You won't starve. It depends on the setting, individual practice, and geographic location.

It's 7-8 MMS, 1-3 excisions, some of which convert to destructions, and 15-25 follow-up or new patients. Generates 30+ billable encounters a day.

Also do not underestimate how rare it actually is do 1500 legitimate cases a year.

 

[abefromann]

These numbers are probably reasonable on average, correct?

"It's 7-8 MMS - (~800-1000 each)
1-3 excisions - (~250-300 each)
Some of which convert to destructions (less)
15-25 follow-up or new patients (say 120-170 each)
Generates 30+ billable encounters a day."

By the way thanks for your reply above, MOHS_01. Totally agree with you at after reading it.

 

[Bradieux]

ALWAYS go to a plastic surgeon for repair of a skin cancer defect on the face. 99% of the time you will get a better cosmetic result. 6-9 years of plastic surgery training makes all the difference. If you need convincing go rotate with a Mohs dermatologist and then with a plastic surgeon.
Remember this in any thing you do...Practice makes permanent, NOT perfect.

 

[Wordead]

ALWAYS go to a plastic surgeon for repair of a skin cancer defect on the face. 99% of the time you will get a better cosmetic result. 6-9 years of plastic surgery training makes all the difference. If you need convincing go rotate with a Mohs dermatologist and then with a plastic surgeon.
Remember this in any thing you do...Practice makes permanent, NOT perfect.