There is a misconception on Mohs being a very lucrative procedure. If you do it properly, Mohs surgery cases generate not much more than a wide excision. Mohs surgeon gets a bad rep for "over-utilization". Truth is that it really doesn't cost the system that much more unless you compare to ED&C all Basal Cells. It maybe true 15 years ago when Multiple Surgical Reduction didn't apply to Mohs' codes. But now it is no longer the case.
I dare to say the majority of Mohs cases are reimbursed at Medicare rate, being through Medicare directly or through one of its "managed care" counterpart. At that fee schedule, you get paid roughly $500 for 1st stage and another $300 for each additional stage. The national average of Mohs Stages is roughly at 1.6-1.7. So you are lucky to get $650-700 for the Mohs on the average. If you include an intermediate closure the same day, they pay you $150-200 after the Multiple Surgical Reduction. You are looking at about 800-900 per cancer. Even if you are looking at the private insurance cases, you have to contend with prior authorizations, deductibles, and bill collection. When all said and done, each Mohs cases is worth < $1000.
On the other hand, if you do "Slow Mo", You get paid $300-400 for excision (given the bigger margin) and another $300-400 for closure 3 days later after clearance of the margin. You get roughly 500-700 per cancer.
On the surface, you get paid $200-$300 doing Mohs s. Slo-Mo. Let's call it $250 to simplify. Now that $250 also accounts for additional Mohs equipment (can get pretty expensive), specialized staff (college education required per CLIA), lots of reagents, slides, and consumables, and Human resources to manage the staff. Suddenly, the $250 barely covers those costs.
You can try to increase the stage unethically or fraudulently, but your 17311:17312 ratio is there for the world to see at the annual release of Medicare data. You do 4 stages per patient on 1000 patients a year, everyone knows.
So with that said, the whole "Mohs surgeons are unethical" or most "Mohs procedures are unnecessary" accusation is overdone. There is really not that much profit in comparison unless you compare to EDC only. Mohs surgeons can make more money than general derm, but they need to do a lot of cases to do that and have the referral network and biopsy-proven cancer patients to make it possible. You don't just finish your fellowship and have people all put money in your pocket.
AUC or not, if my mother has a small basal cell on her back, she is getting Mohs. You can EDC your mother if you'd like, but my mother will get the treatment with the best cure rate. If the patient has no say in what treatment they get, we are no different than serving on the "death panel" in our office and decide who will get the medical treatment. I would argue the patient should be given the information to make the informed decision together with the physician. Then again, this is a whole different controversy.
To answer the title of original thread: "Why not Mohs?" Because there are easier ways to make money...
