Differences in management of high-risk skin cancers among providers practicing in rural, micropolitan, and metropolitan areas based on 2023 fee-for-service Medicare provider data

Abstract Geographic disparities in dermatologic care may contribute to differences in skin cancer outcomes across the United States. Mohs micrographic surgery (MMS) improves outcomes for high-risk non-melanoma skin cancers, but MMS providers are unevenly distributed, with relatively few practicing in rural areas. In this study, we examine national, regional, and provider-level trends in treatment of skin cancers at high-risk anatomical sites (head and neck, anogenital area, hands, feet) using 2023 fee-for-service (FFS) Medicare data, and assess how treatment modality and provider distribution vary by rurality and region. Rurality was classified by Rural Urban Commuting Area (RUCA) code as metropolitan, micropolitan, or rural, based on provider billing address; regions were defined by US Census categories. Chi-squared tests assessed associations between rurality and procedure and provider counts, and two-sample t-tests compared the proportion of MMS use across metropolitan, micropolitan, and rural areas. Of high-risk skin cancers treated in 2023, 76.51% underwent MMS, 15.92% destruction, and 7.59% excision. MMS use varied significantly by rurality (metropolitan 77.70%, micropolitan 60.65%, rural 62.35%; p<0.001), with significantly higher MMS proportions in metropolitan versus micropolitan or rural areas nationally and in nearly all regions. Among 2,894 MMS providers nationwide, most practiced in the South (43.39%), followed by the West (24.95%), Midwest (16.01%), and Northeast (15.58%). MMS providers were disproportionately concentrated in metropolitan areas (45.88%) compared to micropolitan (27.09%) and rural (26.97%) areas, a pattern consistent across all regions. The ratio of MMS providers to all skin cancer–treating providers was also higher in metropolitan areas (51.15%) than micropolitan (35.57%) or rural (33.67%) areas. Provider-level Medicare data reveal significantly lower use of MMS for high-risk skin cancers in micropolitan and rural areas compared to metropolitan areas, likely reflecting the geographic concentration of MMS providers. Given the higher recurrence risk associated with excision and destruction at high-risk sites, improving access to MMS in underserved rural regions may help reduce disparities in skin cancer outcomes.