No Body's Perfect: Physicians Offer More Than Just Check-ups to Bolster the Bottom Line

MDNG Primary Care, December 2007, Volume 9, Issue 12

Publications targeted to the young (and young-at-heart) are bursting with ads promising an end to lip hair, wrinkles, drooping chins, and fixes for other body parts farther south. If it's hairy...

Publications targeted to the young (and young-at-heart) are bursting with ads promising an end to lip hair, wrinkles, drooping chins, and fixes for other body parts farther south. If it’s hairy, saggy, or baggy, it seems there’s a cure. Even tests for those who want to try to predict the future—genetic tests for everything from breast cancer risk to diabetes—are available for a price. But just who are consumers willing to hand their most delicate, personal, and sensitive health issues over to? Judging from the sheer number of salons and spas offering these services, it would seem that consumers in pursuit of beauty and long life are

startlingly trusting.

Rather than have consumers go to a “shopping mall salon” for these procedures, as medical professionals despairingly call some of these shops, family practitioners are seeing an opportunity to offer them at their own practices. This not only offers safer environments for consumers seeking beauty and health treatments, supporters say, but also augments what some studies claim are stagnant and declining salaries for traditional family practitioners. A 2006 study from the Center for Studying Health System Change, a Washington, DC-based group primarily funded by the Robert Wood Johnson Foundation, is often cited to back up claims regarding the slide in doctors’ salaries. Income for all physicians dropped about 7% between 1995 and 2003, according to the CSHS report.

“The study confirms what physicians already know in the office—that their income is not keeping up with inflation,” American Medical Association Board Chair Cecil B. Wilson, MD, says. The study acknowledged US physicians still remain among the best paid professionals, averaging more than $200,000 per year in net income, but predicted flat and declining incomes will hurt the profession. “It’s not that we’re struggling to make ends meet and standing in line at soup kitchens,” says Dr. Terry L. Mills, former chair of the Commission for Practice Enhancement for the American Academy of Family Physicians. “But while the average cost of staying in practice has gone up during the last decade, salaries have remained the same or declined. Doctors end up needing to see more patients per day and then take administrative work home just to keep up.” Combined with the never-ending battle with HMOs over reimbursement rates and a wave of maturing baby boomers ready to crash into the Medicare rolls, Dr. Mills and his colleagues worry family medicine will become less and less appealing to not only doctors just coming out of medical school, but also those who are nearing retirement.

These factors are contributing to more family and general practitioners who are adding optional or “niche” services to their practices. Some specialists are grumbling about the increased competition for patients by these “non-core” physicians, but even they concede it is better to get medical procedures from a doctor rather than the person who cuts your hair or paints your nails. Cosmetic procedures that remove hair, spider veins, acne scars, and tattoos are among the most popular and increasingly accepted niche services family practitioners offer, as are Botox injections and other measures meant to help hide the effects of aging. To learn how to do these, many doctors take continuing medical education courses or join professional societies related to the field. The Chicago-based American Academy of Cosmetic Surgery (AACS), for example, invites family practitioners to join the AACS as associate members. Although family practitioners represent only 51 out of the group’s 1,800 members, their membership in the group has doubled since 2004. According to AACS Marketing and Communications Manager Charlie Baase, OB/GYNs have shown particular interest in joining AACS. Other physicians, however, are enticed by the sales pitches and promises of the manufacturers of the machines and devices used to perform these procedures—a trend many medical professionals say is courting danger.

BEYOND BOTOX: A BRAVE NEW WORLD

Botox and other strictly cosmetic procedures aren’t the only new services showing up in the family doctor’s office. Genetic tests that promise to tell patients their risk of getting anything from breast, ovarian, skin, or colon cancer to Alzheimer’s disease to diabetes sometime during their lifetime are either currently available or soon to hit the market, raising more than a few eyebrows among professional medical societies and patient advocacy groups. Such sensitive and potentially life-altering tests were once reserved only for those patients deemed by their physicians to be at higher risk for certain diseases, who then referred their patients to professional genetic counselors. Now, these tests are being offered and marketed directly to patients.

A notable entry in the commercial genetic testing field is Salt Lake City-based Myriad Genetics, a division of Myriad Pharmaceuticals. The company recently kicked off large, public, and somewhat controversial direct-to-physician and direct-to-patient campaigns geared toward letting patients know genetic testing may be as close as their next annual exam. “You don’t have to specialize in oncology to prevent cancer,” physicians are told in Myriad’s professional advertisements, whereas ads geared toward patients say, “The best time to beat cancer is before you even get it.”

Patients who visit Myriad’s website are offered a short “Hereditary Cancer Quiz” and a referral to a participating “cancer risk assessment” doctor in their area. Correspondingly, physicians who visit the professional area of the site learn they can become a “cancer risk assessment” professional—all they need to do is order Myriad test kits, draw blood from the patient, send it to Myriad’s Lab, and report the results to the patient. Doctors are even given tips and downloadable forms to help navigate insurance companies’ reimbursement processes in order to receive payment for administering the tests. Some genetic tests can costs hundreds or even thousands of dollars, although Myriad tells doctors most patients won’t need to spend more than $300 out-of-pocket if insurance picks up the rest. (And, naturally, the referring doctors get a slice of the pie, too.)

Another genetic testing company, San Francisco-based DNA Direct, offers genetic testing kits both to practicing physicians and directly to patients. Physicians can request, on behalf of a patient, a genetic test from DNA Direct, which will then send a cheek-swab test directly to the patient’s home. If patients order the

test themselves, they are sent a blood-draw kit with instructions, which they take to their doctor’s office to complete. Genetic tests are available for everything from alpha-1 antitrypsin deficiency to infertility to thrombophilia and cost anywhere from $300 to $3,500.

TOP-NOTCH NICHES

“What service or procedure you choose to add depends on your region,” Dr. Mills says. “In Kansas, where I practice, I don’t see a lot of doctors buying lasers and setting up shop to do cosmetic and aesthetic procedures. But I do see more practices adding CT, MRI, and other imaging services.” Simple orthopedic services like joint injections and the treatment of uncomplicated fractures may also be good ways to start easing into the “niche service” arena, Dr. Mills suggests.

Another option for family physicians seeking to expand their practices is to partner with an established service provider franchise, rather than buying a new $100,000 machine, hanging out another shingle, and winging it. Dermacare, a Scottsdale, AZ-based company that has set up 27 stand-alone laser and skin care clinics across the country (and recently went international with its fi rst location in Singapore), is one such company. The company is rolling out a franchise model called “The Dermacare Laser Clinic” that it describes as being designed for physician practices located in smaller demographic areas (defi ned as having a population of 75,000 or less) that don’t have the numbers to support a stand-alone Dermacare facility. After pre-screening and a face-to-face interview, qualifi ed franchisees are given a week-long training course and the equipment and training to offer laser hair and spider vein removal, collagen and Botox treatments, and other popular cosmetic procedures. This has already drawn particular interest from OB/GYNs and general practitioners, according to Dermacare president and CEO Carl Mudd.

“Physicians are leaving medicine in droves because of quality-of-life and business issues,” Mudd says. “Having to pay skyrocketing malpractice insurance and hiring extra personnel just to chase insurance companies down for reimbursement has created a tragedy in medicine, not just for doctors, but for patients as well.” Although adding niche services may make it easier (or at least more profitable) for family physicians to stay in business, Mudd warns those looking for a quick infusion of cash to think twice. “The technology, marketing, and management of this industry are complex,” he says. “There are more than 50 manufacturers of hair removal lasers alone, all with compelling stories and great ‘before and after’ photos and industry experts paid to validate their equipment.

But the history of technological failure and class action litigation by physicians against these manufacturers is substantial.” What a physician considering adding niche services to their practices should have, Dr. Mills says, “is an open mind and a curious spirit.” But they should also be mindful, whether they’re giving onsite

Botox injections or adding a CT scanner, that there are both risks and rewards, as with any business venture. When all is said and done, thoughtful physicians must consider the needs of their patients, the needs of their community, and the needs of their practice and balance them accordingly.

Five Keys to a Successful Niche Practice

1 Training, Training, and More Training

“It is extremely important to have adequate training if you’re a physician planning to do cosmetic procedures,” says Dr. Arielle NB Kauvar, clinical associate professor of dermatology at the New York University School of Medicine. She has personally treated patients who have received permanent burns from “routine” laser hair removal performed at salons and spas. “It’s not just textbook training, but hands-on training that comes from having treated hundreds of patients and [dealing with] possible complications versus a one-afternoon course.” Other mishaps she has seen due to procedures performed by inadequately trained

practitioners include worsening of tattoos and permanent make-up that were supposed to be removed.

2 Match Community Needs With Your Skill Set and Interests

“Keep your ears open, listen to the soccer moms, and see what services they’re seeking for themselves and for their families,” Dr. Mills says. “Many physicians overestimate how many procedures their practice will potentially perform and find they’re only doing half as many as they expected. Once you’ve identifi ed a need in your community, really look at your own skill set and interests, because you’ll have to be committed to continuing medical education.”

3 Add a Service or Add a Procedure? Decide whether you want to offer a specialty service, such as diagnostic imaging or genetic testing, or perform a medical procedure, like laser hair removal. Many dermatologists and plastic surgeons aren’t happy fighting for patients with colleagues from other specialties. And genetic testing, already a lightening rod for controversy, is becoming even more so now that it’s being commercially advertised. “Botox isn’t brain surgery, but the more complex a procedure is, the more valid the argument that a specialist should perform it becomes,” says Dr. Mills.

4 Leave Marketing To Marketers “Marketing is complicated,”

Carl Mudd of Dermacare says. “Many physicians have beautiful facilities with the right equipment and the right staff, only to fail within a year due to lack of marketing expertise and the inability to drive a high volume of patients through the door.” Becoming a franchisee of a larger company can alleviate some or all of the difficulties associated with this part of the equation.

5 Seek Professional Affiliations

Recognizing the number of physicians who are “crossing over,” many medical associations and organizations are expanding their continuing medical education curricula and/or offering associate memberships to nonspecialists. The American Academy of Family Physicians, a big supporter of niche services, provides members CME for cosmetic procedures, courses for many of which were offered at the AAFP’s Annual Scientific Assembly this October. Visit www.aafp.org for more information. Other medical groups that offer full or affiliate membership to non-specialists include the American Society for Dermatologic Surgery, the American Society for Laser Medicine and Surgery, and the American Academy of Cosmetic Surgery.

Diane West is a freelance healthcare journalist