I received this email today from the International Medical Spa Association:

"Dear Spa Professional,

There has been much press lately about California Assembly Bill 2398 and we at the International Medical Spa Association feel this is a very important matter.

An important hearing was held in Sacramento on April 25th regarding this bill. The committee decided to put this topic on a watch and work with the California Nurses Board to address the educational and supervisional needs at California medspas.

Although it appears this matter is being "shelved" for the moment, this is actually an ongoing issue, relevant to all states, and will now go to the Appropriations Committee. This bill could significantly impact medspa owners, managing service organizations, medspa physicians and staff, medspa consumers and all vendors serving the California medspa industry.

California Assembly Bill 2398

The International Medical Spa Association, an association with a large number of members in California, and over 1,000 members worldwide, is concerned that California Assembly Bill 2398 may be unwarranted restraint of trade that threatens the public's safety and undermines a doctor's or small business owner's right to earn a living.

The Bill has nothing to do with consumer safety. It was drawn up with the support of a special interest group (the American Society of Dermatologic Surgery) representing dermatologists with a vested business interest in restricting who can own or operate a medical spa. Since a dermatologist can become board certified without receiving any training in esthetic procedures, there is no guarantee that these specialists will have any greater knowledge of esthetic procedures than other doctors, healthcare professionals, and estheticians.

The negative comments about medical spa safety and the need for greater supervision made to the committee belie the facts that medical spa malpractice insurance premiums have actually come down over the last two years.

Our Association believes that medical spas need to offer the highest level of care possible. That is why we define a medical spa as "a facility that works under the supervision of a licensed healthcare professional working within their scope of practice, with a staff working within their scope of practice."

We do agree that a non-doctor licensed healthcare professional should be supervised by a MD or DO. However, we do NOT believe that a doctor or DO acting as a medical director should be required to be on-site.

Click to read more ...

An excellent explanation of RSS and why you should use it for your own medical spa web site.

If you have a site for your medical spa but don't have an RSS feed, it's time to take a look at that. RSS is perhaps the easiest way of disseminating information. It's even easier than email. (Although you should have an email list as well.)

Key No. 6: Service Service Service.

It sounds like a platitude to say that “the most important thing you can do for your clinic is to provide your patients with first rate service from the first phone call”. Most of us have heard many times that customer service is probably the most important factor in the success of any business. Nonetheless, it may still surprise you that YOU (the physician) rank a lowly FOURTH in the hierarchy of “the top four factors influencing patient satisfaction” in a survey of family practice clinics conducted by the Horizon Group Ltd in 1997.

Like most medical doctors, you undoubtedly pride yourself on your professional skills and perhaps agonize over the latest controversies about the best technology for laser resurfacing (traditional CO2 vs. fractional CO2 vs. fractional erbium, etc., etc.) when in fact very few of your patients have any idea what you are talking about. In fact, chances are that your patients are unable to differentiate between the results they might receive from an experienced, highly skilled aesthetic physician and a beginner. They will, however, know when they are treated in a rude manner or when they feel like they are being rushed. According to the survey conducted by the Horizon Group, the top three factors cited by patients were as follows:

Click to read more ...

I received this frantic email from " Sandy Elliott, CISR, Medspa Insurance Specialist". Evidently Sandy is concerned that her medspa insurance company may not be as relevant if California bans non-physicians from operating, owning or overseeing the operations of medical spas.

"There has been much press lately about California Assembly Bill 2398 & I feel this is such an important matter, that I am emailing information regarding this bill to medspas in all states. If this bill (sponsored by the American Society for Dermatologic Surgery) passes, it could be devastating to California medspas & since California is a bellwether state, it could very well set a precedent for other states to follow suit. Following is pertinent, current information from www.aestheticmedicinenews.com, from an article dated April 16, 2008:

“ The Business & Professions Committee of the State Assembly held a bill hearing on April 9, 2008 at which time the proposed AB 2398 (Amended April 1, 2008) was presented to the Committee. Unfortunately, following a brief discussion and only a few minor changes made, the bill was approved by the Committee.

An amended draft of the bill was drafted on 4-10-08 and was approved by the Assembly Judiciary Committee on April 15th. The bill will now go to the full Assembly where it must be approved prior to May 31, 2008 in order to be sent to the Senate or it will die. Refer to the current attached draft.

This legislation is sponsored by the American Society for Dermatologic Surgery, and if passed will have a monumental impact on physicians, nurses, NPs , PAs and management companies involved in the aesthetic field. Physicians who are involved in aesthetic practices on a part-time basis must be on-site, providing direct supervision of delegated procedures, and must personally provide good faith exams on all patients prior to delegation. RNs will not be allowed to perform any procedures without the physician on-site unless the treatment is performed in a physician owned office with certain restrictions.

Of great note included in this bill is the severe scrutiny of lay (non-physician), corporate owned entities, or management companies, that manage “medspas”, which would deemed to be the “owners / operators” of the practice in violation of the “corporate practice of medicine prohibition.”

Click to read more ...

There has been some back and forth on one of the threads about who gets to decide what medicine is and who can perform it.

Bill Sappenfield, who is part of a medical spa franchise called Mona Spa & Laser (He's Mona's husband I think) has taken the positon that... well, I'll let his comments speak form him.

Bill Sappenfield of Mona Spa & Laser Centers:

"So right you are. We have been running lasers for over 5 years with only estheticians. The medical boards seem to think that only nurse practitioners, physician assistants, and nurses are the only people qualified to run lasers.

Oh Contraire! Estheticians have more knowledge about skin care than 95% of the nursing community. Now don't get me wrong. Any qualified individual can learn and be trained in this business.

I am a firm supporter of the medical community in this business. However; this is the BEAUTY business no matter what the state medical boards say.

Most medical people don't even know what CIDESCO is! (We are 1 of 8 certified CIDESCO day spas in the U.S.) They don't realize that even some dermatologists have failed the CIDESCO exam.

As to your last comment, this is why so many physicians fail in this business. They just can't comprehend why their standard medical protocols and practices aren't working in this industry..."

And then there's this from Bill:

"Medical Board Regulations are regulations for the Medical Board. That does not make it law and even if a state board comes after someone for the "practice of medicine", that individual has the right to defend himself in a court of law. My point is that in most states, no one has questioned these regulations with a few exceptions. You don't have to believe me, but take a look at what is going on Texas and what has happened in Michigan.

It is the courts and the legislature that are the ultimate judges of what is and is not the practice of medicine..."

Of course LH (who is well know to medspaMD members) has a differing point of view:

"...From your previous posts you are a business person. Also,I am not sold that individuals with 600 hours of "training" know skin that well.

I would disagree with you on the idea that there is a significant dividing line between ablative and non-ablative lasers. The non-ablative lasers can cause severe scarring. IPL can cause significant problems as well.

I do think we agree on one thing though. You feel that the physicians can have all of the fillers, botox and ablative lasers and I feel you can have all of the body wraps and facials. I only offer facials, microderms and light chemical peels to my patients. I offer these because I do not want some cosmetologist telling them that they have some topical which is better than botox..."

Of course the problem is that the IPL's and lasers are where the money is. Hair salons and day spas are the second most common business in the U.S. (after restaurants). It's only the medical license that provides any barrier to entry in the practice of medicine and, of course, that's where the money is.. the practice of medicine.

So who gets to decide what constitutes the practice of medicine? Is it the courts or the medical boards? 

MedicalBoard has an excellent comment on what is legal in California around Medical Spas and physicians acting as medical directors.

There is a huge amount of information on this site around this issue but this is an excellent comment and I'm reposting it here. 

Q & A: 

I've been approached by a nurse to be her "sponsoring physician" for her laser and Botox practice; would that be legal?

No. There is no such thing as a "sponsoring physician." Nurses may not, under California law, employ or contract with a physician for supervision. A nurse may not have a private practice with no actual supervision. While the laws governing nursing recognize "the existence of overlapping functions between physicians and registered nurses" and permit "additional sharing of functions within organized health care systems that provide for collaboration between physicians and registered nurses" (Business and Professions Code section 2725), nurses only may perform medical functions under "standardized procedures." The board does not believe this allows a nurse to have a private medical cosmetic practice without any physician supervision.

I've been asked by a layperson to serve as "medical director" for a "medi-spa" that provides laser and other cosmetic medical services; would that be legal?

Click to read more ...

There's been some comments over on the Dermacare thread (Now at almost 800 comments) that reference SEO (Search Engine Optimization).

First, a bit of background about what SEO is and why you'd want it.

SEO is the process of 'elevating' your site's rankings when someone searches for information using 'keywords' (Think of these as what you'd type into the search box). If someone types in Medspa, IPL treatments, or Botox, you'd like your web site to be at the top of the list. Unfortunately for you... so does everyone else.

(If you're not in the first two pages for any keyword your chances of someone finding you are essentially nil. The first five links get the vast majority of all clicks.) 

SEO is a catch-all phrase for anything that improves the chances of search engines ranking your site higher.

Search engines love original content that's relevant to what their users are searching for. So, they have sophisticated algorithms that are designed to find relevant content and separate it from the flotsam and jetsam. (People often try to game the system but search engines actively 'sandbox' or penalize them. The search engines have gotten very good at this.}

When someone comes along and promises you SEO, take that with a grain of salt. Real SEO is expensive and very time consuming. You generate a list of keywords that you'd like to rank higher in and then start doing things that make you more attractive to the search engines. Things like generating backlinks (Other sites linking to yours) and providing lots of fresh content that matches what users are searching for. It's an ongoing, labor intensive process and can be filled with smoke and mirrors that are essentially useless. 

Happy to answer any questions on this. 

Can Medical Spa MD be turned into a marketing an purchasing co-operative?

Hmmm. I've been struggling with this for some time now. Certainly I get any number of emails from physicians each week. In most cases they're looking for information, but a growing number have been interested in some sort of 'banding together' as independents. Here's a good example from one of the discussion threads on this site:

"These laser companies and allergan and restylane have sucked the money out of the medspas are the only ones making any money, and yet they do a piss poor job of creating any new markets for there wonderful products. Everone's ads all look the same, they are too full of too much information about things that people don't care about. Medicis has been generous as to product samples, but I would much rather have clients calling me and asking for the product rather than spending an hour convincing them why they need it and that they won't look like that dancing with the stars actress lady or why they won't look frozen, or why they won't get burned.

It is late, I have insomnia, and I have been in this business for a long, long time. There are 900 members plus on this site. 900 times $300.00 monthly membership is $270,000 times 12 months is $3,240,000.00. Nice ad budget. They get the Seal, they referral links, marketing support, reps would be begging to give group discounts and deal on a large scale. No franchises, just The America Medspa Advisory Board:"

Click to read more ...

Knowing your competition inside and out is one of the most important prerequisites to opening an esthetics practice or a med spa.

Ideally, you do not want to put yourself in the middle of a host of established competitors. If you do this, you will be forced to try to take business away from your competition in order to survive. This often results in cost cutting and promotions that have a detrimental result on your bottom line. Ideally, you will be able to secure a location which will enable you to reach a largely "untapped market" in your community. You can also establish a unique "value proposition" and carve out your own niche for your special blend of services and products.

Before you make your final decision on your location, make a detailed analysis of your competition. Clip and study their newspaper ads, visit their web sites, and call them for information. Have someone make numerous telephone calls to listen to sales consultations and gather treatment menus. Have friends and family members visit competitors and schedule consultations and treatments. Oftentimes you will be surprised how the picture painted by the advertisement or web site is a far cry from reality. Once you have thoroughly checked the local competition you will know precisely what services they offer and what you will need to offer to not only be competitive but to differentiate your business from everyone else. Pay careful attention to the services and products they offer as well as the number of employees they have and the credentials of their staff. Determine whether or not they are a true medical spa or not. If they have only a token "medical director" you will want to position your clinic as one in which the physician has active involvement in every step of the process. Enlist the aid of family and friends to make visits to med spas in the area, schedule consultations and treatments to enable you to truly evaluate the playing field. Your research will help you a great deal in designing your own unique service menu and setting prices at the highest levels the market will bear. It will also enable you to offer services and products that no one else in the area offers.

A thorough analysis of the competition will help you make your med spa unique by creating a special niche that will help you stand out from everyone else. Find and fulfill a need that will make you stand out from the crowd, no matter how crowded the playing field is. You might decide to focus on a particular specialty—such as acne treatments, mesotherapy, or injectables such as Botox and Restylane. Other options are a focus on anti-aging treatments or a med spa for men. Many marketing consultants recommend developing a "signature service" which you can promote heavily and which can be your claim to local fame. No matter what services you decide to provide, let your uniqueness be your selling point.

Before you decide to transition to an aesthetic practice or open a medical spa, it is important to research the demographics and locations of competitors in the area you are considering for your location. It is critical that you find answers to each of the following questions before you take the plunge:

You can determine the socioeconomic makeup of your proposed location by gathering information from the U.S. Census Bureau (www.census.gov), the town clerk’s office, and local real estate agencies and business organizations in the area. Check out the foot traffic in and around your proposed site. Excellent foot traffic can provide a significant boost to a start up operation. High visibility, convenience and free parking are all extremely beneficial. Strip malls have turned out to be excellent locations for laser centers and medical spas because they offer both visibility and accessibility. If you have the luxury of negotiating a lease with an option to expand in the future you may want to consider starting small with the plan to enlarge your space and staff as your business grows. A shorter lease with options for renewal is a much safer and lower risk proposition than a long term lease.

I've received a number of inquiries about buying Restylane, Botox, Juvederm, and other injectables from Canada, Ireland or even Bulgaria.

Here's are two threads from the Physician to Physician discussion area:

Purchasing Restylane from Canada: Legal or not?

Buying Restylan Cheaper Oversees.

There does seem to be a great deal of pricing disparity. The Canadian suppliers and pharmacies who are selling Restylane and Botox are certainly undercutting the pricing that doctors are charged in the US.

(There are often pharmacies offering Botox and Restylane for 75% off advertising on this site.) 

My own experience is that some of our physicians have and are currently buying all of these (Restylane, Botox, Juvederm, and whatever else they can find) from Canada or elsewhere. It brings up a number of questions for docs and problems for the companies. How can they exploit the market opportunity in the US which will generally accept higher prices while still selling into countries that won't?