Requred Disclosures For Physicians & Medical Spas

By Arlen Meyers MD MBA

When it comes to working with industry, keep your karma clean.

Working with industry comes with strings. The Patient Protection and Affordable Care Act, signed into law on March 23, 2010,  includes a number of provisions including a requirement that all pharmaceutical and medical device manufacturers publicly post on a website all payments or transfers of value from the manufacturer to a health care professional or institute. Some companies, like Allergan, have taken it a step further and entered into a Corporate Integrity Agreement with the feds. (http://www.allergan.com)

The present oversight environment demands that you disclose and make transparent your interactions with industry and any financial interests that result from that interaction. Here are some things to do to be sure you don't get caught with your stock options down.

Keep score

Be sure to keep an updated inventory of your consulting engagments, contracts and activities and  how you were compensated in cash, stock or some other financial instrument

Disclose

If you are an employee of an organization, like a univeristy of hospital chain, it is likely that you will get  a friendly (hopefully) reminder from your compliance officer to submit your conflict of interest statement. They will review it and get back to you if they see problems.

Don't study or use what you own

Big ticket conflicts make headlines. If you are being paid as a consultant to an orthopedic company and use lots of their products, beware. If you give lectures on depression to docs who like to eat expensive steaks and drink top shelf wines for free, and, you are the biggest prescriber of antidressants in your galaxy, that will raise a red flag.

Disclose your activity to peers and others

When you publish something or give a talk, disclose your interests. If you participate in medical legal activities, like expert witness participation, understand that your commercial interests will come under the magnifying glass of opposing counsel. Likewise, if you agree to work with one company, you will usually be asked to sign something saying that you will not work with another company where there might be a conflict.

When working with industry, it's best be safe than sorry. Doctors hate to flunk tests. The worst one to flunk is the New York Times test.

Arlen Meyers MD MBA is the cofounder, and Chief Medical Officer of MedVoy, a medical tourism company. He is also a Professor of Otolaryngology, Dentistry and Engineering at the University of Colorado at Denver and CEO and President of the Society of Physician Entrepreneurs. He blogs at Freelance MD

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Chicago Doctor Sues Over Yelp & Citysearch Reviews

The next time three of Dr. Jay Pensler's patients could be seeing him will be in a court of law. But it's probably not what you're thinking. Pensler's patients aren't suing him -- he's suing them.

Pensler is upset about negative remarks they made about him on Yelp and Citysearch , two websites where customers can anonymously post reviews about almost anything and everything.

I was trying to prevent what happened to me from happening to other women," one of his former patients told FOX Chicago News. "I didn't want people to go through the same thing I went through."

If you want to know exactly what the women who posted reviews went through, they said the pictures speak for themselves. One woman's breasts are clearly uneven and the nipples point in different directions. The X-ray from another woman who received a tummy tuck showed an object that looks like a staple. She said it is actually the head of a needle Pensler left in her body, but Pensler says was left by another doctor in a previous procedure.

Some people call him a butcher, which I agree with," another woman who went to Pensler told us.

Like the other patients we interviewed, she asked we don't identity her because she's embarrassed and scared what she says can be used against her in a trial. Since seeing Pensler, she said she's been operated on twice by another surgeon to correct Pensler's work.

Pretty harsh stuff. Click here for the rest of the article.

Dr. Pensler is in way over his head of course since he's got no recourse if either the patient's claims are true or they're the patients opinions. The law suit that Dr. Pensler was hoping would keep negative reviews of his practice off of the internet are having exactly the oposite effect. His lawyer should have told him as much.

Injecting Botox As A 'Medical Esthetician'

It seems that there are medical spas that are having non-medical staff performing medical treatments... In this case, Botox injections.

Here's a comment that someone posted on the comment thread from the post: Medical Assistants Can Not Inject Botox.

As a medical aesthetician I have injected under a physician's supervision for nearly eight years. That is the concept of a med spa? Medical Aesthetic procedures delivered under a physician's supervision. I have more often seen patients injured by laser treatments. In fact, in a decade of working in spas that offered Botox, I've never seen serious side effect. I've seen one temporarily droopy brow, once, injected by a "diamond" injector physician.
AestheticInjector

@Aesthetic Injector
You may have been doing this. Your supervising physician may know that you're doing this... but this is not legal in the US (or Canada or Euroope as far as I know).

First: There is no such licensee as a 'Medical Aesthetician'. If you're an esthetician working in a medical spa, you're an esthetician working in a medical spa. You have no expanded scope of practice or licensure about what medical treatments you can perform. Your esthetican license allows you to perform certain treatments... none of which allow you to break the dermis. You have no licensure that allows you  to perform injections. In this case there is no difference between an esthetician and the front desk staff (or anyone off the street).

Second; you equate what you're doing directly with a physician. In this you're correct. You are indeed performing medicine.

However, your supervising physician can not extend his or her license to allow you to perform Botox injections. It does not matter if the physician knows about it. It does not matter if the physician trained you to do it. It does not matter if the physician tells you to do it. The fact that it's relatively easy and that you've been doing it (even successfully) is irrelevent. Your physician can not 'expand' the treatments that you're licensed to perform. Injecting Botox is not one of them. There is no legal difference between what you're doing inside of this 'medical spa' and what you would be doing if you were injecting Botox in a motel room somewhere, other than the physician that's allowing you to do this is on the chopping block too.

Third; If you have any issue at all, you are not going to be covered by any malpractice carrier. You (and your supervising physician) are performing entirely without any net or recourse. Your supervising physician is probably in deeper water since his or her medical license is also at risk.

You mention that you've seen 'diamond' injectors who's Botox treatments have resulted in drooping around the eye. This is a known potential complication with Botox. So, if a diamond level physician who's squirting Botox day and night can have a complication, what are the odd that you could run into any sort of complication?

If you ever perform a treatment with a negative outcome that results in any investigation, you'll be found to be performing medicine without a license, without malpractice coverage, and without a chance of any good outcome.

So, what's going to happen?

Truthfully, I don't know, but here's a probable outcome based on experience.

Something is going to go wrong; you're going to have a complication, a patient is going to be unhappy, a staff member is going to be fired but has a grudge... something will happen. It always does at some point. It may even be unrelated.

Someone is going to point out that this clinic is operating outside of both legal and ethical guidelines, and then it's going to get ugly. If it involves a patient or civil suit it's going to be even uglier. These things have a way of cascading out of control.

If you disagree, I'd truly love to hear your arguments.

Anyone else want to weigh in on this?

Refuting Negative Online Reviews

Protecting your medical spa, personal, and professional reputation online can be damn near impossible.

With internet marketing opportunities on the rise, today's aesthetic clinicians are faced with a "double edge sword". One side, if you don't advertise yourself on the internet you have less of a chance to gain presence and new business over your competitors. The other side of the blade is that you are opening yourself and your practice up to negative comments and reviews.

While patients do have a right to exercise The First Amendment, what we really find in our industry is that positive reviews don't come freely. Seldom does a "customer" of a business post how wonderful a place is or what a great experience they had. Typically, rave reviews are solicited by the business encouraging their customers to post reviews if they are "happy". Whereas, someone who is disgruntled in some sort of way has no apprehension whatsoever in posting their views on the internet.

With many sites not requiring the identity of the poster to be verified, this opens up the "Wild West", so-to-speak, for anyone to post anything he or she desires. This also includes your competitors who can acquire an email address with any vendor, then post anonymous false reviews of you and your practice.

How can you combat this? First, you have to be diligent in canvassing your reputation on the web. You have a choice to let the comments go, or research them to see if you can determine who they are so you can have the opportunity to correct the review (if it is a legitimate complaint). You can also report the review to the posting internet site with a clear description of why you believe the post should be removed. However, there is no guarantee you will even receive a response.

Many social media marketing gurus state that all positive reviews on a business tends to make the consumer think something is a little fishy with the business, so one bad review can add to the business's authenticity. Take book reviews on Amazon for example. I know I read through them all, good and bad, then make my decision. After reading a few, you get a general idea of what reviews are just "out there" (i.e., insults, poor language, obscenities, etc.) and which ones are more reliable and genuine.

David Goldberg, M.D., J.D. has written an excellent article for Dermatology Times entitled "Physicians have limited recourse against online defamation". This is a must read article for any clinician!

From the post:

There are known instances of dentists being accused online by their competitors of being child molesters. Similarly, laudatory online comments can be written by the physician himself.

One way to try to work around such frivolous online statements is to have patients sign a waiver that has them promise, in case they are not happy with their care, that they will not post online comments to that effect. The way such contracts are enforceable is as follows.

In general, websites acting as platforms for outside commentary are not liable for defamation suits. They are, according to North Carolina neurosurgeon/attorney Jeffrey Segal, M.D., J.D., subject to copyright laws. Waivers can be written to assign copyright to the treating physician. If the treating physician asks the patient to sign such a "copyright" waiver, the physician can claim ownership of any anonymous review of the practice and demand that such an online review then be removed. There are now examples of website posts removing such deleterious copyrighted comments.

Needless to say, not all patients will agree to sign such a waiver. Some may feel such waivers are simply "gag orders." The reality is that disgruntled patients are free to speak with family, friends, other physicians, lawyers, hospital peer review committees or credentialing committees. There are many appropriate places where patients can express their views.

This guest post is written by Paula D. Young RN, author of Advanced IPL & Laser Training For Non-Physicians and co-owner of Young Medical Spa in Center Valley PA.

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Hollywood Body & Laser Center: Practicing Medicine Without A License

Hollywood Body And Laser Center seems to have been preforming cosmetic medicine and prescribing mediciations out of their Sandy, Utah location.

The owner of the Hollywood Body and Laser Center in Sandy Utah was jailed Thursday, accused of representing himself as a doctor and performing medical treatments and dispensing prescription medications.

While you don't expect these types of things to actually be happening outside of a motel room, they do.

What's most surprising is that the investigation started in 2008 and it took them this long to make an arrest and (presumably) stop this.

(After our interview with Mr. Adrian Richards, an English plastic surgeon, I'm not sure if any of this would actually be illegal in the UK.)

From the news article

 William Ricker Ferguson, 51, was booked into the Salt Lake County Jail for investigation of aggravated assault, practicing as a pharmacist without a license, practicing medicine without a license, selling, dispensing or otherwise trafficking prescriptions without a license and forgery, all felonies.

A Sandy police press release said an investigation included the Division of Occupational and Professional Licensing. Police identified Ferguson as the owner of the cosmetic procedures business, at 7430 S. Creek Road, which is the corporate office for locations elsewhere in Utah and in other states, according to the company's website.

The Sandy laser clinic, located at 7430 S. Creek Rd., came under investigation by police and the Utah Department of Occupational and Professional Licensing in January 2008, after complaints surfaced regarding owner Richard Ferguson.

Investigators from both Sandy police and the licensing department discovered several illegal actions since 2008, including one incident when an undercover investigator attempted to purchase HCG and Latice under the pretext of giving it to a girlfriend and was able to obtain them without a prescription from laser clinic staff members.

According to charges filed in the 3rd District Court Thursday, the Provo owner left one woman in June 2008 with third-degree burns all over her face and the herpes virus during attempts to give her an Active FX laser treatment on her face.

Charges also list an incident in March 2009 when another woman required skin grafts to repair damage done to her stomach when the 51-year-old defendant attempted to administer liposuction treatment.

Prosecutors say Ferguson refused to refund another woman's money in October 2009 after a laser hair removal procedure wouldn't work on her blond hair. Charges state the woman called several establishments that told her the laser treatment would not work on her blond hair.

A former medical director for the laser center told police that the defendant was using his name and information to obtain controlled substances and HCG without his authorization, charges state. Staff members said Ferguson would use a copy of the medical director's signature to order HCG from a company based out of Florida, and another doctor's signature to write prescriptions.

Ferguson was charged with one count of second-degree felony aggravated assault and another third-degree felony count of the same charge, as well as one count of unlawful conduct of practicing as a pharmacist without a license and three counts of unlawful conduct of practicing medicine without a license, both third-degree felonies.

Prosecutors also charged the defendant with two counts of selling, dispersing or otherwise trafficking prescriptions without a license and 10 counts of forgery, all third-degree felonies.

Medical Spa Advertising: Keeping it Legal - PART 2


State and federal regulations centering on medical spa advertising can often be daunting to navigate through.  How can you make sure your ads are within the “legal” realm?   Read on through Part 2 of Medical Spa Advertising - Keeping it Legal. 

Read: Medical Spa Advertising: Keeping it legal Part 1

The ever increasing number of State and Federal laws that can pertain to the use of photographs of patients has triggered a lot of questions from the medical community.  Below are some frequently asked questions and answers from Michael Sacopulos, General Counsel for Medical Justice Services.  Note these are general answers and are not State specific.  You should consult local licensed counsel to address laws, regulations and prohibitions specific to the State in which you practice.

Question #5: What concerns should I have if I want to implement an e-campaign to my database?

Answer: You will not be surprised to learn that there are specific Federal laws related to the use of e-mail campaigns for commercial purposes.  Specifically, the CAN-Spam Act sets forth the Federal requirements for those wishing to promote goods and services by e-mail.   Before you start to send those e-mails, check out the Federal Trade Commission’s website on this act:  http://www.ftc.gov/bcp/edu/tubs/business/ecommerce/bus61.shtm  

Question #6: What should I know before I start a Facebook account?

Answer: From the legal perspective, information that you place on Facebook is treated exactly the same as information that you would place on your practice’s website.  However, some have found Facebook to have a more intimate feel.  People tend to make statements and do things on Facebook that they might not otherwise do on a typical web page.  We have all read the accounts of individuals losing a job because of some posting on Facebook.  I recommend that you keep two separate Facebook accounts.  You may have one for your practice and one for personal use.  I believe it to be a mistake to mix your personal and professional activities in one Facebook account. 

Question #7: Can I give a referral patient a gift card to use towards services?

Answer: Yes.  Few problems arise from giving a gift card or a discount to a patient that has been referred to your practice.  It is more difficult to compensate patients for the promotion of your practice.  As we discussed above, should you wish to compensate a patient for the use of his or her before and after photographs on your website, this fact must be disclosed. 

Question #8: If all these are legal requirements, why don’t more doctors get prosecuted?

Answer: This sounds like a practical question from a risk taker.  The answer to this question rests in the limited resources for enforcement.  Most people driving above the speed limit don’t receive a ticket, but it is clearly a possibility every time someone exceeds the speed limit.  One more word of caution: The penalties for violating some of the rules and regulations described above can be quite harsh.  Your smartest move is to try to comply with all rules and regulations regarding online advertising.                 

One final word of caution about online advertising and the use of patient images…Many professional societies have ethical guidelines that members are to follow when advertising.  These guidelines may be stricter than State or Federal laws.  The AAFPRS has some well reasoned guidelines that should be known by members prior to initiating an advertising campaign.  Members of the ACS should consult that society’s Code of Professional Conduct which can be found at http://www.facs.org/fellows_info/statements/stoprin.html. The AMA has an extensive document entitled “Principles Governing Advertising in Publications of the American Medical Association” which provides guidance.  This document can be found at http:/pubs.ama-assn.org/misc/adprinciples.pdf .

Mr. Sacopulos is a practicing attorney in Indiana.  This article reflects his opinions and perspectives on advertising and legal issues set forth in this article. 

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Medical Spa Photographs & Testimonials: Keeping it Legal

Medical Spa ads are often peppered with photos (highlighting “real” patients and models) and glowing testimonials.   

Images of more than ideal treatment results from Botox, laser hair removal, fillers, chemical peels, photofacials grace local rags to targeted online ad placements…okay, you get the picture. 

A recent article stated that there are now more medical spas in the US than Starbucks!  Now, that makes for a very competitive market. 

As you strategically, aggressively advertise your Medical Spa – are you aware of the legal guidelines & do you know how to keep your advertising legal? 

The ever increasing number of State and Federal laws that can pertain to the use of photographs of patients has triggered a lot of questions from the medical community.  Below are some frequently asked questions and answers from Michael Sacopulos, General Counsel for Medical Justice Services.  Note these are general answers and are not State specific.  You should consult local licensed counsel to address laws, regulations and prohibitions specific to the State in which you practice.

Question #1:

When do I need to use the label “MODEL” on a photograph?

Answer:

The term “model” should be used when the photograph is displaying the results of a procedure or procedures not performed by the physician or practice (displaying the photograph).  Here the term “model” is being used in a general representative fashion and is not being used to display a specific practice or physician’s professional services/results. 

Physicians should secure a written release from any individual, patient, or model before using a photograph of that individual, patient, or model in any way.  The release should be specific to the photographs being used.   The release should also specify the way or ways that the photographs may be used.  For example, a release “for educational purposes”, will not cover internet marketing.  Do not attempt to get a release signed that covers “any and all future images, photographs or depictions…”  Courts have ruled that releases can go stale.  Finally, it is best for the release to specify the conditions and manner by which an individual may revoke the release at a later date.  

Question #2:

I hear the use of testimonials has regulations. Please explain.

Answer:

There are several sources of regulations over the use of patient testimonials.  Some state licensing boards greatly restrict or prohibit testimonials.  Each state has different standards; some flexible, some very restrictive.  The Federal Trade Commission also has rules that apply to the posting of testimonials.  In general, a physician should make sure that the testimonial is accurate (what the patient really said and not paraphrased).

Question #3:

What does HIPAA have to say in its marketing regulations about the use of “before and after” photographs and testimonials?

Answer:

HIPAA in general protects patient privacy.  Although the act does many things, it would prohibit the use of before/after photographs without a patient’s permission.  However there is nothing in the act that would prevent the use of accurate before and after photographs with a patient’s prior approval.  As always, this approval should be documented.  Finally, it should be made clear that a patient can withdraw his or her approval to use the photographs at a later date and that the physician must comply with this subsequent withdrawal of approval.

Question #4:

What is this I am hearing about The Federal Trade Commission in regards to “results not typical” and endorsements?

Answer:

Earlier this year, The Federal Trade Commission set forth new guidelines for the use of testimonials and advertising that apply to many areas including healthcare.  In the past, The Federal Trade Commission has taken action against certain weight loss products when these products were advertised by an individual claiming extreme weight loss.  The FTC’s position was that it is a deceptive trade practice to show an individual has lost 100 lbs. when this result is not at all representative of a typical patient’s outcome.  In this situation, the term “results not typical,” would need to be used.  Under the new regulations, we should expect that the FTC will take a similar approach.  My discussions with FTC officials have led me to believe that the Commission acknowledges that health care results vary.  The Commission’s goal is to see that potential consumers are not misled by advertising.  It is not advisable to select a statistical outlier to be representative and then try to protect it by adding the term” results may vary.”  Under the new FTC rules, you must also disclose the fact if an individual has received compensation (of any amount) or discounted services in exchange for providing a testimonial or endorsement. 

Mr. Sacopulos is a practicing attorney in Indiana.  This article reflects his opinions and perspectives on advertising and legal issues set forth in this article. 

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Medical Fusion Conference: Guest Speaker Medical Justice

Dr. Jeffrey Segal, founder of Medical Justice, will be speaking at the Medical Fusion conference in November.  He also happens to be a Medical Spa MD Select Partner to boot.

Turning A Negative Into A Positive, The Medical Justice Story

I am a board-certified neurosurgeon who was sued one time for what I perceived to be a frivolous reason. The single expert who testified against me had been expelled from our professional society for delivering frivolous testimony. This expert had never performed or even observed the specific technique in question.

At the time I was practicing in Indiana, a state that embraced substantive tort reform years earlier. Nonetheless, I was in the crosshairs.  After two years, the case was dismissed a few weeks before trial. But, I never felt as if I won anything. I just felt as if I lost less.  I learned I was in good company. Many have been sued. Few talk about it.

Beyond the age of 40, I quit my day job and started Medical Justice, a physician-based organization focused on keeping doctors from being sued for frivolous reasons. The organization now addresses an array of medico-legal threats and serves thousands of physicians nationwide.  The single goal is to make it easier for doctors to practice medicine.

Migrating from a comfortable living as a neurosurgeon to the calculated risk inherent in the entrepreneurial world was not easy.  Many lessons were learned.  My session at the Medical Fusion Conference, "Physicians and the Legal System, the Story of Medical Justice", will focus on the story and these lessons --the good, the bad, and the ugly.

Take in some more information from Dr. Segal at the Medical Fusion Conference, November 5th throught the 7th at the Wynn confernce center in Las Vegas.

Medical Spa MD: Change In Federal Gift Certificate Law

On Sunday, August 22nd, the new federal gift certificate law went into effect. What does this mean to your medical spa?

In essence, the new law sets a 5-year minimum term for most gift certificates sold in the U.S. and it doesn't shorten any minimum terms required by your State law. Period.

The new law is just extending the terms of expiration if they previously were less than 5 years. If your State had a minimum term of more than 5 years, such as MA (7 years), your term will not change.

In addition, if your State does not permit you to apply an expiration date, such as the Stets of CA, CT, FL, ME, MN, MT, NH, RI and WA, of course those terms would still apply to any gift certificates you sell.

Gift certificates sold prior to August 22nd will be grandfathered in. If you have questions you can always visit the National Conference of State Legislatures.

If you have any questions about whether this new federal law pertains to you, you should check your state laws regarding gift certificate expiration, or consult with your legal representative or accountant.

New Medical Spa Regulations for Arizona & Texas

Arizona Medical Spa Regulation Update: Esthetician & IPL Laser Technicians

Arizona requires all training providers be registered with the state to provide training to comply with their requirements. The program shall provide a provisional certificate to the applicant verifying the successful completion of the didactic training.

An esthetician who has been using laser and IPL devices before the effective date of this amendment to this section may continue to do so if the esthetician applies for and receives a certificate pursuant to this section before October 1, 2010. Arizona state legislature requires a laser technician who wishes to perform cosmetic laser procedures and procedures using IPL devices to successfully complete 40 hours of didactic training as required by agency rules at a certified training program.
More Information From State Website

Texas IPL & Cosmetic Laser Regulations Update

The Texas Legislature has passed legislation in House Bill 449that establishes a regulatory program for laser hair removal. The Department of State Health Services is charged with implementing that program. The legislation requires every laser hair removal facility to be licensed by the department. It also requires that each individual who performs laser hair removal procedures, except physicians, be certified by the department. By September 1, 2010, every laser hair removal facility must be licensed and each individual who performs laser hair removal must be certified.

However, the adoption of the laser hair removal rules and implementation of the laser hair removal program has been delayed for a number of reasons, including the request from state leadership for each state agency to submit a plan to reduce budgets by 5%, as well as implementing an agency hiring freeze to help address the state's budget situation. Work on implementation, however, does continue forward.
More Information From State Website

Information adapted from Aesthetic Trends & Technologies

Guest post by Paula D. Young RN, author of Advanced IPL & Laser Training and the Medical Esthetician Training Manual & Study Guide and head of operations at Young Medical Spa.

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Medical Spa Horror Stories: Woman Dies From Silicone Butt Injections

Illegal medical spas and filler injection services are up and running, and actually killing people.

If it weren't bad enough that there are websites marketing "do it yourself Botox injections" and "filler injection kits" for home use, there are still people out there who are willing to go to a motel room and have non-physicians inject them will industrial silicon.

Two sisters who were selling Botox, filler injections, and butt augmentation in motel rooms are now on the run. Police say they performed illegal cosmetic surgery from inside their residential home and are the cause of one woman’s death.

Some of their patients (victims) went to police after experiencing infections and hardened body parts after receiving silicon injections. One woman, 22-year-old Mayra Lissette Contreras, would die from respiratory failure a day after getting some silicone shots in her buttocks. The sisters were arrested and charged with practicing medicine without a license but were released on bond and have probably fled to Mexico (see below). 

There's always plenty of  smartass advice to give to anyone who may ever contemplate injecting themselves with fake botox or getting cosmetic surgery while bent over someone’s kitchen counter, but I just couldn’t do better than the advice given by by Deputy Chief Kirk Albanese. “If you are receiving an injection at a home in a residential area, that should be the first warning sign that you shouldn’t be there.” But I will add that whether or not a facility is residential or not,  it’s normally not a good idea to receive cosmetic treatment from a 50-year-old woman who looks like a creature commonly seen in movies being chased around by villagers with pitchforks.

Sisters sought after woman dies from silicone butt injections


Sisters Guadalupe Viveros, left, and Alejandra Viveros, above, allegedly ran an illegal cosmetic filler injection service and squirted silicon into anyone with a check book.

Guadalupe Viveros, 53, and Alejandra Viveros, 50, may have fled the country after Mayra Lissette Contreras, 22, of Pacoima died Friday after receiving the injection, police said. An autopsy was pending Wednesday, said Ed Winter of the Los Angeles County coroner's office. Initial reports indicated that Contreras died from respiratory distress.

The Viveros sisters were investigated last month by the Los Angeles Police Department after other patients complained that the fillers, typically injected in the face or the buttocks, made them ill. The sisters were taken into custody June 21 for practicing medicine without a license, police said. They were held on $20,000 bail before being released.

They were supposed to be arraigned on Monday, but they skipped their arraignment. Police realized that they are probably on the run, and since the two women have connections in Mexico, authorities suspect they have fled south.

Police say the Viveros sisters are not doctors. Neither is licensed to perform medical procedures in the United States.

They have been allegedly operating an illegal cosmetic surgery business and performing expensive procedures in their home rather than in a licensed operating room, cosmetic clinic or doctor`s office. Patients told police they developed infections and said the silicone used by the sisters turned to hard plastic once inside their body.

LA police are searching for these two women and believe they could be in Mexico. People with information on their whereabouts as well as victims are asked to come forward and contact the Los Angeles Police Department.

LA Times article

And if you thought this was a one-of-a-kind event...

San Diego transgender woman dies after illegal silicone injections.

A 45-year-old transgender woman who received illegal silicone injections at a party in a private home in San Diego has died after nearly a month on life support, the county medical examiner said on Monday.

Patricio Gonzalez, who police said received silicone injections to her hips, buttocks, cheeks and lips, died on Sunday. Gonzalez and at least nine other people were injected at a so-called "pumping party" on June 19, police said.

"Pumping parties," where people seeking a more feminine appearance have silicone injected into their bodies, have been on the upswing in the last few years, experts say. The silicone used at the parties is often industrial-grade material like floor sealant.

The Food and Drug Administration banned direct injections of silicone in 1992 and the substance has been known to migrate within the body and cause chronic, degenerative illnesses.

Gonzalez and another transgender woman received more silicone than the other party guests and suffered immediate respiratory problems, prompting the Los Angeles-area woman who was administering the silicone to flee, police said.

Police have issued an arrest warrant for Sammia "Angelica" Gonzalez, 39, who was injecting the party guests with silicone, is believed to have fled to Mexico.

Transgender women often have humiliating experiences with traditional surgery clinics, and surgeons often require a psychological exam before they will consider treatment.

Article

Is Suing Your Medical Spas Patients Ever A Good Business Strategy?

Your medical spa or laser clinic is going to be the target of negative reviews at some point. How are you going to deal with unhappy patients who have a forum?

In the aesthetic medicine business, reputation management is a big deal. First, of course, you want to do good work for your patients. You want them to be happy with the results, and then you want them to tell all of their friends how happy they are. Good reputations take time to build, but bad ones can be made very quickly. A California plastic surgeon is now dealing with the fallout of some bad online reviews by taking legal action against the people who posted them.

Unhappy patients aren't anything new, but the Internet, with it's assortment of social media and consumer review sites give grudge-holding patients a significant amount of power. A few of those patients recently vented their opinions of Greenbrae, CA, plastic surgeon Kimberly Henry, MD, on consumer rating sites Yelp.com and DoctorScorecard.com. The doctor, in return, sued the patients.

What may have begun as a consumer rant--the sort that goes on every day about restaurants, car dealerships and plumbers-just got serious. According to an article in the Contra Costa Times, Dr. Henry is currently seeking injunctions against 12 reviewers, allegedly former patients, for libel, defamation, invasion of privacy and interference with prospective economic advantage. The doctor is seeking $2 million in damages plus other unspecified costs.

Earl Thurston, the proprietor of DoctorScorecard, confirmed that he provided Nordskog e-mail and IP addresses of Henry critics in January, but has not done so since. Nordskog's subpoena was the first he had ever received.

"I was inexperienced with the law and the way the court system works," Thurston said. "I assumed that if a judge ordered that I provide the information, that I was required to do so by law."

Since then, another lawyer sent him a subpoena for user information for a similar lawsuit in Texas. Thurston said he is fighting the subpoena with the help of Public Citizen, a nonprofit consumer advocacy organization in Washington D.C.

"I spent many hours reading online about the legal process and came to the conclusion that I could fight to keep our users anonymous, even if a judge orders us to reveal their identities," Thurston said.

Stephanie Ichinose, a spokeswoman for www.Yelp.com, a site that posts user reviews on numerous subjects, noted that a similar case played out last year in San Francisco. In that case, dentist Gelareh Rahbar filed a defamation suit against Jennifer Batoon, a patient who wrote a negative review about the dentist on Yelp.com.

"The judge threw out the defamation counts and ordered Rahbar to pay $43,000 for Batoon's legal fees," Ichinose said.

The claim was dismissed because of California's law against so-called SLAPPs - strategic lawsuits against public participation - which are lawsuits aimed to squelch free speech. Batoon was represented by the California Anti-SLAPP Project, a public interest law firm in Berkeley.

John Diamond, a professor at University of California, Hastings College of the Law, in San Francisco, said forum providers such as Yelp.com are immune from defamation suits, and that anti-SLAPP laws provide some protection for online commentators.

But Diamond, who has no knowledge of Henry's case, said reviewers can be held liable if they assert "false facts, not just opinions."

"They actually have to commit defamations, and that is something that is false and damaging to reputation," said Diamond, a Tiburon resident. "I think what's happened is many more people have a forum now to make comments and have a impact. Previously there haven't been that many opportunities."

This guest post is written by Grant Clauser, Editor of Healthy Aging Magazine. Read Grant's post: Plastic Surgeon Strikes Back At Online Reviews on the Healthy Aging blog.

Submit a guest post and be heard.

Thermage Repetitive Motion Lawsuit

Thermage has been sued by a Dr. Supriya Goyal Bellew on for negligence, strict products liability, and breach of implied warranties.

To be honest this looks somewhat bogus, with a physician claiming that the design of the Thermage handpeice caused recurring pain and that Thermage was negligent. You'll want to read the entire finding though. It's interesting stuff; especially the findings that preclude summary judgement.

GOYAL v. THERMAGE, INC.

SUPRIYA GOYAL, Plaintiff,
v.
THERMAGE, INC., Defendant.

Civil No. WDQ-08-0020.

United States District Court, D. Maryland, Northern Division.

July 1, 2010.

MEMORANDUM OPINION

WILLIAM D. QUARLES Jr., District Judge.

Dr. Supriya Goyal Bellew[ 1 ] sued Thermage, Inc. ("Thermage") for negligence, strict products liability, and breach of implied warranties. For the following reasons, Thermage's motion for summary judgment will be granted in part and denied in part, and Bellew's motion to strike will be denied.

I. Background[ 2 ]

On September 1, 2004, Bellew began working at the Maryland Laser, Skin, and Vein Institute ("MLSVI") as a cosmetic dermatology research fellow. Bellew Dep. 90:17-91:3. Within her first month at MLSVI, Bellew began treating patients using the ThermaCool device developed by Thermage to reduce the signs of aging in skin. Id. 124:3-16.[ 3 ] Dr. Robert Weiss[ 4 ] and his wife Dr. Margaret Weiss—both physicians at MLSVI—taught Bellew how to use the device. Id. 130:9-10; Margaret Weiss Dep. 174:2-8.[ 5 ]

The ThermaCool device has a handheld component (the "ThermaCool handpiece"), which the operator holds to the patient's skin while pressing a manual button or a foot pedal to deliver radio frequency pulses. Pl.'s Dep. 111:8-112:5, 135:4-7. After instructing Bellew on its proper use, Robert Weiss observed her using the ThermaCool handpiece and told her that she "was doing everything properly and appropriately and delivering treatments the way that they were supposed to be done." Id. 131:21-132:6. The design of the handpiece required Bellew to hold her wrist and arm "in a bent, flexed position at a very odd angle for the entire treatment," id. 112:7-10,[ 6 ] and several physicians at MLSVI, including Bellew and Robert Weiss, commented that the device was "awkward" to use, id. 134:9-20.

In October or November 2004,[ 7 ] Bellew began to have soreness and pain, which she associated with her use of the ThermaCool device. Id. 208:13-20. At first, she experienced temporary soreness in her right hand, arm, shoulder, and neck, but her symptoms progressed to intermittent "shooting pain" and "clawing up of [her] ring and pinky fingers" for up to a few days after she performed a Thermage treatment. Id. 206:14-21, 208:13-20. Bellew mentioned these symptoms to the Weisses, who told her that they experienced similar pain and that it was "normal and not anything unusual." Id. 152:16-21. Upon the Weisses' advice, Bellew took over-the-counter pain medications and rested her arm, which completely relieved her symptoms. Id. 151:17-20, 153:8-11. Because the pain was transient and manageable with Advil, Bellew attributed her discomfort to use of new muscle groups that she had not previously used and "did [not] really worry about it." Id. 151:3-20.

On January 4, 2005, Bellew delivered almost 1200 pulses during two Thermage treatments, id. 170:6-8, 209:3-5, and developed pain that was different and more severe than her previous pains, id. 213:18-214:4.[ 8 ] That evening, Bellew wrote to the Weisses to explain that she had "shooting pains and muscle spasms in [her] right hand and wrist," which she attributed to the ThermaCool handpiece. Def.'s Ex. 7 (Jan. 4, 2005 e-mail from Bellew).[ 9 ] On January 5, 2005, Bellew wrote again to say that she was "concerned about nerve damage," planned to schedule an orthopedics appointment, and would not be able to perform Thermage treatments until her hand had healed. Def.'s Ex. 6.[ 10 ]

On January 18, 2005, Dr. Thomas Brushart diagnosed Bellew with "irritation [of her] right ulnar nerve secondary to repetitive motion," which "appear[ed] directly related to her use of the Thermage machine." Pl.'s Ex. 8 at GOYAL:JHH:0010. Although Bellew never again used the Thermage device, her ulnar neuropathy and a resulting chronic pain syndrome have persisted. Pl.'s Dep. 51:13-20, 52:8-17, 209:15-16.

On January 2, 2008, Bellew sued Thermage for negligence, strict products liability, and breach of the implied warranties of merchantability and fitness for its ordinary purpose. Paper No. 1. On March 20, 2008, Thermage moved to dismiss the breach of warranty claims, Paper No. 5, and answered the other claims, Paper No. 6. On June 5, 2008, Judge Andre M. Davis denied the motion to dismiss and ordered Thermage to file an amended answer by June 19, 2008. Paper No. 12.[ 11 ] On October 31, 2008, Judge Davis granted Thermage's motion to amend its answer to include several new affirmative defenses. Paper No. 32. On November 18, 2009, Thermage moved for summary judgment. Paper No. 55. On February 23, 2010, Bellew moved to strike the statute of limitations defense to the implied warranty claims from the motion for summary judgment. Paper No. 66.

II. Analysis

A. Standard of Review

Under Rule 56(c), summary judgment "should be rendered if the pleadings, the discovery and disclosure materials on file, and any affidavits show that there is no genuine dispute as to any material fact and that the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(c). In considering a motion for summary judgment, "the judge's function is not . . . to weigh the evidence and determine the truth of the matter but to determine whether there is a genuine issue for trial." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249 (1986). A dispute about a material fact is genuine "if the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Id. at 248. The Court must "view the evidence in the light most favorable to . . . the nonmovant, and draw all reasonable inferences in h[is] favor," Dennis v. Columbia Colleton Med. Ctr., Inc., 290 F.3d 639, 645 (4th Cir. 2002), but the Court also "must abide by the affirmative obligation of the trial judge to prevent factually unsupported claims and defenses from proceeding to trial," Bouchat v. Baltimore Ravens Football Club, Inc., 346 F.3d 514, 526 (4th Cir. 2003).

B. Statute of Limitations for Breach of Warranty Claims

Thermage argues that Bellew's breach of warranty claims are barred by the four-year statute of limitations. Def.'s Summ. J. Mot. 10-11. Bellew moved to strike this affirmative defense from the motion for summary judgment, arguing that Thermage waived this defense by not timely raising it. Paper No. 66 at 6-12.[ 12 ]

Generally, a defendant waives the statute of limitations by failing to raise that defense in its answer or a pre-answer motion. See Fed. R. Civ. P. 8(c) & 12(b); Erline Co. S.A. v. Johnson, 440 F.3d 648, 653-54 (4th Cir. 2006). However, the court will "freely give leave" to amend pleadings "when justice so requires." Fed. R. Civ. P. 15(a)(2). The Court previously considered and rejected Bellew's argument that Thermage waived the statute of limitations defense by failing to raise it in the original answer and allowed amendment of the answer to include that defense. See Paper No. 28 at 13-14; Paper No. 32. Because Thermage asserted the statutes of limitations as an affirmative defense in its amended answer, see Paper No. 24, Ex. 2 at 10,[ 13 ] that defense was not waived and may be raised on summary judgment. Accordingly, her motion to strike the breach of implied warranties claims will be denied.

Under Maryland law, "[a]n action for breach of any contract for sale must be commenced within four years after the cause of action has accrued." Md. Code Ann., Com. Law § 2-725(1). Generally, a cause of action for breach of warranty accrues "when tender of delivery is made." Id. § 2-725(2). But if "a warranty explicitly extends to future performance of the goods and discovery of the breach must await the time of such performance [then] the cause of action accrues when the breach is or should have been discovered." Id.

Here, no explicit warranty extended the implied warranties to future performance of the Thermage device. Thus, a timely filing would have required Bellew to have been injured by a device delivered between January 2, 2004[ 14 ] and January 4, 2005.[ 15 ] Shipment records indicate that Thermage delivered a ThermaCool system to MLSVI in 2002; no Therma-Cool system handpieces were delivered to Dr. Robert Weiss or MLSVI from January 1, 2004 to January 5, 2005. Julie Hill Aff. ¶¶ 3-6, Nov. 16, 2009. Because Bellew did not bring her breach of warranty claims within four years of the ThermaCool handpiece's delivery, those claims are barred by the statute of limitations.

C. Statute of Limitations for Tort Claims

Thermage argues that Bellew's tort claims are barred by the three-year statute of limitations. Def.'s Mot. Summ. J. 11-18. Bellew argues that this issue cannot be decided on summary judgment because there is a question of fact about when the limitations period began. Pl.'s Summ. J. Opp. 8-33.

Under Maryland law, "[a] civil action at law shall be filed within three years from the date it accrues" unless otherwise provided by another Code provision. Md. Code Ann., Cts. & Jud. Proc. § 5-101.[ 16 ] To determine when a cause of action "accrues," Maryland follows the "discovery rule," which starts the limitations period when the plaintiff had notice of a claim. Pennwalt Corp. v. Nasios, 314 Md. 433, 550 A.2d 1155, 1165 (Md. 1988). Notice requires actual knowledge, either express or implied, of the facts underlying the cause of action. Id. at 1160, 1165-66.[ 17 ] Accordingly, in a products liability tort action, "the statute of limitations [does] not begin to run until the plaintiff knows or through the exercise of due diligence should know of injury, its probable cause, and either manufacturer wrongdoing or product defect." Id.

"[T]he party raising a statute of limitations defense has the burden of proving that the cause of action accrued prior to the statutory time limit for filing the suit." Newell v. Richards, 323 Md. 717, 594 A.2d 1152, 1156 (Md. 1991). To show that a plaintiff was on inquiry notice of her potential claim, the defendant must prove that "(1) the plaintiff[] knew of facts sufficient to cause a reasonable person to investigate further, and (2) a diligent investigation would have revealed that the plaintiff[]" suffered injury probably caused by the defendant's wrongdoing. Pennwalt, 550 A.2d at 1163-64; Quillin v. C.B. Fleet Holding Co., No. CCB-07-00503, 2007 WL 3103903, at *3 (D. Md. Oct. 11, 2007). "[Q]uestions of fact on which a limitations defense will turn are to be decided by the jury or, when sitting as a jury, by the court." O'Hara v. Kovens, 305 Md. 280, 503 A.2d 1313, 1323 (Md. 1986).[ 18 ]

Because Bellew filed this suit on January 2, 2008, her tort claims must have accrued on or after January 2, 2005 to be within the limitations period. The parties dispute when Bellew knew or should have known that she was injured and had a potential claim against Thermage.

Bellew argues that she was not on notice of her injury until January 4, 2005. In support of that position, she has produced an affidavit and deposition from one of her treating neurologists at Johns Hopkins, Dr. Beth Murinson. See Pl.'s Ex. 2 & 3. In her deposition, Murinson explained that neuropathic nerve injury can be difficult to diagnose and requires a "correlation of medical history with . . . diagnostic testing." Beth Murinson Dep. 113:9-13, 115:5-17, Jan. 13, 2010.[ 19 ] Murinson has testified that the symptoms Bellew experienced in 2004 may have "indicat[ed] that [her] ulnar nerve was being temporarily compressed" but that such "[m]inor temporary compression of the ulnar nerve does not ordinarily result in clinically significant injury to the nerve." Beth Murinson Aff. ¶ 7, Jan. 13, 2010. She further explained that "[t]here is no medical evidence . . . to prove . . . with certainty, that [Bellew] suffered a clinically significant, permanent injury during the initial period of months when she first used the Thermage device." Id. ¶ 7; Murinson Dep. 200:21-202:17, 205:2-14. By contrast, the severe and unabating pain that Bellew experienced on and after January 4, 2005, was indicative of a "clinically significant injury." Murinson Aff. ¶ 8; Murinson Dep. 111:16-113:6.

Consistent with Murinson's testimony, Bellew stated that, until January 4, 2005, she attributed her symptoms to normal pain associated with exercising new muscle groups. Her conversations with Thermage-experienced physicians, the transient nature of her symptoms, and her ability to gain relief using over-the-counter pain medications further reinforced her belief that the pain was "normal" and nothing to worry about. Although she may have known that the Thermage device was "conducive to developing a repetitive use injury" before January 4, 2005, Bellew did not suspect that she had suffered such an injury until that date.

Given this evidence, a reasonable jury could conclude that Bellew did not have notice of her injury until after January 2, 2005; accordingly, summary judgment must be denied.

D. Assumption of the Risk

Thermage argues that Bellew assumed the risk of injury because she recognized that the ThermaCool handpiece might cause a repetitive use injury and experienced symptoms of such an injury but continued to use the device until January 4, 2005. Def.'s Summ. J. Mot. 18-19.

To establish the assumption of the risk defense in a products liability action, the defendant must show that the plaintiff (1) knew of and appreciated the risk of danger, (2) voluntarily confronted that risk, and (3) was unreasonable in her decision to encounter the known risk. Ellsworth v. Sherne Lingerie, Inc., 303 Md. 581, 495 A.2d 348, 356 (Md. 1984).[ 20 ] The test of whether the plaintiff knew of, appreciated, and voluntarily confronted "the risk involved in a particular situation is an objective one . . . and ordinarily is a question to be resolved by the jury." Morgan State Univ. v. Walker, 397 Md. 509, 919 A.2d 21, 24, 26-27 (Md. 2007)(internal citations omitted). But, "when it is clear that a person of normal intelligence in the position of the plaintiff must have understood the danger, the issue is for the court." Schroyer v. McNeal, 323 Md. 275, 592 A.2d 1119, 1123 (Md. 1991).[ 21 ] If established, assumption of the risk is "a complete bar to recovery because `it is a previous abandonment of the right to complain if an accident occurs.'" ADM P'ship, 702 A.2d at 734 (quoting Warner v. Markoe, 171 Md. 351, 189 A. 260, 264 (Md. 1937)).

Here, the parties dispute, inter alia, whether Bellew appreciated the risk of danger and was unreasonable in her choice to continue delivering Thermage treatments until January 4, 2005. To support her argument that she did not fully appreciate the risk, Bellew has offered evidence that she (1) had limited experience with Thermage prior to her fellowship at MLSVI, (2) relied on the Weisses' assurance that her pains were "normal," (3) associated her symptoms in 2004 with new muscle use, and (4) used the device for only a few months before her injury occurred. Bellew also argues that, even if she appreciated the risk of danger, she has shown that her choice to continue delivering Thermage was reasonable because the Weisses had experienced similar pain without long-lasting injury and over-the-counter pain medication alleviated her pain entirely. Because a reasonable jury could find that Bellew did not assume the risk of her injury, summary judgment based on this defense must be denied.

III. Conclusion

For the reasons stated above, Thermage's motion for summary judgment will be granted as to the claims for breach of implied warranty and denied as to the negligence and strict liability claims.

The Thermage sumary judgement is here

Oklahoma Botox Case: Allergan loses $15 million judgement

Allergan lost a a$15 million dollar award to a physician who evidently had her 'friends' testify that she got botulism from Botox injections for wrinkles.

A jury Tuesday awarded $15 million to an Oklahoma City doctor who said she suffered botulism poisoning after using the popular anti-wrinkle drug Botox.

The Oklahoma County jury found 9-3 that Allergan Inc., the maker of Botox Cosmetic, was negligent. In civil cases, at least nine jurors must agree.

Jurors voted 10-2 to give Dr. Sharla Helton $15 million in actual damages. They did not award punitive damages.

"Hopefully, now people will wake up to the real dangers,” Helton, 48, said of the negligence verdict. "It’s a stepping stone for now for public awareness.”

Her attorney, Ray Chester, of Austin, Texas, said, "I think there’s a lot of people out there that have been hurt by the product and maybe now they’ll have the courage to come forward.”

Allergan that produces Botox plans to appeal.

"The negligence verdict … is inconsistent with all credible scientific and medical evidence,” said a company spokeswoman, Caroline Van Hove. "Botox does not cause botulism.”

Helton complained of severe side effects after getting injections of 50 units of Botox Cosmetic on July 14, 2006. It was her fifth treatment for wrinkles. She eventually sold her medical practice and stepped down as medical director of Lakeside Women’s Hospital in Oklahoma City because of pain and weakness.

Attorneys for Botox told jurors the drug does not cause botulism. They also told jurors the doctor never had botulism. They said the diagnosis of botulism came from her friends, who are not experts.

The trial took three weeks. Jurors were deadlocked 8-4 at one point Monday night after hours of deliberations. They deliberated about three hours more Tuesday.

The jury found Tuesday in Allergan’s favor on a second claim against it – that its product was somehow defective.

A key issue in the trial was whether Allergan gave sufficient warning in product labeling about possible problems from Botox Cosmetic use. The labeling in 2006 did not include botulism.

"All they care about is sales,” Chester told jurors in closing arguments Monday. "They were intentionally concealing this evidence.”

Allergan’s attorney, Vaughn Crawford of Arizona, argued that "every known and even remotely possible side effect was in the labeling.” He said the warning in 2006 even included the possibility of death. He said Helton still was willing to use it.

Jurors were instructed they could find negligence if they decided Allergan failed to act like "a reasonably careful pharmaceutical company would” under similar circumstances. One juror told The Oklahoman that the jury found negligence because Allergan’s 2006 product labeling did not have adequate information about side effects. The juror said the jury came to that conclusion after comparing a 2006 label with the 2009 label.

Millions have used Botox since the Food and Drug Administration first approved it in 1989. Helton said Tuesday she is still debilitated by weakness but hopes to get back to practicing medicine again in some way. story

I guess even physicians want to chase an ambulance when possible... Anyone have some thoughts?

Fake Botox: Houston physician sentenced

The fake Botox case in Houston comes to a close with this sentence handed down.

A Houston, Texas physician was sentenced to five months and 15 days in federal prison and three years of supervised release for injecting patients with fake Botox, prosecutors said on Friday.

Dr. Gayle Rothenberg is a local physician specialized in providing image enhancement services. She was also ordered to pay $98,426 in restitution to her affected patients. As a condition of supervised release, Rothenberg is prohibited from seeking reinstatement of her medical license.

Rothenberg and her former husband, Saul Gower, a local attorney, operated The Center for Image Enhancement located at 2000 Bering Drive in Houston.

Rothenberg ordered and administered a drug called Botulinum Toxin Type A that was labeled with the warning “FOR RESEARCH PURPOSES ONLY, NOT FOR HUMAN USE.” Despite this label, Rothenberg injected more than 170 patients with the substance and represented to patients that they were receiving Botox Cosmetic, manufactured by Allergan Inc.

Rothenberg also admitted that she advertised in brochures, magazines and websites that she specialized in treating facial wrinkles with Botox Cosmetic, even though she intentionally stopped ordering it due to the price increase in 2004 and began ordering the unapproved drug from a company named Toxin Research International because it was half the price of the other. She admitted that she did not tell her patients that they were receiving a different substance.

Gower pleaded guilty in 2008 to misbranding of a drug while being held for sale and making false statements to an agent. He then, cooperated with agents and testified against his ex-wife in exchange for a sentence of 4 years’ probation.

Son Of Botax

I was just reading the text of the proposed changes to the Healthcare reform bill. Hidden in the middle of dozens of pages is this gem:

IN GENERAL.—There is hereby imposed on the sale of any taxable medical device by the manufacturer, producer, or importer a tax equal to 2.9 percent of the price for which so sold.

Well guess what, people - Mr. Obama & company may have backed off on the 10% cosmetic surgery tax, but he's still sticking it to you with a 2.9% tax on implants and surgical supplies.  It would also increase the cost of lasers, liposuction equipment, and many other surgical and anesthesia supplies we all use.

That's in addition to the additional 3.9% tax you'll be paying for any profit on investment income. So, if you invested and "saved your pennies" like an honest, hard-working American, you might be penalized up to 6.8% for having cosmetic surgery!

This tax also would apply to pacemakers, stents, heart valves, cataract lenses, artificial hip & knee implants, motorized wheelchairs, and implantable defibrillators. As if these things weren't expensive enough! It's the "Son-of-Bo-tax". Boo!!!

From:  Tom Fiala, MD