Client Referral Rewards

Legitimate Marketing Or Unacceptable Practice?

Your client tells you they will send lots of friends your way, if only you will give them a discount for their goodwill. Or you decide that because your neighboring practice offers a $200 incentive for every referral, perhaps you should do this too in order to compete. You want to show your appreciation for the new business that might have otherwise incurred advertising costs, so why shouldn't you offer financial acknowledgement of the referral?

Hair salons and massage practices rely heavily on referral rewards programs. So why not Medical Spas or Cosmetic Centers? Well, if you are a physician and you offer consideration of any kind for referrals, you are in direct conflict with AMA Code of Ethics Opinion 6.021. You may also be violating your state Board of Medicine regulations, many of which simply defer to the AMA Code for ethical compliance. The opinion argues that the reward may incent the referring client to alter the information and expectations to others in an untruthful or unrealistic way. 

Early in my practice, prior to the AMA opinion, I succumbed for a short time to clients requesting rewards. The referred clients never seemed to have the same level of motivation to have a procedure as someone who came on their own accord. Now when a client asks me for a discount or a free service because they will send lots of friends, I simply tell them the following:

"A referral is the greatest compliment you could ever give me. And I appreciate the kind mention of your pleasant experience. I promise to always give you and those you send to me my very best work."

Is Technology Changing The Doctor-Patient Relationship (for the Worse)?

The first point of contact for a patient to ask post-surgical questions should be the surgeon who performed said surgery. The trend seems to be in exactly the opposite direction.

I've noticed a concerning trend. I participate in websites like RealSelf.com that connect plastic surgery patients and cosmetic surgeons. These sites are allowing patients to have near immediate access to expert plastic surgeons from across the nation and plastic surgeons to interact with potential patients.

In the past few months an increasing number of patients in the early post-operative period (some with dressings still in place!) have posed questions to “online surgeons” seemingly before seeking follow-up with the plastic surgeon who just performed the procedure. It is concerning that a patient would seek advice from a surgeon they do not have a doctor-patient relationship with and who is unfamiliar with the specifics of the surgery that they've recently undergone. Patients have even gone so far as to inquire about where to seek second opinions and whether revision surgery will be necessary all within the first post-operative week.

The early post-operative timing of this phenomenon is most concerning. This is the period in which we need to reassure our patients that bruising and swelling will resolve, dressings and sutures will be removed and that they truly will look great once they’ve healed. This period can cause patients significant distress and many require a lot of hand holding at this point.

We’re obviously failing some of our patients if they're reaching out online during this period instead of calling our offices and dropping in to be evaluated. I agree that second opinions are highly valuable and would not hesitate to arrange such for a concerned patient. However, a patient-initiated second opinion from an unfamiliar, online surgeon who has an incomplete picture of the patient's history is problematic at any time point let alone while the compression dressing is still in place!

What could possibly be responsible for this trend? As cosmetic surgeons are we so difficult to reach that our patients need to seek online advice from others? As we become more amenable to interacting with potential patients online are we failing to care for those who have already made a trip to our operating room? Is it simply easier for our patients to log onto a website rather than call the doctor's office? What can we do to direct those online inquires back to our own practices rather than into the digital ether?

As a Facial Plastic Surgery practice, my entire team is in the business of building relationships. If a patient has a professional, responsible and ethical plastic surgeon, the first point of contact to ask post-surgical questions should be the surgeon who performed said surgery. This trend seems about as far astray of that goal as one could imagine.

Has anybody else noticed this trend online? Have you experienced this with one of your own patients? What you have done to prevent this from happening in your practice? Please contribute your thoughts.

Defensive Medicine: New Survey

25% of every healthcare dollar spent with no purpose other than CYA defensive medicine and lawsuit protection.

Here's a quote from a survey about defensive medicine published by Jackson Healthcare that looks at defensive medicine and unnecessary testing.

The survey of more than 3000 physicians showed that 92% admitted practicing defensive medicine and that, based on physician responses, the annual estimated cost of defensive medicine in the US each year is $650 billion to $850 billion – accounting for $1 out of every $4 spent on US health care.

Of course, the physicians in the survey shouldn't be trusted since they're obviously biased and worried.

Instead, you should listen to the malpractice trial lawyers who have a much clearer opinion about why physicians order so many unnecessary tests and why 'defensive medicine' really doesn't impact the availablity of health care. Here's what lawyers think:

Lawyers who represent patients say one way to slash the exorbitant cost of health care would be to cut down on errors doctors make so that fewer cases wind up in the legal system. The American Association of Justice, an advocacy group for plaintiffs' lawyers, suggests that hospitals should more aggressively report mistakes and state medical boards should impose stiffer penalties on doctors who make them.

As a matter of public policy, it might make sense to spend less money as a society on unnecessary tests. But Jack McGehee, a Houston-based plaintiffs' lawyer, says it is difficult to convince ailing patients that their doctor should order fewer tests.

Ah the clarity that lawyers bring to an argument. It brings a tear to my eye.

While your cosmetic practice is probably not ordering tests, the same basic principals apply. Patients looking for vanity cosmetic treatments can be even more demanding of perfection since they're no expectation other than a perfect outcome.

Anyone have experience with this in a cosmetic practice?

Physicians Social Contract & Healthcare

At the Medical Fusion Conference this last weekend I was fortunate enough to get to hear Dr. Arlen Meyers speak. (You can listen to Dr. Arlen Meyers interview on the Medical Spa MD Podcast as soon as we release it.)

Dr. Meyers is very aware of the general malaise that physicians practicing medicine in the US feel and published this on LinkeIn which I thought was right on.

I've just returned from several meetings on healthcare IT and non-clinical careers. While there is considerable angst, confusion and outright anger over what's going on in healthcare, there are several things to consider:

1. During periods of change there are enormous opportunities. The challenge is to position yourself to identify them and arm yourself with the skills, networks and experience to capitalize on them.

2. Physicians have a social contract with society. We are afforded licenses, privileges, societal considerations and prestige by those we treat. Be careful advocating severing those contracts or unilaterally altering the terms.

3. Restructuring of the healthcare system , if done right, will allow those interested to leverage their abilities to treat more patients with the same amount of effort.

4. Doctors in the US make more money than the large majority of people in the world. Placing individual financial interest over societal and patient interest is understandable from a individual perspective, but, often won't pass the political smell test.

5. While you might feel dejected, unappreciated and stripped of your control, keep in mind that the initials after your name and the domain expertise you have, still commands respect in the business community and is highly sought. 

There is a tremendous amount of disruption that's happening in healthcare. Physicians who recognize how to take advantage of this are going to be far ahead when the music stops.

Allergan: $600 Million Poorer, but Closer to New Botox Uses

Sounds like Allergan may have been getting a little greedy and got busted....

Allergan, the maker of Botox, will pay $600 million in fines and civil settlements after pleading guilty to marketing their product for uses for which it hasn't been FDA approved.

The Justice Department accused Allergan of encouraging doctors to use the powerful neurotoxin through kickbacks and by teaching them how to forge drug reports.

"The FDA had approved therapeutic uses of Botox for only four rare conditions, yet Allergan made it a top corporate priority to maximize sales of far more lucrative off-label uses that were not approved by the FDA," U.S. Attorney Sally Yates explained.

Botox is most famous for its use by dermatologists to temporarily diminish the appearance of facial wrinkles, but the drug, which is scientifically known as Botulinum toxin and works by temporarily paralyzing nerves, has been approved for rare conditions like eye muscle spasms since 1989.  In March, the FDA approved Botox use to treat muscle spasms in elbow, wrist and finger injuries among adults.

According to the suit, Allergan paid doctors millions and taught them how to miscode the drug to avoid being caught, all so that they would use Botox for "off-label" treatments – uses for which it has never been approved, though it may be effective. Botox was promoted for migraine relief and juvenile cerebral palsy, for which observational data suggests it is effective.

When a drug has been approved for a certain medical use, it cannot be marketed to treat other uses, even if patients report those other uses as a side benefit. Still, marketing drugs for side benefits is common. In 2008, Bayer ran afoul of the FDA when it over-emphasized the acne reducing benefits of its popular birth control pill, Yaz.

Though off-label usage is legal and often beneficial for patients, it can be dangerous. In April 2009, after repeated reports of side effects among children with cerebral palsy that mimicked botulism poisoning, the FDA ordered Botox to carry "black box labeling," the strictest possible warning for a product.  Doctors reported respiratory problems, muscle weakness, loss of bladder control and double vision among their young patients, along with hospitalizations.

Currently, the FDA is reviewing Allergan's application to approve Botox for migraine headaches. The agency is not reviewing information on juvenile cerebral palsy and no known tests are in the works, though CBS is reporting that Botox is being tested in countries like India, Poland, Serbia and Turkey for a host of ailments, including Parkinson's disease, spinal cord injuries, excessive perspiration, depression and something called "curvature of the penis."

If any of these studies abroad provide conclusive data, they could potentially spur bids for approval of new uses of Botox in the United States.

Are the best medical spas making the most money?

Is you're medical spa providing the best medical care or just making the most money? Are they mutually exclusive?

There's a New Yorker article detailing the commencement address Atul Gawande Atul Gawande delivered this commencement address, titled “Money,” to the graduates of the University of Chicago Pritzker School of Medicine. It expands on the themes he touched on in his recent article about health-care costs in McAllen, Texas, which figured in President Obama’s speech on health care.

The text of this speech is available in this article in the New Yorker:

No one talks to you about money in medical school, or how decisions are really made. That may be because we’ve not thought carefully about what we really believe about money and how decisions should be made. But as you look across the spectrum of health care in the United States—across the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. And as you become doctors today, I want you to know that you are our hope for how this battle will play out.

Kevin MD has this on: Can doctors resist the lure of money?

That’s a tall order for many American physicians.

In his speech, which is an extension of his celebrated New Yorker piece, he looks at so-called “positive deviants,” or doctors who practice higher value, higher quality care, than everyone else.

What makes these doctors so special? In essence, they have to “resist the tendency built into every financial incentive in our system to see patients as a revenue stream.”

Indeed, “These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.”

Unfortunately, most American doctors fail to resist the allure of money. In some cases, it’s greed. But in many others, patients and business have to be intertwined simply to keep the doors open. Doctors cannot practice quality medicine while bankrupt.

Changing physician behavior needs to be accompanied by fundamentally modifying the incentives that influence doctors. Without radical physician payment reform, Dr. Gawande can implore future doctors to fight the financial incentives all he wants, but most will realize that resistance alone will be futile.

So where does that leave us? Are plastic surgeons and medical spas practicing medicine first, or business? How, if ever, does cosmetic medicine differ from 'real' medicine? Is there any ethical guideline that applies or is cosmetic medicine fundimentally different?

Are a dermatologists medical patients second class citizens?

There's been some debate about whether it's ethical for dermatologists to be focusing on treating cosmetic patients at the expense of skin cancer and other 'real medical' patients.

Here's an example via WPS:

NY Times Article: As Doctors Cater to Looks, Skin Patients Wait

“Cosmetic patients have a much more private environment than general medical patients because they expect that,” said Dr. Richey, who estimated that he spent about 40 percent of his time treating cosmetic patients. “We are a little bit more sensitive to their needs.”

Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists’ offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees.

In other offices, cosmetic patients spend more time with a doctor. And in still others, doctors employ a special receptionist, called a cosmetic concierge, for their beauty patients.

...According to a presentation for doctors from Allergan, the makers of Botox, a medical dermatology practice might have a net income of $387,198 annually, but a dermatologist who decreased focus on skin diseases while adding cosmetic medical procedures to a practice could net $695,850 annually. The same material advises doctors to “identify and segment high priority customers.”

Are Medspa Franchises Cheating Patients?

The following comment by Another Ex was left as part of the discussion on Dermacare Laser Clinics:

I as a doctor was pressured to sell elective procedures and product, which goes against the medical ethics that governed my practice for so many years.

The problem with getting a client in the treatment room and deciding that the sold package is inappropriate is that Dermacare (at least not in the corporate clinics) does NOT GIVE REFUNDS. I was performing 80 to 90% of the laser treatments and was not available to double check every recommendation made by the sale consultant before money was collected.

It is tough to sell $3900 worth of product to someone who would be better served by a plastic surgeon than by the 3D package.

A doctor cannot defend himself in a malpractice suit with the excuse that he was doing good business or doing what he was told by the office manager. When a nonmedical professional is in authority over a physician, the physician is still liable for the results of doing what he is told. I agree that good business is not always good medicine and vice versa. There has to be a compromise. No company, employer, or senior partner will take the hit for me in a malpractice suit. Ultimately, each doctor has to be responsible for his reputation and license.

I heard a rumor that a corporate medical director was left without corporate legal backup when appearing for a malpractice claim.

Double Dermadare You, any comments?

This comment touches on a point I've made repeatedly, that medical spa franchises using a business model designed to remove the physician as far from the patient as possible are inherently dangerous for the doctor as well as the patient.

While I don't recommend a 'money back guarantee', it's common for a 'sales force' to oversell the treatment leaving the patient dissatisfied. Happens all the time. I can see that physicians (and patients) could potentially find themselves in something of a quandry where the businesses main concern is to sell.

Manimal: Animal-human hybrid cloning

Whoa. Attention grabbing headline. While its still a ways from The Island of Dr. Moreau, it's not as far as it once was. 

Animal-human hybrid cloning deferred 

 
Controversial proposals to make embryos by merging human and animal material remain on hold following a decision on Thursday by the UK regulator of embryo research.

Under intense pressure from scientists to allow three UK teams to make the embryos, the Human Fertilisation and Embryology Authority decided instead to hold a public consultation on the issue.

hat tip: Inevitable.org/anism 

Wall Stree Journal Article on Medical Spa Franchises: Medspa boom is a bust for some

The following article on problems with medical spa franchises ran in the Wall Stree Journal. It's a telling article that points the finger at the current crop of medical spa franchises. I signed up and read it after Ron posted his comments on being an unhappy Sona owner.

Medspa Boom Has Become a Bust for Some

By RHONDA L. RUNDLE: November 21, 2006

Jeff Nebot thought he had struck gold. Two years after opening a laser hair-removal franchise in St. Louis, annual revenue hit $3 million. And over time, the lavish salon added other cosmetic services as Mr. Nebot joined the rush of entrepreneurs into the emerging business of medical spas. Medspas (also called medispas) offer such medical treatments as Botox injections and laser hair removal in a luxurious environment rather than a doctor's office. The field has been rapidly expanding in recent years as entrepreneurs and doctors alike have sought to profit from the dual quests of many affluent consumers: prettification and pampering. For an increasing number of those who entered the business, the boom is proving a bust.

"Several Sona franchisees, though not Mr. Nebot, are in private arbitration over problems that include misrepresenting a complicated business as a turnkey operation and failing to provide needed support. Sona officials declined to comment.

Several franchisees of Radiance MedSpa Franchise Group PLLC, a franchiser in Scottsdale, Ariz., say the company's financial projections overestimated revenue and underestimated initial start-up costs, including working capital.

The president of Radiance, Charles L. Engelmann, recently said: "There are currently 32 open stores and we will have 47 or 49 open by the end of the year. None of the stores have closed." He also acknowledged that some franchisees are attempting to get their money back.

"I can't be my own medical director any more, which is an added expense I can't afford," says one Florida physician who is not a dermatologist. He says he is "facing personal bankruptcy and trying my best to get out while there is something left for my family" after miscalculating what it would take to market, advertise and build his business. Indeed, many medspa owners are doctors who hope to make easy cash at a time when income is shrinking from their traditional medical practices.

You can read the entire article on the Wall Street Journal site here. It does require a subscription.