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Who Can Do What in a Medical Spa?

Posted By Administration, Friday, November 15, 2019

medical spa team

By Bala Mohan, JD, ByrdAdatto

As the new kid on the block, medical spas are breaking the mold of the traditional medical practice model. The merging of medicine and day spa services has created a new industry with multiple governing authorities to regulate it and the varying roles within it.

Most medical spas provide some combination of medical and aesthetic procedures—lasers, Botox, fillers, Kybella, microneedling, microdermabrasion, dermaplaning, chemical peels, dermabrasion and CoolSculpting. Often, this menu of services blurs the line between medical and spa treatments. While these procedures are considered medical in most states, exemptions exist in others. For example, the cosmetology boards of certain states allow aestheticians and cosmetologists to perform microdermabrasion and dermaplaning, as long as the procedure does not penetrate the dermal layer of the skin. On the other hand, more restrictive state regulating boards limit aesthetic and cosmetology practices to the topmost layer of the skin. This leads to the common question—who can do what in a medical spa?

The authority to administer medical aesthetic treatments follows a basic hierarchy:

  1. Physician;
  2. Nurse practitioner (NP) and physician assistant (PA);
  3. Registered nurse (RN);
  4. Licensed practical nurse (LPN)/licensed vocational nurse (LVN); and
  5. Aesthetician, cosmetologist and unlicensed personnel.

Physicians

Physicians have the broadest authority and often fill the role of owner or medical director in medical spas. The delegation of medical treatments to the rest of the staff falls under the supervision of these physicians, and sometimes NPs and PAs.

NPs and PAs

Certain states grant independent practice authority to NPs, and in those states, physician delegation or supervision is not required. Independent practice NPs can provide medical procedures falling under their scope of practice. Where NPs due not have autonomy, state laws generally indicate the level of physician supervision required for both NPs and PAs. In most cases, NPs practice in collaboration with a physician. Depending on the state’s laws, collaboration commonly follows written protocols (e.g., a list of delegated medical tasks, restrictions or limitations, prescriptive authority and level of supervision). Similarly, PAs usually practice pursuant to a supervision or delegation agreement, addressing their scope of practice and any applicable restrictions.

RNs

The scope of practice of an RN is more limited and subject to stricter delegation and supervision than that of an NP or PA. Unless state law dictates otherwise, a qualified physician or independent practice NP may delegate medical tasks to RNs, as long as the procedure is within their scope of practice and competency has been verified. If required, written protocols are delineated and appropriate supervision provided. If state laws do not define the level of supervision, the delegating practitioner must use their professional judgement to identify and engage in it appropriately.

LPN/LVN

The scope of practice of LPNs/LVNs is more limited and subject to stricter delegation and supervision than an NP, PA or RN. State laws generally dictate the medical tasks that a qualified physician or independent practice NP can delegate to LPNs/LVNs, whether written protocols are required, and the appropriate level of supervision. Similar to RNs, if state laws do not define the level of supervision, the delegating practitioner must use professional judgement to identify and engage in it appropriately.

Aestheticians and Cosmetologists

There is much confusion in the medical spa world about who is considered licensed personnel. While aestheticians and cosmetologists are licensed by cosmetology boards, they are considered unlicensed personnel by medical standards. They generally are permitted to perform spa procedures—e.g., facials and certain types of massages—that fall under their cosmetology licensure, but prohibited from doing anything requiring medical training.

Unlicensed Personnel

In addition to estheticians and cosmetologists, medical assistants (MAs) are considered unlicensed personnel for medical treatments and can perform treatments in medical spas only as state law allows. With limited to no medical training, these staff members generally are not permitted to perform medical or invasive procedures. Even if state law allows delegation, it often requires that the delegating practitioner provide onsite direct supervision during procedures. Delegation of medical treatments to unlicensed personnel must be approached with extreme caution.

From state to state, laws related to medical spa treatments vary from the very detailed to the very sparse, leaving room for legal interpretation.

AmSpa members receive a complimentary 20-minute Introductory Compliance Assessment with a ByrdAdatto attorney. Click here to learn how to join AmSpa today!

Bala Mohan, JD, knew from a very young age that her choice of career would be related to science because she excelled in her biology and chemistry coursework. With a strong passion for genetics and the desire to find a cure for her mother—who was diagnosed with diabetes at an early age—Mohan obtained a Bachelor of Technology in Pharmaceutical Biotechnology. Having worked as a scientific researcher during her undergraduate studies, Mohan greatly values attention to detail and is a meticulous person. She then pursued a master’s in Entrepreneurial Biotechnology to gain knowledge about business and startups. This landed her a position with Cleveland Clinic Innovations, where she evaluated over 100 innovations and negotiated deals with potential investors. In this role, Mohan had the opportunity to interact with business and health care lawyers from multiple health care organizations, and she quickly realized that her real calling in life was to be a health care attorney. Subsequently Mohan obtained her JD and was able to pursue a career that combined all her interests—science, business, and law.

Tags:  ByrdAdatto  Med Spa Law 

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The Pros and Cons of Becoming a Medical Director for a Medical Spa

Posted By Administration, Wednesday, November 13, 2019

medical director

By Alex R. Thiersch, JD, CEO of the American Med Spa Association (AmSpa)

The medical aesthetic industry is booming. According to AmSpa’s 2019 Medical Spa State of the Industry Report, the annual revenue for the industry as a whole is estimated to approach or surpass $10 billion in 2019, which would represent an increase of more than 919% from 2010. The number of medical spas in the United States has more than quadrupled since 2010—from 1,600 to an estimated 6,582 in 2019—and the average medical spa brings in more than $1.5 million in revenue.

Thus, it makes sense that an ambitious dermatologist might be curious about joining or founding a medical spa as a medical director. And although it certainly seems to make sense to join a flourishing industry, there are also a number of reasons why you might not want to take that leap. Here are some pros and cons of becoming a medical director for an aesthetic practice.

Pro: Money

Dermatologists are among the specialists known in the medical spa industry as “core doctors”—doctors whose specialties align with the industry in fundamental ways. Core doctors tend to incorporate their medical spas into their existing practices, which is a less lucrative business model than running them as a business independent of their practices. However, the money still can be exceptionally good, especially if the dermatologist in question allows his or her medical spa to be run as an independent arm of the business by people who understand how to effectively market and promote a more retail-focused business.

Now is the time to earn your money in the medical aesthetics industry. AmSpa’s report suggests that the value of the industry is projected to double in the next five years, and given that it projects a fairly conservative rate of growth compared with those of recent years, the actual rate of growth could be even higher. Dermatologists are in a uniquely advantageous position to benefit from this.

Con: Compliance

When you are the medical director of a medical aesthetic practice, you are responsible for all aspects of the medical side of the business, and that includes compliance. You not only need to be sure that you are properly delegating and supervising the procedures being performed at the practice, but also create protocols for the non-medical employees of the practice in order to make sure they remain compliant with the regulations that govern medical practices in your state.

AmSpa members receive a complimentary 20-minute Introductory Compliance Assessment with a ByrdAdatto attorney. Click here to learn about this and many other benefits of becoming a member.

Pro: Referrals

As stated earlier, dermatologists who operate medical spas typically incorporate them into their existing practices. When this arrangement is properly carried out, a medical spa can create referrals to the dermatology side of the business. However, it is important to understand that creating referrals cannot be the primary reason to add a medical spa to the practice. As previously mentioned, a medical spa must be operated as a separate entity, since a medical spa is significantly different than a dermatology practice in form and function. A medical spa should be able to succeed on its own terms, regardless of what is going on with the dermatology practice.

This might be difficult to come to terms with. I’ve spoken with several core doctors who have had bad experiences with running medical spas, and they can hardly believe that the industry is as successful as it is. Invariably, they went wrong by viewing their medical spas as existing primarily to drive business to their main practices. This can’t be the primary reason you run a medical spa. Any referrals you receive from your medical spa should be viewed as a bonus.

Con: Hands Off

Serving as the medical director of a medical spa is more work than you might imagine, but it may not be the type of work you’re used to or prefer. An effective medical director needs to trust his or her staff to conduct most of the everyday treatments at a medical spa, and this may be difficult for a physician who is used to performing treatments and consultations with his or her patients. Unfortunately for dermatologists who enjoy this aspect of their work, it just doesn’t make sense to be hands-on with the high-volume medical spa side of your business when you could be doing more lucrative work at your dermatology practice. There are only so many hours in the day, after all.

This also speaks to the importance of maintaining a qualified, conscientious staff. You have to be able to trust the people who work under you, and that requires you to pay very close attention to who you hire and how they’re performing. At the end of the day, the medical aspects of the medical spa are the physician’s responsibility, regardless of whether or not he or she is on the premises.

Understanding the Commitment

Owning a medical spa is a great, fun way for dermatologists to supplement their income, but do not underestimate the amount of work you will need to do to make it a success. Serving as a medical director is a major commitment, and it’s best to approach it with realistic expectations.

For legal updates and business best practices delivered straight to your inbox, subscribe to AmSpa’s email newsletter. For more information on how AmSpa can help your practice operate legally and profitably, Contact Us online or call us at 312-981-0993.

Tags:  Business and Financials  Med Spa Ownership  Med Spa Trends 

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Home-grown Success

Posted By Administration, Monday, November 11, 2019

rejuv fargo north dakota

By Michael Meyer, Content Writer/Editor, American Med Spa Association

According to the U.S. Census Bureau, the population of the Midwest—which includes Ohio, Michigan, Indiana, Illinois, Wisconsin, Minnesota, Iowa, Missouri, Kansas, Nebraska, South Dakota and North Dakota—represented approximately 21% of the U.S. population in 2018 (the most recent year for which this estimation is available). However, according to AmSpa’s 2019 Medical Spa State of the Industry Report, the Midwest is host to approximately 24% of the medical spas in the country, an increase from 22% in the 2017 report. This represents the largest positive discrepancy between the population and the number of medical spas in any of the four census-recognized regions.

So why are there so many med spas in the Midwest, and why is the number growing? Simply put, demand is exploding. Consider the story of Radiant Divine Medical Spa, which opened in Brecksville, Ohio, in suburban Cleveland, in May 2017.

“After the first six months, we were at about $500,000 in sales, so I’m like, this is something—we’ve got something here,” says Ryan DeVault, Radiant Divine’s co-owner. “We had demand from other areas and other markets, so we opened up another medical spa about 25 miles away in Avon, Ohio. I signed that lease in January 2018. Then we had demand from another market that was about 25 miles south of us in Medina, Ohio. I signed that lease for new construction in June of 2018 and we opened up in October of 2018, so we turned one practice into three spas in the first 17 months.”

According to DeVault, Radiant Divine is on pace for $3.5 million in revenue across its three sites in 2019. (Author’s note: Read more about Radiant Divine in the “Cleveland Rocks” a little later in this article.) And although not every medical spa owner has the same ability to open new locations, many in the Midwest have discovered that the path to profitability leads to some far-flung places that one would not necessarily consider to be hotbeds for aesthetic services.

Dakota Dreams

Fargo, North Dakota, is the 222nd-largest city in the United States, with an estimated population of 124,844 in 2018, so it is not exactly a sprawling urban center. Its economy has traditionally been associated with agriculture, and farm families are not generally thought of as traditional medical spa customers. However, Fargo is growing—its population has more than doubled since 1980, and it has increased 18.3% since 2010—its economy is diversifying, and, perhaps surprisingly, it is home to one of the country’s most consistently successful medical spas.

Rejuv Medical Aesthetic Clinic opened in 2005 with 1,500 square feet and three employees. Today, it operates out of a 12,000-square-foot facility, has 40 employees and is on track for approximately $8 million in revenue in 2019.

“We’ve had 15 years consecutive growth at a minimum of 20% every year,” says Melissa Rogne, president and founder of Rejuv. “We really haven’t struggled in finding an audience, and we really have always defied what the typical aesthetic patient is supposed to look like. We’ll tell stories where some of our patients come in and they bring us eggs from their farms. We really feel like Rejuv has broken down the stereotype of what a typical aesthetic patient’s profile is.”

Conventional wisdom suggests that having a large population base is necessary for medical spa success. However, Rogne believes that being part of a smaller, more insular community actually works in the practice’s favor.

“Because of the tight-knit community, the referral network is alive and well, and we’re able to really capitalize on the good nature of the people in this area,” Rogne says. “The Midwest is known for having the friendliest people in the United States, and that’s true. Those people want to tell their friends, they want to see you succeed and they know you really genuinely care about them.”

However, despite its size and success, Rejuv is not the only game in town, which speaks to the medical aesthetic industry’s growth in recent years.

“One of the things that people think is that there’s no competition; it’s actually quite the opposite,” Rogne explains. “I did some research about a year ago, and we have essentially one aesthetic medical spa for every 5,000 people in this community. The competition is extremely stiff—it’s not what people think it is.”

Royal Treatment

To Rogne’s point, according to AmSpa’s 2019 Medical Spa State of the Industry Report, there are an estimated 6,582 medical spas in the United States, up from approximately 1,800 in 2011. Back then, it was possible to find markets in the Midwest that simply were not being served at all, and that is how aNu Aesthetics and Optimal Wellness in Kansas City, Missouri, came to be.

“Where we started, there was a really big void of providers,” says Cristyn Watkins, MD, founder, owner and medical director for aNu. “There was really nobody around us.”

For several years, Watkins and her partners—a nurse practitioner and two other doctors—kept their practice low-key, working evenings and weekends as time permitted and building up a devoted patient base.

“The nice thing was that, since we were all small-business owners and this was kind of our side job, everybody had our cell phone number, we e-mailed every single patient after we saw them, and we were our own schedulers,” Watkins explains. “Our patients really liked the fact that they had access to a physician who cared for them and who they had direct access to.”

During this time, aNu’s reputation grew via word of mouth, and when Watkins decided to dedicate herself to the practice full-time in February 2016, business “went crazy.” The practice moved to a new 6,000-square-foot location in November 2017, and it is projected to bring in $3.5 million in revenue in 2019. Watkins refuses to rest on her laurels, however—she is doing everything she can to spur on aNu’s growth, and that means doing everything she can to give her patients what they want.

“Between medical aesthetics and wellness, you have to be on the cutting edge all the time,” she says. “If there’s something I’m interested in or my staff is interested in, we usually implement it within about 90 days, if it’s got good ROI and I think it’s something we should be doing. You have to always be figuring out what the new thing is in order to make it [to the top], I truly believe. But I also believe that if you care about your patients and you take care of them, that they’ll take care of you.”

Cleveland Rocks

Compared to Rejuv and aNu, Radiant Divine is an overnight sensation; however, although the spa itself has only been open since 2017, its primary provider, Rachel DeVault, RN—Ryan’s wife—has been building a reputation in the Cleveland area for far longer.

“My wife became an RN in 2010,” Ryan says. “She was working just regular hospital jobs, and then a friend of ours opened up a medical spa in the back of his tanning salon. He knew she was an RN and introduced her to aesthetics. She just has a niche for it. She grew his injectable practice from zero to 200 people in about 60 days. She created the following for him.”

Since then, Rachel has become an expert injector. She is currently a Galderma GAIN trainer, and not surprisingly, her loyal clients from those early days formed the foundation of Radiant Divine’s success.

“We didn’t solicit any of her old people—they found us,” Ryan says. “We didn’t do really any forms of advertising. The website was not the strongest. But it just seemed to be that word of mouth and referral was our best source.”

Close to Home

The success of these practices demonstrates the value of establishing a reputation for exceptional service, particularly in places where members of communities are close and inclined to recommend businesses that provide what they promise. However, there are certain disadvantages to working in places that are off the beaten path for aesthetic professionals.

“For us, probably the biggest issue has been hiring,” says Rogne, of Fargo’s Rejuv. “It’s really difficult for us to find people who have experience in this industry in a smaller market like ours. We’ve really had to invest a lot in training people and bringing them up new in this industry. We don’t get to just hire a nurse injector—we have to create a nurse injector. Without a doubt, the biggest challenge for us is the availability of human resources and staffing.”

“It’s always staff,” agrees aNu’s Watkins. “It’s always finding a good front-desk person and a manager.”

However, dealing with issues such as these is a small price to pay for home-grown success.

“I’ve lived here forever, she’s lived here forever,” says Radiant Divine’s Ryan DeVault of his wife, Rachel. “It’s an area I’m familiar with. I know a lot of people here and I know the approach and I know what they’re looking for—the services they’re interested in. I feel we can accommodate our market because we’re familiar with it. Can we do this in different market? I don’t know, but we know this market. Cleveland’s home, you know?

Tags:  AmSpa's 2019 Medical Spa Statistical Survey  Business and Financials  Med Spa Trends  QP 

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Proposed Changes to Texas Rule §193.17 Now Available for Comment

Posted By Administration, Friday, November 8, 2019

texas capitol

By Patrick O’Brien, JD, legal coordinator, American Med Spa Association

As we covered previously, the Texas Medical Board (TMB) voted to officially propose a set of changes to Texas Administrative Code Rule §193.17—the rule that provides guidance of the delegation of nonsurgical medical cosmetic procedures. The TMB proposed some changes at a stakeholder meeting in early October (covered here) but did not publicly disclose the final version it approved for publication; it instead intended the publication in Texas Register to serve as the changes’ public debut. The wait is over—this week’s issue of Texas Register contains the TMB’s proposed rule changes (starting on page 6669).

These proposed changes are broadly similar to the initial version discussed at the stakeholder meeting in early October. However, this approved version makes significantly more minor adjustments than the original proposal would have. The prior version would have made significant changes to who can perform procedures and what supervision is needed; the proposed version maintains the current rule and permits physicians to delegate to both licensed and unlicensed people, provided they are “qualified and properly trained.” Similarly, the proposed rules still require that supervision be provided by an advanced practice registered nurse (APRN) or physician assistant (PA) who is onsite or by a physician who may be offsite. The current rule requires that the physician be available for emergency consultation, whereas the proposed rule would require the physician’s “immediate availability… for consultation.” The proposed language does clarify that supervision does not require direct observation.

This new proposal also makes a significant addition to the current rules by adding a requirement that the physician notify the board of their intent to delegate and supervise medical spa-type procedures. This notification would be made on a board-supplied form and would include:

  • Information on the business’s owner, location and phone number;
  • A list of all PAs, APRNs and qualified persons who will be performing procedures; and
  • The name and license information of the supervising physician.

This document would need to be updated within 30 days of changes, additions or terminations.  Additionally, the physician would need to secure an alternate supervising physician if they are unable to provide supervision. The proposed rules go on to state that all physicians who delegate and supervise procedures are responsible for ensuring compliance with all applicable rules and laws, and violations are grounds for discipline. 

It is important to remember that these are only proposed changes—they are not yet official or final. We are currently in a 30-day window during which members of the public can submit comments and feedback. At the end of the 30 days, the TMB, at a public hearing, will vote on whether to formally adopt the changes as they are currently written or to make modifications as a result of public comments. If you would like to submit feedback to the TMB, it can be sent to the attention of Rita Chapin at:

P.O. Box 2018
Austin, Texas 78768-2018

It also can be emailed to rules.development@tmb.state.tx.us.

For legal updates and business best practices delivered straight to your inbox, subscribe to AmSpa’s email newsletter. For more information on how AmSpa can help your practice operate legally and profitably, Contact Us online or call us at 312-981-0993.

Tags:  Med Spa Law 

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The Power of Patient Retention

Posted By Administration, Wednesday, November 6, 2019

patient retention

By Terri Ross, Terri Ross Consulting

Patient retention is a very powerful—and sometimes overlooked—way to rapidly expand your medical aesthetics practice. Why? Because once you’ve captured the interest of your patient population, the hard work is done. At this point, making genuine connections and encouraging them to take action are your primary goals. They can be achieved through engaging conversation, personalized treatment plans and intentional follow-up. Patient retention is directly correlated with how well your front office staff performs, their ability to educate and, more importantly, how well the consultation is conducted by the medical provider.

Is every staff member in your office engaging, direct and knowledgeable of the services and treatment plans you offer? (Click here to read more about the LAER model I developed for staff training.) Another key aspect of patient retention is related to your brand as a medical aesthetic office—i.e. the level at which you perform, as evidenced by a top notch facility, expertise, state-of-the-art equipment and marketing efforts that match the brand. Sophisticated and educational marketing materials relay a consistent message to your patient population—they should choose you for their medical aesthetics needs.

Why Is Patient Retention So Important?

Focusing on your current patient population is the best way to rapidly increase your profitability. Invest in high-quality staff, branding and technology, and gear these elements towards encouraging your current patients to take action. Research shows that increasing your patient retention by 5% increases your profitability by more than 25%. The concept is simple: your current patient population, including both new and established patients, has already expressed some level of interest in your practice. Your goal now is to capitalize on this interest, gain their trust and guide them toward taking action—whether that is scheduling a consultation appointment or moving forward with a personalized treatment plan that includes multiple treatments; this will do two things: ensure a better outcome and protect their investment.

Key Elements to Maximize Patient Retention

Engaging staff: Every member of your front office staff should strive to make a connection with your patients, both new and established. As outlined in my LAER model for staff training, it is critical that your front office staff listens, engages and responds to patient questions and needs. They should be proactive in their patient interactions. Ask a new patient if they’d like to read some new literature on the procedure in which they expressed interest. Ask an established patient if they’re interested in a new promotion that would extend their current treatment plan.

In addition to being proactive, your front office staff should be knowledgeable about all aspects of the treatments you offer and the aesthetics industry as a whole. Having had the pleasure of working with many practices, I know this is one area that is sadly overlooked. Staff members should know what procedures and treatments you offer, how they can be incorporated into a treatment plan, and how they compare to your competitors. It is critical that your staff is capable of discussing your technology and services, so that patients are encouraged to choose your practice over another. Patients want to feel like their needs are not only being met, but also being exceeded. This is what makes that lasting impression—the one that makes new patients commit to a treatment plan and keeps established patients coming back, year after year.

Consistent marketing: Be consistent in your marketing efforts. Find your niche in the market of medical aesthetics practices and commit to it. This applies to everything—from the font style of your website to your business statement to your appointment cards. Patients want to feel like they’re coming back to a familiar place when they visit your office or website. This familiarity is established by an inviting atmosphere, sophisticated décor, office-branded brochures and pamphlets, regular e-newsletters, and a streamlined and informative website.

  • Office space: The physical structure of your medical aesthetic office—including the building, exterior sign, interior waiting area and treatment areas—sets the tone of your patient’s experience. The waiting area is where your patient’s experience begins and ends. An inviting, sophisticated and well-conceived space can create a familiar environment to which patients want to return. Clean, accommodating treatment areas, equipped with cutting-edge technology, convey a clear message of expertise and professionalism to your patients. The bottom line is this: If a patient enjoys their experience in your office and receives top-notch, personalized care, they will return.
  • Technology: Commit to being the expert in your niche of the medical aesthetics field and acquire the equipment to make it happen. Align your passion and expertise with the newest technology and make it available to your patients. Patients don’t want to feel sold on any and every treatment out there, but if they feel that you are the expert in a specific treatment, and this is supported not only by your knowledge as a clinician, but also in the technology available in your office, they will be encouraged to choose you for this treatment.
  • Brochures and pamphlets: Devote a significant portion of your overall marketing budget to creating and maintaining office-branded literature. Develop brochures for each major treatment or service you offer, going through general information about the treatment, relevant technology and how your office excels above the rest. Include your office name, logo, statement and contact information on each brochure. Personalized brochures relay a sense of expertise and sophistication to your patients and encourage them to follow through with a plan of action in your office.
  • E-newsletters: Beyond office literature, it is important that you send out regular, informative and branded e-newsletters. Either monthly or quarterly, send a newsletter to your patients outlining new technology, promotional treatment plans, new staff and/or new expertise. Did you recently acquire a piece of technology that will greatly expand your treatment options? Did you hire a new team member who adds specific and impressive expertise? Highlight this information. Keep your patients informed and engaged. If they get the impression that your office is constantly growing, diversifying and moving forward in the field of medical aesthetics, they will want to choose your office. This will not only increase patient loyalty, but also will encourage current patients to try new options, leading to increased treatment appointments and increased profitability.
  • Website: Just as your office serves as the physical representation of your brand, an organized, streamlined and informative website defines your brand online. Make sure your office information, logo and contact information are visible on each page. Keep fonts and styles simple and sophisticated. Clearly outline the treatment and service options you offer, making sure the site is optimized so it ranks on the first page of Google during web searches—and emphasize what makes your office stand out among the competitors. Provide enough information to portray your expertise in the field while encouraging new patients to contact you for additional information. This will lead to increased patient conversion and patient retention. Your website is your virtual brochure—it’s the first place patients look so when they get to your site, so keep them there. Your website should generate more than 100 leads per month. If it’s not, something is wrong.

Personalized Follow-up: Your front office staff should make a proactive, regular effort to follow up with patients. Particularly after introductory or consultation appointments, when new patients may have unanswered questions or concerns, it is critical that your staff remains in touch. Make it a policy to check in with every new patient one week after their first treatment appointment to verify that the treatment was successful and to gauge their satisfaction. It is key that you address any patient concerns as quickly as possible. You want every patient to feel important; this is what will make them return. It’s important to stay in touch with established patients as well—inform them of any new technology, treatment plans or promotions available to them, and encourage them to take action.

If you want to quickly increase the profitability of your office, focus on patient retention. It cost eight times more money to gain a new patient than it does to nurture the ones that you have.

Schedule a strategy call with me and take the first steps towards optimizing your business and improving patient retention today.

Terri Ross brings more than 20 years of sales and management experience to the field, having worked with leading-edge medical device companies such as Zeltiq, Medicis, EMD Serono, Merck Schering Plough and Indigo Medical, a surgical division of Johnson.

Ross’ vast knowledge and experience as a sales director managing upwards of $20M in revenue and successful teams has allowed her to become a renowned plastic surgery management consultant helping aesthetic practices thrive.

To optimize revenues and business performance, Ross’ practice management consulting services help physicians evaluate practice processes including, but not limited to, overall-operating efficiencies, staff skill assessment, customer service and operating efficiency strategies. The goal is to develop a comprehensive plan of action to improve productivity, quality, efficiency and return on investment.

Tags:  Business and Financials  Med Spa Trends  Terri Ross Consulting 

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What Medical Spa Owners Need to Know About LLC Taxation

Posted By Administration, Monday, November 4, 2019

tax forms

By James M. Stanford, JD, Partner, ByrdAdatto

Fake or Real: My company is taxed as an LLC—Fake!

There is no such thing as being taxed as a limited liability company (LLC).

Clients, as well as tax and legal professionals, routinely confuse entity structure with tax classification. Quite commonly, we hear clients state that an entity is taxed as an LLC when, in fact, no such tax classification exists.

Many people do not realize that when forming an entity—such as a medical spa—typically there are two principle filings. Understanding the difference can alleviate a lot of confusion.

  1. The first filing is at the state level, which incorporates the company as a legal entity (i.e., filing as a limited liability company).
  2. The second filing—or filings—are with the Internal Revenue Service to obtain an employer identification number. This filing determines how the new entity will be treated from a federal tax perspective.

An LLC is purely a state-level entity structure. In turn, the LLC elects how it will be taxed: either as a partnership, an S corporation, a C corporation or a disregarded entity. Generally, when someone says they are taxed as an LLC, what they really mean is that they are taxed as a partnership.

AmSpa members receive a complimentary 20-minute Introductory Compliance Assessment with a ByrdAdatto attorney. Click here to learn how to join AmSpa today!

James M. Stanford is an attorney and partner at the ByrdAdatto law firm. From transitions, mergers, and acquisitions to structuring complex ownership arrangements, James enjoys the personal reward that comes from bringing parties together and making deals happen. James practices primarily in the areas of health care and corporate law with a focus on intellectual property. A proud father, Jim served in the U.S. Army and is fluent in Russian. In his spare time, he enjoys hunting, fishing, and spending time outdoors.

Tags:  Business and Financials  ByrdAdatto  Med Spa Law 

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California Continues History of Limiting LVNs and MAs in Medical Spas

Posted By Administration, Friday, November 1, 2019

nurse

By Patrick O’Brien, JD, legal coordinator, American Med Spa Association

Every state has differing rules about what types of tasks and procedures may be delegated to licensed vocational nurses (LVNs) or unlicensed medical assistants (MAs). Usually, LVNs and MAs have a more restricted scope of practice when compared to that of a registered nurse (RN). California, in particular, greatly restricts what MAs and LVNs may do, and it has a history of publishing information confirming this. Recently, it appears that the state’s licensing boards have been increasing enforcement of these restrictions through the use of undercover investigators visiting medical spas. So, in the interest of compliance, now is an excellent time to review what MAs and LVNs can and can’t do.

California defines the specific tasks that MAs may perform in statutes and rules; this leaves very little room for differing interpretations. This differs from the norm in that it the majority of other states only provide general rules or guidance. An MA in California is authorized to perform “basic administrative, clerical and technical supportive services.” Technical support services include listed tasks such as administering medication, performing skin tests and non-invasive specimen collection. The Medical Board of California (MBC) offers a number of resources to help determine what qualifies and what doesn’t. For general questions, it has provided a lengthy FAQ that provides very helpful guidance. You will note that MAs may inject medication in some circumstances; however, that does not include the injection of Botox, as the MBC makes clear elsewhere. MAs also are strictly prohibited from administering any type of laser, intense pulsed light, radio frequency, microneedling, microdermabrasion or chemical peel procedure. As such, MAs would be extremely restricted in a medical spa setting and unable to perform nearly any of the common procedures.

LVNs in California, by the nature of being licensed professionals, do enjoy a much broader and varied scope of practice. LVNs are licensed to perform “services requiring those technical, manual skills acquired” in approved vocational nursing courses. This permits LVNs to perform tasks such as injecting medication, withdrawing blood and starting IV fluids, when directed by a physician. Once again, however, LVNs are very limited in a medical spa setting in California. Like MAs, LVNs are not able to inject Botox, use lasers or light-based devices, or provide microdermabrasion services.

AmSpa also has become aware that the TMB is increasing its enforcement for these types of procedures by using undercover investigators who pose as potential customers. From the limited information available, it is not entirely clear if the investigators are acting based solely on the procedures offered or if they also are looking for insufficient or improper physician oversight. Regardless, LVNs who offer Botox and filler injections are subject to disciplinary hearings for practicing outside of their scope. If you want to learn more about the Board of Vocational Nursing’s Enforcement Division, you can read more here.

In the past, we have discussed the importance of remaining compliant and operating within each license’s scope of practice (here and here, for example). A board investigation such as those mentioned above can be a much greater problem than it appears. The LVN can be disciplined for acting outside of their scope of practice and may have their license suspended or revoked. The physician may also be subject to discipline from the MBC for aiding in the unlicensed practice of medicine or providing inappropriate supervision. They also can be subject to penalty, including suspension or revocation. If that were to happen, every other nurse or physician assistant at that medical spa would be out of a job unless there was another physician in the practice who could supervise.

If you would like to learn more about the practice and structure of medical spas, plus all of the latest trends and best practices, attend The Medical Spa Show 2020 in Las Vegas from January 31 – February 2, 2020.

Tags:  Med Spa Law  The Medical Spa Show 2020 

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How Forming an LLC Can Help Your Medical Spa

Posted By Administration, Wednesday, October 30, 2019

llc

By Courtney P. Cowan, JD, ByrdAdatto

Beginning Labor Day Weekend through the first few weeks of 2020, you will find ByrdAdatto attorney Robert Fisher proudly wearing the same red fishing shirt imprinted with the distinctive University of Georgia “G” logo. That garish shirt signals to everyone in the office that college football is upon us. We take football seriously at ByrdAdatto—and in the state of Texas, generally—so it seemed fitting to compare the similarities of our two loves of college football and limited liability companies (LLCs). “What could these two things possibly have in common?” you ask. The answer is simple: absolutely nothing.

But that hasn’t seemed to stop people, particularly college football coaches, from using LLCs as a means of conducting business. Originally used as a way to circumvent the optics of making more money than prominent state officials, collegiate head coaches formed LLCs to function as depositories for the large amount of supplemental income they received in addition to their base salaries. A recent Dallas Morning News article detailed some of the reasons for doing this, including tax relief and liability protection.

While we appreciate the publicity the head football coaches bring to the LLC, these reasons are not novel to those familiar with this business structure. Many business owners, accountants and attorneys have long been proponents of the LLC due to the advantages offered by it, including:

  • Tax flexibility: The LLC can elect to be taxed as a disregarded entity, partnership or corporation (s-corporation or c-corporation). By default, an LLC is taxed as a “pass-through entity” (i.e., a disregarded entity or partnership, depending on the number of members), meaning all of the profits and losses of the LLC “pass through” the LLC to the members, who then report the profits and losses on their personal tax returns. The LLC itself does not pay federal income taxes, unless it elects to be taxed as a c-corporation.
  • Limited personal liability: The owners (members) of an LLC are protected from the liabilities and creditors of the LLC as long as the LLC is formed and operated properly. Moreover, LLCs provide protection against outside liabilities (i.e., the liabilities of the other members).
  • Perpetual existence: The LLC can survive the death of its owners. This means the business will survive even if its owners do not.

Whether you are a Power Five coach making millions or a small medical spa, virtually anyone can form and take advantage of the benefits of an LLC.

AmSpa members receive a complimentary 20-minute Introductory Compliance Assessment with a ByrdAdatto attorney. Click here to learn how to join AmSpa today!

As the daughter of a periodontist, Courtney P. Cowan has been fascinated by the health care field since childhood. She often accompanied her father to his office, where she developed an appreciation for physicians and their respective practices. Having absolutely none of the dexterity that is required to be a surgeon, however, Cowan instead decided to pursue a degree in business while attending Baylor University. It wasn’t until she was required to take a business law course that she discovered her passion for the law. After graduating from Southern Methodist University Dedman School of Law, Cowan serendipitously connected with ByrdAdatto and now assists clients by combining her business background with her enthusiasm for health care and the law.

Tags:  Business and Financials  ByrdAdatto 

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What to Look for When Purchasing a Laser

Posted By Administration, Monday, October 28, 2019

laser treatment

By Alex R. Thiersch, JD, CEO of the American Med Spa Association (AmSpa)

Laser treatments are a staple of the medical aesthetic industry. According to the American Medical Spa Association’s (AmSpa’s) 2019 Medical Spa State of the Industry Report, laser hair removal is offered by 59% of medical spas, and it is the second-most common procedure for a first-time patient, so it actively brings patients into practices. Additionally, the report found that 29% of medical spas offer full-field ablative laser skin resurfacing. What’s more, 8% of medical spas that don’t offer laser hair removal and 5% of medical spas that don’t offer laser skin resurfacing are considering adding them.

In order to perform any of these laser treatments, however, the proper equipment must be acquired. And that can be more expensive and complicated than one might imagine.

Laser Overview

In recent years, a number of new companies have begun offering laser equipment designed for use by medical aesthetic practices, which has resulted in unprecedented competition. This equipment can be very expensive, costing as much as $250,000, so the stakes in the market are very high.

The representatives who sell this laser equipment typically are compensated, at least partially, on commission, and the commissions they can make are substantial. As is typically the result of commission-based compensation plans, the reps are very motivated to close the deal. Potential clients often forget this fact when they are shopping for a new machine, but savvy consumers always will remember that the sales reps, even at the most reputable companies, make most of their money when they actually sell a machine. Because of this, some reps can be very aggressive.

Although there are many reputable laser companies with very knowledgeable, considerate reps, some other companies employ laser sales reps who act in an unscrupulous manner because of the potential for lucrative commissions. This is the primary reason why you should work with reputable companies with established track records.

Unscrupulous reps often pressure potential customers to make a decision immediately, before they have a chance to truly evaluate their options. These reps will tell customers that they are on a tight timeframe or that they have limited-time discounts that expire soon. However, prospective clients should take a step back and evaluate their options. These are major investments and should be treated with a great deal of care. Good sales reps from trustworthy companies will understand the gravity of the decision and provide customers with the time, information and references they need to make an informed decision.

Prospective customers also should keep in mind that the only time they have leverage in this situation is before the contract is signed—when you can still walk away. This is the time in the process when they must do everything they can to negotiate the deal in their best interest. Therefore, when a representative offers a prospective customer a contract to purchase a laser, that customer must fully understand that contract, because this likely will be the only time that contract can be negotiated.

Preventing Problems

Taking the time to read and understand the contracts offered by the salesperson is the best way for laser customers to protect themselves. If provisions you don’t understand are in the contract, ask the sales representative to thoroughly explain them to you. A good rep will always make sure you understand the contract. But it is always a good idea to get an independent explanation. If your lawyer is familiar with negotiating laser contracts, you should consult him or her; if not, you should consider hiring an attorney with knowledge in this area. Laser contracts can be much more complex than contracts for other types of medical aesthetic equipment—they may include convoluted provisions on warranties, maintenance, technical support or authorized use, so enlisting the aid of someone who has experience with them can be tremendously helpful.

The amount of marketing support the manufacturer is offering is an aspect of a laser contract that should be carefully considered. Some laser companies offer excellent support; others say they will but offer nothing in writing to guarantee it. The inclusion of a well-developed marketing assistance program often will increase the price of the laser, but it can add substantial value to the deal. The customer must make sure that the contract he or she signs includes language that guarantees sufficient manufacturer support. With a purchase of this size, it is crucial to the customer to have as much support as possible.

It also is important to ask the representative to provide references from people who own the laser model you are considering purchasing. These should not be clients who just bought the laser and are still in the “honeymoon” period—these should be experienced users who know the highs and lows of owning the laser long term. Or, better yet, ask a group of medical aesthetics professionals you know to ensure you get an honest answer. For example, AmSpa offers a private Facebook group to its members, which acts as a forum for these and any other professional questions that come up in the course of your medical aesthetics business. A prospective buyer should ask about how the laser performs, its service record, its return-on-investment, manufacturer support and any additional relevant information. Good reps will have a large number of references from people they have dealt with throughout the years; if they don’t, that should be seen as a red flag.

Deciphering Laser Provisions

Some provisions that prospective customers need to carefully consider are often found in laser contracts. It can take hours to review and analyze all elements of contracts, but there are three provisions that I often focus on when representing clients in laser purchases.

Recertification fees. The most controversial provision deals with recertification fees. It dictates that the manufacturer must inspect a used laser device to “certify” that it is in working order and operating to the manufacturer’s standards before it can be resold on the open market. The fee that the manufacturer charges for this service can be quite high—$50,000 or more—and it must be paid before the machine can be supported at a new customer site, which not only cuts into the resale value, but also makes it difficult to resell on the open market. However, some manufacturers provide a warranty and clinical training as part of the recertification fee, which may actually enhance the machine’s resale value.

There are valid reasons for having this fee in place—ideally, it helps ensure safety for both patient and provider—but it still is a very significant cost that should be understood before the laser is purchased. This is one reason why it’s very important to make sure that the laser you’re purchasing can be supported by your market. If, after a few months, you decide that the equipment is not ideal, you might be stuck with an extremely expensive piece of equipment you don’t use and can’t easily sell— since the secondary market for lasers can be extremely volatile and tends to favor buyers.

Prospective laser buyers should know that they can, in some instances, negotiate recertification fees, and some laser manufacturers are sometimes even willing to waive them altogether, typically when a practice is introducing laser treatments in markets where they have not yet proven to be successful. In fact, some manufacturers will even offer to repurchase the machine after a period of time if customers can show that their market is not responding to the product offerings. However, these are all things that must be negotiated into the contract before the sale is finalized. If the contract is signed and these elements aren’t included, you are out of luck.

Resale restriction. A resale restriction dictates that the customer cannot resell a laser without the manufacturer’s approval, or that the laser must be sold back to the manufacturer at a discounted price. As with recertification fees, there are valid reasons for these provisions; however, they can limit a practice’s options when it purchases new technology. Horror stories abound of medical spas with functional laser technology that they don’t use anymore because newer models were released. I’ve seen practices that have more than $1 million worth of technology sitting in a room gathering dust because they simply can’t do anything with them due to contractual restrictions and a weak secondary market.

However, as is the case with recertification fees, a resale restriction can be negotiated. Again, it is extremely important that the customer recognizes these provisions prior to signing the contract in order to maintain leverage. Reputable laser companies stand behind their products and typically have no issues working with new clients to make sure they are satisfied. If nothing else, a good sales rep should explain this provision so that the customer understands why it is there and how it is designed to help the customer.

Service clauses and warranties. Although they are commonly found in medical spas and aesthetic practices, let’s not forget that these machines actually fire lasers. This technology was science fiction in the relatively recent past. These are very sophisticated, sensitive pieces of machinery, and no matter how reputable the manufacturer, the machine will need to be serviced at some point. Good companies ensure that the customer endures little downtime and expense in these situations, but it’s up to the customer to make sure that everything that needs to be covered is covered for a reasonable amount of time, and that service is guaranteed to occur in a timely manner. After all, every day that the machine is offline is a day it is not generating revenue.

Prospective customers need to learn about exactly what happens if the machine breaks, what is covered—and what is not—under the warranty, and what the included customer support entails. Moreover, they must get as much as possible in writing so that they are guaranteed to have efficient, cost-effective service.

Know What You Don’t Know

For a medical aesthetic practice, offering laser treatments can be extremely lucrative, but buying a laser is much more complicated than simply going down to the neighborhood laser store and picking one out. If you know of a lawyer who has experience negotiating laser contracts, it is in your best interest to hire him or her to help negotiate this transaction.

Tags:  AmSpa's 2019 Medical Spa Statistical Survey  Business and Financials  Med Spa Trends 

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Join AmSpa at the Orlando Medical Spa & Aesthetic Boot Camp

Posted By Administration, Friday, October 25, 2019

caribe royale orlando

By Alex R. Thiersch, JD, CEO of the American Med Spa Association (AmSpa)

Starting next Saturday, November 2, AmSpa will host its Orlando Medical Spa & Aesthetic Boot Camp at Caribe Royale Orlando. This is the last AmSpa Boot Camp until April 2020, so if you are a medical aesthetic professional who wants to learn how to improve your practice, make your plans to join us next weekend. There’s still time to register for the event—just click here to sign up.

Here is a quick overview of the program:

Saturday, November 2

The Boot Camp begins at 8 a.m. with a continental breakfast, followed at 8:30 a.m. with my opening keynote. From there, we will move into the main program:

  • 9 – 10:30 a.m.: The Plan, presented by Bryan Durocher (Durocher Enterprises)—What are the most effective ways to develop a business plan for your medical spa? Medical Spa Consultant Bryan Durocher discusses the ins and outs of the planning process and helps determine how long it realistically takes to open a practice.
  • 10:45 – 11:45 a.m.: The Lessons, presented by Louis Frisina—Every medical spa is different, but the successful ones share several common traits. In this session, Business Strategy Consultant Louis Frisina discusses the qualities that are typically found in practices that bring in a significant amount of revenue.
  • 12:45 – 1:30 p.m.: Medical Aesthetic Hot Topics Panel, featuring Tim Sawyer (Crystal Clear Digital Marketing), Candace Noonan (Environ Skincare) and Gail Winneshiek (Galderma)—This panel, moderated by yours truly, will feature a spirited discussion of the current issues and events that concern medical spa owners and operators.
  • 1:30 – 3:30 p.m.: The Law, presented by Alex Thiersch (AmSpa) and Bradford Adatto (ByrdAdatto)—In this presentation, we’ll discuss the long-standing and emerging legal issues that every medical spa owner needs to know about. As you can imagine, there is a lot to cover here, since new concerns seem to be arising daily lately.
  • 4:15 – 5 p.m.: The Treatments, presented by Terri Ross (Terri Ross Consulting)—Learn about the most profitable and popular treatments available to your practice, and find out how to best determine which treatments are right for you based on the state of your practice.
  • 5 – 6 p.m.: The Digital Marketing Ecosystem, presented by Tim Sawyer (Crystal Clear Digital Marketing)—Find out how to effectively spread the word about your medical aesthetic practice and how best to determine what’s working and what’s not. Your practice’s digital presence is more important than ever before, and curating it should be a top priority.

Saturday will wrap up with a cocktail reception from 6 – 7:30 p.m.

Sunday, November 3

Once again, the Boot Camp begins at 8 a.m. with a continental breakfast.

  • 8:30 – 9 a.m.: Anatomy of a $5-Million Med Spa, presented by Alex Thiersch (AmSpa)—Have you ever wondered what the difference is between your medical spa and one that’s mega-successful? It might be less significant than you think. This presentation will show what a $5-million med spa is doing right—and what you might be doing wrong.
  • 9 – 10 a.m.: The Financials, presented by Bryan Durocher (Durocher Enterprises)—At the end of the day, the money you’re bringing in is the most important measure of your practice’s success. This presentation will, among other things, demonstrate how to properly develop a budget and use metrics to determine your med spa’s strengths and weaknesses.
  • 10:30 – 11:30 a.m.: The Long-term Revenue, presented by Brandon and Jenny Robinson (Skin Body Soul)—Simply being successful isn’t enough for a medical aesthetic practice; you have to know how to maintain and grow your success. In this session, Bryan will show you how to build patient loyalty and move your business forward.
  • 11:30 a.m. – 12:15 p.m.: The Consultation, presented by Terri Ross (Terri Ross Consulting)—As the old saying goes, you never get a second chance to make a first impression. Learn how to put your best foot forward with effective patient consultations—and how to turn them into consistent business.
  • 1 – 2 p.m.: The Marketing Plan and Social Media, presented by Brandon and Jenny Robinson (Skin Body Soul)—This session will help you determine how to most effectively market your medical aesthetic practice using both traditional methods and cutting-edge techniques.
  • 2 – 3 p.m.: The Team, presented by Bryan Durocher (Durocher Enterprises)—A medical spa is only as good as its personnel, so it’s important to make sure that you hire a staff that can do everything you want it to—and more. In this session, you’ll learn about recruiting, hiring and retaining employees who can make your medical spa dreams come true.

Also, you’ll have the chance to visit with a number of exceptional vendors during this event. Attend the Orlando Medical Spa & Aesthetic Boot Camp to check out the latest and greatest from the following companies:

We hope you can join us in Orlando next weekend. This Boot Camp is a tremendous opportunity to get a medical aesthetic business started off on the right foot, and learn how to take an already successful business to the next level. Click here to register!

Tags:  AmSpa's Med Spa & Aesthetic Boot Camps  Business and Financials  Med Spa Law  Med Spa Trends 

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