Dermatologists deal with cosmetic competition

National report - With “discount” injectable treatments here to stay, experts say, dermatologists must court sophisticated consumers willing to pay for the quality and expertise that only dermatologists and other core aesthetic specialists offer.

The problem of heavily discounted injectables dates back to unit pricing of neuromodulators and laser package deals, says Vic Narurkar, M.D. In the latter area, he says, “If someone only needs two treatments to get the desired results, selling them a package of five or six is unethical.” Dr. Narurkar is founder and director of the Bay Area Laser Institute, chairman of dermatology at California Pacific Medical Center, San Francisco, and a co-founder of Cosmetic Bootcamp.

John E. Gross, M.D., president of the Physicians Coalition for Injectable Safety (PCIS), adds that low-priced imported or otherwise illicit neuromodulators have been available to U.S. physicians for more than a decade.

“When the economy slid in 2007 to 2008, that encouraged many healthcare providers - including non-core specialists - to look for ways to augment their income,” Dr. Gross says.

The Affordable Care Act further spurred healthcare providers of all stripes to pursue cash-based aesthetic business - and perhaps cut corners, says Dr. Gross, who is also a plastic surgeon based in Pasadena, Calif.

As a result, says Jeanine Downie, M.D., non-core providers ranging from family doctors and OB/GYN's to “medispas that barely have a medical director over them are purchasing fillers and neuromodulators online and marketing them as the real thing. This cheapens our whole marketplace. People come in saying, ‘Dr. So-and-So is selling Botox (onabotulinumtoxinA, Allergan) for $5 a unit’ and expecting you to meet or beat the price.” She is a dermatologist in private practice in Montclair, N.J.

Economically, Dr. Downie says, “I call it a race to the bottom. Non-core competitors try to manipulate all the cosmetic dermatologists into decreasing our prices. And we cannot and should not. We need to maintain that we are board-certified and trained in all aspects of cosmetic and general dermatology; that we are the skincare experts. As a specialty, we should hold ourselves up as the skincare specialists that we are, and therefore should charge a premium for our services.”

Next: Handling complications

It’s complicated

Many non-core competitors have only a weekend injectables course under their belts, according to Dr. Downie. Conversely, “Dermatologists have more expertise in how to do these procedures, because we've done more.”

Unqualified injectors are more likely than core specialists to create two kinds of complications, Dr. Gross says:

• aesthetic complications such as asymmetries or lumps and bumps, which stem from poor technique but may not create medical hazards;

• medical complications such as infections and granulomas.

“Poor training can lead to poor results. And if you never had the training, you’ll never come close to knowing how to manage a complication. Fortunately, devastating complications are rare across the board, Dr. Gross says.

Patients who choose to work with a dermatologist get the benefit of more than just a consultation on aesthetics, says Elizabeth Tanzi, M.D.

“By choosing a dermatologist, the patient gets the added value of discussing skincare, and a review of any suspicious growths, lesions and other skin issues. Unfortunately, I’ve seen a number of new patients who were previously injected at a medispa or by a non-dermatologist, who had an obvious facial skin cancer that I diagnosed during consultation,” Dr. Tanzi says. She is co-director of the Washington Institute of Dermatologic Laser Surgery in Washington, D.C.

Thorough consultation

In aesthetic dermatology, says Dr. Narurkar, “The hardest part of the treatment is the consultation.” But often, he says that in discounters’ practices, “Physicians delegate the consultation to an extender. That’s where we see the worst outcomes, because the motivation may not be there to provide the best outcome, but instead (to reap) financial gain.”

Patients frequently present for aesthetic treatment with one specific complaint, he says. However, he says, “I look at the patient as a whole” and formulate a treatment plan based on patient desires, anatomical knowledge and budget considerations.

Accordingly, Dr. Narurkar eschews unit- or package-based pricing in favor of procedure-based pricing.

“If somebody really requires three or four syringes of fillers to get a good outcome, and based on syringe pricing they can only afford one, I won’t do the procedure,” he says. “I tell them they won’t be happy with the result.”

However, Dr. Downie says, it’s rarely possible to convince price-driven patients that there’s anything wrong with this approach until it’s too late.

“When we find that the neuromodulator is not really Botox, or the filler is not really Juvéderm (hyaluronic acid/HA, Allergan) or Restylane (HA, Medicis), then they wonder, ‘What did that doctor inject in me?’” she says.

This creates another challenge for dermatologists. If a patient has a complication, they cannot always tell their dermatologist exactly what was used in their treatment from the non-core provider.

 “I’ve seen practitioners who are giving treatments that are not approved in the United States for the specific indication, or a patient gets a product from Mexico or another neighboring country, and we have no idea what was injected into their face,” Dr. Narurkar says. “Not knowing, we don’t know how to correct it.”

Regarding providers, Dr. Downie says, “Some people will have a small account with Allergan, for example, through which they order 10 vials of Botox yearly. But somehow they’re injecting a ton of toxins per year,” often using materials purchased online from Canada or Asia.

Along with importation, “We’ve even seen practitioners who have injected expired products,” Dr. Narurkar says.

Next: Response from doctors' groups

Physician groups respond

As the public’s comfort level with injectables has grown, Dr. Gross says, “Sometimes patients may not always do their homework - not as much as if they were undergoing surgery.”

With minimal funding, he says, the PCIS mainly encourages core specialty societies to educate patients. Here, he adds, the message may be changing.

“In the past, there’s been a lot of push to educate patients about board certification. Now it’s not only board certification, but also board certification in an appropriate specialty that mandates training in aesthetic medicine,” he says. “You don't necessarily want a board-certified ER physician injecting your fillers.”

Created in 2007, the PCIS exists to “eradicate the practice of unqualified persons providing injections, to promote treatment supervised by properly qualified and trained, board-certified doctors and to promote only the use of Food and Drug Administration-approved, appropriately administered products,” according to its website. Most of its funding comes from the American Society for Aesthetic Plastic Surgery, Dr. Gross says.

As for policing discount providers, he says, “There’s no way we can knock on someone’s door and say, ‘You have to raise your prices.’”

Importance of education

“Consumer education is the key,” Dr. Gross says. “If it looks too good to be true, it might be.”

To address this issue, the American Society for Dermatologic Surgery (ASDS) launched a campaign that educates the public about why they should select a dermatologic surgeon for certain procedures, according to Dr. Narurkar. The campaign includes a video contest won by H.L. Greenberg, M.D., owner of Las Vegas Dermatology (see sidebar).

Although the American Academy of Dermatology (AAD) has no program or policy directed at discounting, it too has been a pioneer in educating the public about the importance of seeing a board-certified dermatologist. Additionally, Dr. Tanzi says, “The specialty societies - particularly the AAD and ASDS - are at the forefront of providing their members access to learn the most advanced injection techniques through various meetings and hands-on courses.”

Patients who insist on discounts should be reminded of the risks of using someone with less experience, according to Dr. Downie. When patients push the discount issue she refers them back to the discount provider, “With a warning that he or she doesn’t have the expertise that I do,” Dr. Downie says. “And I tell them that their face is their most important accessory. Many of them stop, think, and agree with me; some don’t.”

Dr. Narurkar adds that his practice constantly attracts patients who are dissatisfied with bargain injectors because, “We give the right treatment without gouging them.” Dr. Narurkar never discusses prices with patients - his coordinators do.

“Coordinators are trained to say (to patients), ‘I respect that. Here is what we charge.’ The worst thing to do is talk negatively of the competition, because that makes you look like you’re not being upfront,” Dr. Narurkar says.

And if prodigal patients experience a complication elsewhere, Dr. Downie says, “They can still come back to me, and I’ll take care of them. You can’t have a giant ego when patients don’t listen to you.”

Next: The expansion of commoditization

Commoditization expanding

Henceforth, Drs. Downie, Tanzi and Gross agree that, thanks to factors such as the growing popularity of organizations such as Groupon, the price-conscious tier of the injectables market will persist - if not grow.

“In procedures or offerings that can’t easily show clear differentiation based on quality, safety or results,” Dr. Gross says, “commoditization will continue.”

Along with neuromodulators and, to a lesser degree, fillers, he says, lasers are hardly immune. Ten to 15 years ago, “Laser hair removal (LHR) was new,” he says. “Various lasers did it, with varying degrees of success. And different providers had different techniques. Now, most of the devices work well. All the providers know how to use them,” and how much to charge. Accordingly, “LHR is becoming a commodity.”

That said, the devices are still best used in the hands of someone with plenty of training.

“It is still a laser, and you can burn someone with it,” a fact which highlights the professional component of any aesthetic procedure, Dr. Gross says.

“What’s in the syringe is important, but who’s behind the syringe, many times, is much more important,” he says. “It’s harder to commoditize the skill provided by the injector.”

So far, he says, fillers have been less affected by commoditization.

“There’s too much differentiation in the quality of results between experienced and inexperienced injectors,” Dr. Gross says.

Dr. Tanzi disagrees, however, saying that fillers are just as vulnerable as neuromodulators to discounting.

Dr. Downie predicts that because of new products such as Juvéderm Voluma (HA, Allergan), public interest in injectable treatments will continue to grow - as will patients’ appreciation of dermatologists’ pioneering efforts in developing such products.

Whenever a product achieves widespread acceptance, Dr. Narurkar says, “You’re going to see price wars and competitiveness. Don’t view that as a negative - patients are more aware of aesthetic treatments than ever.

“Don’t worry about what the guy or woman down the street is up to,” he says. “Provide the best service in your community,” and savvy patients will reward you.

Disclosures: This article grew from comments made by Drs. Narurkar and Downie at Cosmetic Boot Camp, June 20-23, 2013, Aspen, Colo. Dr. Narurkar is a Cosmetic Boot Camp co-director and has performed clinical trials for Allergan and Merz. Dr. Downie is a consultant for Allergan, Valeant and Merz. Dr. Gross has been a consultant and speaker for Allergan. Dr. Tanzi reports no relevant financial interests.