Adding ancillary services? Here’s what you need to know

Extra revenue from cosmetic procedures, such as Botox and Juvederm treatments, allows the physicians at Chelsea (Mich.) Medicine & Laser, a private primary care practice, to give more thorough care to all of their patients, says staff physician Carla Page, DO.

“Because of the additional revenue we generate from those services, we have the opportunity to spend more time with our patients,” she says. “I see roughly five to 10 fewer patients a day than I did in a practice where I was an employed physician for a bigger health center system. It was all about numbers and revenue.”

Paul M. Kosmorsky, DO, says there’s no way his Yardley, Pa., practice would be viable if he didn’t offer cosmetic services. About a fifth of his revenue comes from these services as well as sales and insertions of hormone pellets.

“If I were just doing family practice, I wouldn’t survive,” he says. “I’d be overstressed. I’d never see my family.”

New demands on physicians, such as electronic health records and changing regulations, have left many, especially family physicians in private practice, working longer hours for the same, or reduced, income.

Some physicians are seeking relief by getting trained to administer Botox, dermal fillers and chemical peels. Some are adding acupuncture, nutrition counseling, imaging services and laser hair removal to their practice’s offerings. Others are selling skin creams and supplements. Medscape’s 2014 physician compensation survey found that 21% of physicians offered ancillary services to their patients, a 2% increase over last year.

Florian Miranzadeh, DO, added Botox and dermal fillers to his Chicago family practice about five years ago because patients were asking for the services, he says. Between 2000 and 2012, American Board of Medical Specialties-certified physicians more than doubled the number of minimally invasive cosmetic procedures they provided, according to the American Society of Plastic Surgeons.

“The scope of family practice is changing, and it’s becoming a bit different than it was 15 or 20 years ago,” he says. “Providing some basic cosmetic procedures in family practice is the future. Most physicians eventually will incorporate them, and they won’t be called ancillary services.”

Ethics and patient safety

While the extra money is alluring, physicians should focus on ethical considerations when pondering ancillary services, says Thomas A. Quinn, DO. For one, DOs need to keep their patients’ best interests in mind, notes Dr. Quinn, who teaches medical ethics at the Lake Erie College of Osteopathic Medicine-Bradenton in Florida.

“If you found yourself a gimmick where you can make revenue but it’s not really benefiting your patients, then that, in my opinion, would be unethical,” he says. “But if what you’re adding has a genuine benefit to the patients, there’s nothing wrong with making some money while you’re doing it.”

Physicians should make sure they are thoroughly trained to perform any new procedures they are offering, says William T. Betz, DO, who teaches medical ethics at the University of Pikeville-Kentucky College of Osteopathic Medicine.

“I truly don’t have a problem with a physician providing Botox, as long as that individual has taken an effective training program and not just a weekend visit to a stop-and-shop program,” he says. “Physicians really must learn the techniques and the treatment modalities to administer Botox safely, effectively and competently.”

Layne E. Subera, DO, a member of the AOA Ethics Subcommittee, agrees.

“The practice of medicine changes,” says Dr. Subera, a family physician in Skiatook, Okla. “There are pressures to increase revenue. That’s understandable. Practices need to be a viable business. But we also need to consider patient safety when we add on things and make sure we are only providing services that we are trained to safely deliver.”

Dr. Page and her staff take precautions to make sure their aesthetic services don’t overshadow their medical services.

“If you need to come in, you’re seen,” she says. “We don’t turn sick patients away because we have cosmetic procedures to do. We’re very mindful of that.”

Dr. Page also knows the importance of not pitching services to patients during appointments, she says. Pamphlets are laid out in the practice’s waiting room, and the practice advertises specials in local newspapers and email newsletters.

Product sales

Besides performing cosmetic procedures, Dr. Page’s practice earns additional revenue by selling its own line of skin care products.

“These are higher medical-grade creams,” she says. “We have green tea serum for inflammation and aging lines, retinols for pores and fine lines, and glycolics for overall complexion and pore size.”

Dr. Kosmorsky used to sell supplements at his practice, but he pulled them after seeing a number of studies that made him doubt their effectiveness. Also, he was worried that patients would feel obligated to buy them.

“I do not want to do any harm,” he says. “I don’t want to do anything just for money.”

Physicians should sell products to help their patients, not to earn money, Dr. Betz says.

“If physicians are selling vitamins for the sake of making money, then I have a problem with that,” he says. “The ethical physician provides services to improve of the health of the patient without doing harm.”

The American Medical Association’s code of ethics advises physicians only to sell health-related products that have been scientifically evaluated and found to be of benefit to patients. The AMA also recommends limiting sales to products that serve patients’ immediate needs and selling products at cost to minimize financial conflicts of interest.

Dr. Quinn agrees with this policy.

“It’s the physicians’ responsibility to be aware that the products they are selling are scientifically sound no matter the particular field, whether they are cosmetics or hormones,” he says. “They have to have scientific background and evidence-based medicine behind them.”

Physicians selling products should check the consumer statutes of their state to make sure what they’re doing is not construed as conflict of interest by state law, says Stephen Boreman, JD, of San Francisco, who specializes in medical licensing with the firm Slote, Links & Boreman.

“In California, Business and Professions Code 650 says that a physician cannot have, in effect, kickbacks, or be paid by third-party organizations for which the physician is sending patients for either services or products,” he says. “If the physician enters into a contract with the supplier or manufacturer of certain supplements, and then is telling patients they need to take this supplement, that physician could be in violation of 650, which has criminal penalties.”

California law does allow physicians to sell products at their normal retail value, Boreman notes.

Ancillary services and liability

Physicians should know that ancillary services carry other legal risks. Both Dr. Kosmorsky and Dr. Page note that with each added procedure, physicians shoulder added liability. This is another reason to be properly trained and to document that training.

Boreman advises sticking with products that are approved by the Food and Drug Administration, citing a case he worked on around 2007 in which physicians had been using gray-market Botox.

“It was a little expensive to get the FDA-approved Botox, and there was a lot of Botox out there in the gray market that was not intended for human use or it was not approved by the FDA,” he says. “But it was, according to the physicians who ended up defending themselves, chemically identical. But they got into trouble, and they lost. It’s an issue of purity and of control. For better or worse, the FDA is the body that regulates these kinds of things. Doctors need to be careful if something is not clearly FDA-approved.”

And consult your professional liability insurance provider to ask if your policy covers the services in question, suggests Jud DeLoss, JD, a health care lawyer in Frankfort, Ill.

“If activities such as cosmetic surgery are considered outside the scope of your typical practice, they may not be covered for your standard family practice physician,” he says. “I have seen a trend toward medical spa insurance policies to address some of these side or alternative activities. That might be something to take a look at. Make sure you have proper coverage.”

DeLoss also notes that minimally invasive aesthetic procedures are not prone to major malpractice claims or major malpractice settlements or judgments, and therefore, experienced malpractice attorneys are generally not interested in pursuing such cases.

Dr. Kosmorsky says his ancillary services haven’t caused his professional liability insurance rates to increase.

Dr. Page’s practice seeks to work with unsatisfied patients directly. If patients are unhappy with their treatment, they can come back to get it fixed, she says.

“If somebody calls and has a question, a concern or any problem, he or she comes right in and is evaluated for free,” she says. “If there’s something that we need to do to address the problem, we do it right there and then.”

To minimize legal exposure, physicians can also set up a separate limited liability company to house their ancillary services, notes DeLoss. This makes particular sense when the service is unrelated to a physician’s main line of work, such as a cardiologist interested in providing laser hair removal.

Physicians can assess their state’s laws or policies on laser regulation in the Federation of State Medical Board’s board-by-board overview on the use of lasers and delegation of medical functions. Some states, such as Missouri, Florida and Indiana, consider the use of lasers to alter human tissue to be surgery and require that a physician supervise any treatment of patients with a laser. Other states, such as Virginia, have no specific guidelines, according to the document.

For a more thorough rundown of specific state laws on other ancillary services, a health care attorney licensed in that state can provide counsel, DeLoss notes.

The AOA’s policy on office-based surgery calls for the office to have a written protocol for transferring patients to a nearby hospital in case of an emergency. If an office procedure requires anesthesia, a physician must be physically present during the surgery and until the patient is discharged from anesthesia care.

Benefits of one-stop shops

The popularity of Target, Walmart and other one-stop shopping powerhouses suggests that patients may appreciate the ability to get laser hair removal, treatment for strep throat and skin care products under the same roof. Adding pharmaceuticals or “nutraceuticals” to one’s practice may be particularly helpful for patients in rural and other areas where there are access-to-care issues, says Dr. Subera.

Physicians who provide ancillary treatments sometimes spot conditions that other professionals would miss, notes Barbara Gordon-Cohen, DO, who has a family practice in Court Suffern, N.Y., where she sells supplements, offers Botox and vitamin B-12 injections, and works alongside her sister, an acupuncturist. Once, when a patient asked for a B-12 injection for fatigue, Dr. Gordon-Cohen ordered blood tests, which revealed that he was severely anemic.

“I sent the patient to a gastroenterologist, and he had colon cancer,” Dr. Gordon-Cohen says. “It’s really great to have the medical background behind you. You have your diagnostic skills that you’ve learned in medical school, so you know when a condition requires Western medicine or can be treated with alternative medicine. That’s the art of medicine.”

Dr. Page notes that aesthetic services such as Botox injections, chemical peels and laser treatments can be surprisingly gratifying. She’s minimized patients’ scars, reduced their wrinkles and cleared up acne.

“Aesthetic treatments are usually the lighter part of your day, and they’re fun,” she says. “It’s rewarding when you can make somebody feel better about themselves.”

And with Botox popping up in spas and nail salons around the country, Dr. Kosmorsky says he’d rather have his patients be treated by a licensed physician.

“People are going everywhere and getting Botox,” he says. “Why not get it from someone you trust?”

But Boreman, the attorney, cautions that physicians who become too enmeshed in providing aesthetic or other services may miss serious health issues in their patients. He speaks from personal experience.

“Some years ago, my doctor (not a DO) became so involved in the side practice of enhancements that, in my case, he missed complaints of possible basal cells, and I ended up having a very large surgery on my face,” he says. “I felt like he wasn’t paying attention to his day-to-day internal medicine practice. He was focusing too much on the aesthetic practice. That’s a danger. Physicians need to be aware that they have to practice good medicine all the time.”