How we approach private-pay injectables

These cosmetic procedures bring a new challenge and self-pay patients.

By Steven Yoelin, MD

About the Author
	Steven Yoelin, MD, is in private practices in Newport Beach, Calif. His e-mail is syoelinmd@aol.com. Disclosure: Dr. Yoelin is a consultant, speaker and conducts reasearch for, Allergan, and is a consultant to Valeant.

When I completed my ophthalmology residency, I envisioned a career treating glaucoma, cataracts, macular degeneration and other ocular disorders. And for my first 10 years, that’s exactly what I did.

But medicine has changed a lot since I started my practice, and it’s continuing to change in unforeseen ways. Today, I have a thriving practice that meets both my economic and my intellectual needs, although it differs dramatically from how it began. It’s a practice involving minimal dependence on third-party reimbursements yet engenders high patient satisfaction. My practice is centered on injectables, namely dermal fillers and neuromodulators, designed to improve the appearance of the face.

WHY INJECTABLES MAKE SENSE

The volume/revenue imbalance

I first began offering injectables to my patients in 2001. I entered the field because I realized it is a reliable source of revenue and would utilize my strengths as an ophthalmologist. If that piques your interest, and you are wondering if you should introduce injectables into your practice, I encourage you to consider this field.

The Affordable Care Act is changing the landscape of medicine. We know our core patient base — the older population — is growing. The U.S. Department of Health & Human Services predicts the number of Americans age 65 and older is increasing from nearly 14% of the population in 2012 to nearly 20% by 2030. Obviously this translates to growth in the need for ophthalmological services. However, can the increased volume make up for less revenue per patient visit?

Palette Resources advertises training workshops around the country on its website.

Minimal up-front capital

Facial injectables require no capital investment. You are the “capital equipment,” and offering the service is as simple as buying the product and learning the technique. The margin on procedures is thus higher than for other nonsurgical facial rejuvenation procedures. For example, energy device procedures, such as laser skin resurfacing, often require a large up-front investment with maintenance contracts, not to mention limited-use tips or handpieces.

It is my experience that injectables deliver the highest level of patient satisfaction. An additional benefit to injectables is that loyal patients generally return about three times a year over the course of many years to maintain the desired effect. Just as people return regularly for haircuts at their favorite salons, patients return regularly for injections from their favorite doctors, generating many more potential visits per patient relative to traditional ophthalmology.

GETTING STARTED

The aesthetics patient profile

Before you introduce aesthetics to your practice, you should understand the demographics of patients who want aesthetic injections. Your typical aesthetics patient will likely be female, middle-aged and well educated.

Nonetheless, you should also anticipate some of your patients to be men: The American Society for Aesthetic Plastic Surgery reports that 10% of patients who received aesthetic injections in 2012 were men.

Honing your technique

Training is the first step to developing an injectables practice. Professional education in nonsurgical facial rejuvenation is available through a variety of sources. For example, Palette Resources (paletteresources.com) offers four-hour programs at various locations around the country. The workshops include didactic and hands-on instruction with experts. Palette Resources offers multiple levels of training based on trainees’ experience.

Alternatively, you can find websites, such as Medscape, that provide educational videos, most of which are complimentary. AAO and ASCRS can also serve as educational resources. Sales representatives can be great resources because they can connect you with teaching programs led by experienced practitioners. Sales representatives also know how successful physicians developed their practices, and they can advise you on how to avoid common pitfalls.

Regardless of which training resources you select, you must be diligent in learning. Like most skills, you will learn best through practice. Since the glabellar and crow’s feet regions are easiest to treat with neuromodulators, and nasal labial folds and marionette lines are easiest to treat with dermal fillers, you will likely begin with these areas.

These patients tend to desire treatment in other facial regions as well. You will need to expand your skills quickly as you gain experience to include more challenging areas, such as lower-face neuromodulator administration, and tear-trough correction and nasal contour correction with dermal fillers.

KNOW YOUR INJECTABLE OPTIONS

Keep up with patients’ knowledge

In addition to training, you will need to gain familiarity with the specific types of injectables and other products available. The market is expanding rapidly, with companies constantly introducing new products. Patients tend to be well informed about new products and techniques, so you need to stay up-to-date as well.

For nonsurgical facial rejuvenation, injectables may be classified into two categories: dermal fillers and neuromodulators.

Dermal fillers

Commonly used dermal fillers include:

• Hyaluronic acids, such as Juvederm Ultra, Juvederm Ultra Plus and Juvederm Voluma (Allergan, Irvine, Calif.); Restylane and Perlane (Medicis, Scottsdale, Ariz.); and Belotero (Merz, Frankfurt, Germany).

• Calcium hydroxylapatite, such as Merz’s Radiesse.

• PMMA, such as ArteFill (Suneva, San Diego).

• Poly-L-lactic acid, such as Medicis’ Sculptra.

Each category has different options, and with experience you will learn which products are best suited for you and your patients.

Neuromodulators

Neuromodulators are limited to a few brands. They are:

• Allergan’s Botox Cosmetic.

• Medicis’ Dysport.

• Merz’s Xeomin.

Practitioners and patients alike often have their own preferences regarding neuromodulators and dermal fillers. Some patients may respond more favorably to one than the other due to better results, fewer side effects or both.

First, limit options

During the early stages of your new injectables practice, choose a limited selection of products to offer. I suggest using products in high demand. Speak to established injectors in your region to determine what products they feel most comfortable using and their patients tend to request most often. A limited selection will reduce your required investment in inventory. As you gain experience and develop your patient base, you can effectively integrate more products into your practice.

Your waiting room should offer a relaxing, harmonious atmosphere.
COURTESY OF STEVEN YOELIN, MD

GETTING THE WORD OUT

Marketing an injectables practice

Once you are trained and ready to administer injectables, you’ll need to market your services. For reasons I’ve already described, your existing ophthalmic patient base is not your typical target market. You may want to speak to sales representatives about any in-house consulting services their companies may offer.

Moreover, as the injectables market becomes more saturated with providers, you’ll need to differentiate yourself. Position yourself as a seasoned ophthalmologist whose core practice depends upon practitioner precision, a skill set easy to transfer to injectables.

Injectables patients tend to be most concerned with exceptional outcomes, and I believe that the fine-motor skills I have honed as an ophthalmologist, combined with my injectables training and experience, have helped me deliver such outcomes for my patients.

Community outreach

An effective way to build a patient base is to establish relationships with local salons and aestheticians. Carefully explain the scientific principles and effectiveness of injectables for the salon professionals and aestheticians so they will recognize your subject matter expertise, understand the services you offer and feel confident referring their clients. I recommend finding salons and aestheticians that you similarly trust so that you can feel comfortable referring your own patients to them when appropriate.

Some practitioners also use websites that describe their services. I strongly discourage promotional discounts; they mostly appeal to those looking for the cheapest injectables available rather than a long-term practitioner-patient relationship.

MAKE THEM FEEL WELCOME

A new kind of practice

Your new, younger patient base will expect an inviting waiting room. If necessary, update your office with current magazines, tasteful artwork and modern décor to create a quiet, relaxing ambiance. If your aesthetics practice coexists with traditional ophthalmology, I suggest exclusively allocating a set amount of time, either a half- or full day, for injectables patients to most efficiently administer these classes of services. For reference, I typically require 15 minutes to administer neuromodulators and 30 minutes to administer either fillers or a combination of neuromodulators and fillers.

In terms of employees, I have only two: one full-time and one part-time. This lean human resource approach, among other aspects of my practice, is instrumental to minimize costs. My low number of employees has not limited my patient volume.

Outlook for the future

As physicians, we face many challenges navigating our ever-changing health-care system. Nonsurgical facial rejuvenation using injectables represents an effective means of practice diversification. Injectables will increasingly appeal to patients as an alternative to surgery, especially as new products and injection techniques continue to evolve. Ophthalmologists are well positioned and would be well served to take advantage of this growing demand for injectables.

Today, aesthetics constitute the majority of my practice. Most of my patients return several times a year, not because they are ill and unhappy, but because they were delighted with the experience and outcome from their previous visits. Although this is not the practice that I envisioned when I entered ophthalmology, I find the work personally fulfilling, and I highly recommend the field to other ophthalmologists. OM