by Andrea B. Epstein
Perspectives from Dr. E.J. Sanchez of Laser & Vein Center at Batey
According to the most recent statistics from the American Society of Plastic Surgeons (ASPS), cosmetic surgeries in the U.S. are not just for the Hollywood crowd; more than 12.1 million of these procedures were performed in 2008. Even with continued gloom in the economic forecast projected for the remainder of 2010 and possibly 2011, cosmetic surgery is big business. Of the top five cosmetic procedures listed by the ASPS, number three is liposuction, with 245,000 procedures performed 2008. Though the reported liposuction procedure volume-was down 19% from the prior year, there is clearly a vast supply of patients still demanding this procedure. Should you consider adding this to your vein practice to meet the continued demand for liposuction and laser lipolysis?
VEIN spoke with Dr. E.J. Sanchez, a Florida based cardiologist who practices at Laser &Vein Center at Batey Cardiovascular in the Tampa Bay area. Since joining the practice in the mid-1990s, Dr. Sanchez has continued to be a pioneer in expanding his practice with new service offerings, including laser lipolysis and liposuction. Below, he offers valuable insights to other vein physicians seeking to broaden their practices.
As background, how did your practice first evolve and expand over time from cardiology to vein care?
I am an invasive cardiologist, board certified in internal medicine, cardiology, and nuclear cardiology. I joined a cardiology practice in 199? and my primary focus was and continues to be clinical cardiology – from diagnosis to intervention.
My practice has always been busy. I wasn’t really looking to add other disciplines but this (veins) fell in my lap. A friend asked if I had given any thought to adding vein care to my practice. I already had a good reputation in my community. I treat many doctors and their families, and people know that I won’t perform any type of procedure without doing my due diligence first.
Originally, my cardiology practice was only involved with the aspects of thromboembolic venous disease and bypass grafts. Veins are a natural progression for a cardiologist who already is doing endovenous procedures. Anything with catheters is really second nature and it can be a smooth transition.
I attended the IVC meeting in Miami and then followed up with training with Dr. Jose Almeida in April 2006. I visited other practices that year and by October, I added vein treatment to my practice. I dedicated one day per week to veins but then it quickly became two and then three days per week. I built my credibility as a cardiologist; once the community heard I was adding vein care to my practice, I received a lot of referrals. I also made it a point to educate other doctors, showing them how to identify all presentations and manifestations of vein conditions so they could refer these types of cases to me.
As the vein side of my practice grew, I knew I needed help, as it was taking too much time away from my cardiology practice. I brought in Dr John Mauriello; with his expertise in research, we began attracting and participating in research trials.
How many years were you in an established vein practice before you opted to add laser lipolysis and liposuction to your services?
Through discussions at many meetings, I discovered that many phlebologists were also offering laser lipolysis. They were using tumescent anesthesia and a laser; I already used both. I believed that I could add this to my practice without needing much additional staff training. For these reasons, I became interested in the procedures.
I started by doing site visits with several physicians. I visited a successful doctor in Napa who provided vein care and added laser lipolysis. I worked with a Colorado plastic surgeon to get on-site training and then went to investigate different technologies. I also began investigating VASER (ultrasound lipolysis) and became very interested in this technology. My VASER research took me to Miami; I spent two weeks with a surgeon to learn this procedure via hands-on training.
How were you able to spend the time away from your practice to research and train in laser lipolysis?
I was able to spend the time because I have a number of partners. The practice trusts me to research new procedures. In total, I probably spent about 100 hours in training, reading and working with other physicians before I brought laser lipo into my practice.
What are the biggest challenges with adding laser lipolysis to your practice?
There is a lot of myth about laser lipolysis. Mainly, physicians need to realize that by adding these services, there is more potential to hurt a practice than to have it grow. Phlebologists oversimplify what’s involved in adding this to their practice.
There are several key things to consider when adding laser lipolysis to a vein practice. First, the complications are different. Second, you are adding a service that is purely cosmetic. This is in direct contrast to phlebology, which is still clinical medicine, requiring management of real clinical issues such as ulcers and phlebitis. There is a big difference between treating these types of patients and those who come in seeking to improve how their arms or legs look.
Moving into pure cosmetic procedures may lead you to offer other services, which in turn may influence how you are perceived in the community. In short, some may perceive that you are adding procedures just to make more money. This can backfire in terms of your reputation as a phlebologist or whatever you primary specialty is.
Doctors need to ask themselves one question. What am I trying to accomplish here? For certain practitioners, there are some procedures that may cheapen the community perception of your practice.
How much time did you spend researching these procedures before you moved forward with adding them to your practice?
To add laser lipolysis and liposuction to my practice, I invested about three times the amount of research and training time that I spent to add other services to my prac-tice (i.e., adding veins to my cardiology practice.) The cost of my time alone probably exceeded $100,000. I spent more than 100 hours in research; I read every book on laser lipolysis. For my first case – using VASER – I brought in a cosmetic surgeon, and paid him a stipend to scrub in and be a part of the procedure.
Phlebologists considering adding this to their practice need to know that it’s not a walk in the park. If you can’t take care of the compli-cation, you shouldn’t be doing the procedure. Clearly, if you don’t train and prep properly, the risk is much greater to your established vein practice than the upside you can gain in new patients and revenue.
You have shared that phlebologists are well positioned to deliver this service. Why do you believe phlebologists offer the natural skill set for this procedure?
Phlebologists are the nicest, most willing doctors in terms of wanting to share information. My feeling is that if you are successful in what you are doing now, you can be successful in laser lipolysis. Be aware, though, that the amount of time and the resources required to add this to your practice cannot be taken lightly. Any physician must look at the entire picture - in terms of the business model - to figure out if this addition will really augment his or her practice financially.
Take a laser lipolysis procedure, for ex-ample. It may take three hours of procedure time, but six total hours of work, with an operating cost of $1800. That equates to $300 per hour. This is often overlooked when creating a business model for your practice.
Did you encounter any hurdles in acquiring malpractice coverage for these procedures?
This is a key issue. Should you modify your insurance, and should you address this before or after you start investing in adding this service? You have to do your due your diligence; ask your malpractice insurance representative about your options. I told my rep that I already offer laser and tumescent anesthesia and explained that this (laser lipolysis) was basically an add-on procedure; as a result, I was able to get the coverage. Make sure you test the waters with your rep before you spend the money on purchasing equipment. My premiums went up about $5,000 when I added lipolysis to my practice.
What equipment do you consider essential for these procedures?
Companies will prey on you to buy a $150,000 piece of equipment. A 980 laser is sufficient and most phlebologists already own this. Some companies will say your 980 only provides 15 watts versus 30 watts. That just means the procedures will take an extra five minutes to complete but you’ll save $50,000 in new equipment costs.
I purchased VASER (ultrasound lipolysis) versus laser lipolysis. I wanted to set myself apart from the plastic surgeons who primarily offer laser but not VASER. Most plastic surgeons shy away from ultrasound lipolysis because early generations had some issues with complications which are not seen in the newer ultrasound lipolysis equipment. Additional equipment costs can include the tumescent pump, suction, and cannulae. However, you don’t have to buy these; you can opt to pay by the case. This is a more cost-effective option since buying the equipment outright can be a substantial expense, with costs varying between $30,000 and $60,000.
To be clear, the per case payment option requires an upfront payment for 25% of the total equipment cost. A wireless chip in the machine sends information to the company on your equipment usage and you are then billed for your variable usage. Your cost per case also goes down as your volume-goes up. It is a less expensive approach if your caseload for these procedures is sporadic.
Another cost to consider is back-up electricity if you don’t have this already. You don’t want to be in an office if the lights go out and a larger 3000 cc tumescent has been injected into a patient’s belly. I purchased a generator to avoid the risk of losing power in the middle of this type of procedure.
Do you perform these cases in an accredited surgical center or an office setting? Which do you recommend?
I recommend the office setting for these procedures. This is your competitive advantage over plastic surgeons that perform these procedures in a surgery center. With an office setting, you can promote convenience to your patients. Also, you can price these services more competitively without the burden of the surgery center overhead.
If you are going to offer these procedures in the office setting, a sterile environment needs to be emphasized. You must have the right personnel. I use a surgical scrub nurse every time I do these cases; she also works with one of the local plastic surgeons. I pay her on a per case basis. This is less costly than hiring an employee when the cases are sporadic. Since she is an RN, she can mix tumescent and also handle the wound care.
What are the key factors that a vein physician should consider before deciding to add these services to his or her practice?
If you are not a busy phlebologist, this can be a good procedure to add to your practice. It’s important to keep in mind that this is a different patient market than a vein practice. Less than 20% of lipo patients will have a venous procedure too.
Physicians need to do their homework. It takes intense preparation to successfully add this to a vein practice. You need to go in with your eyes wide open.
Take a hard look at the economics of your individual practice. You may end up taking procedures just for the short-term money but may not be able to cover your costs longer term. Also, consider that some patients require touch-ups six months later and for these, you can typically bill only to cover your costs. When you put pencil to paper, it may not work out.
Another key piece of advice I can offer is to find a friendly plastic surgeon who wants to be your referral source for
advanced cases or complications. Turn these potential competitors or adversaries into your friends. They also will back you up when you have a complication that you refer to them.
Finally, remember that you can never be too cautious. Make sure that you are ACLS trained and certified. When patients come to my practice, safety is a top priority. These patients are seen pre-op for lab work, medications and an exam because infection is a big concern with laser lipolysis. A catastrophic event can be avoided with proper safety preparation and precautions.
What are the main differences between laser lipolysis, liposuction and ultrasound lipolysis?
There is no difference between the outcomes for laser lipolysis and liposuction in the right hands. If you went out and marketed traditional liposuction as an addition to your practice, you would have no competitive edge. That’s the reason to offer laser or VASER.
In terms of results, there is no difference between laser and traditional liposuction. Rather than raking up fat, you are melting it with the laser, but suction is still required. Skin retraction is not dependent on the procedure but rather on the operator (i.e., the physician doing the procedure). VASER offers a smoother contour but also has its pros and cons.I recommend that before any physician embarks on this, he or she takes a traditional liposuction course; laser lipolysis and VASER can be added afterwards.
You have offered a great deal of information to consider before a phlebologist should proceed with adding laser lipolysis to his or her practice. In closing, can you offer a brief summary of your key recommendations?
My overriding advice is that you have to be serious about adding this to your practice and go into this with your eyes wide open.
In summary, there are five key areas that must be evaluated seriously:
1. LEARN THE BASICS FIRST:
Take a CME accredited program; don’t waste your time trying to learn the techniques with a solo practitioner promoting his laser. You will end up with a skewed point-of-view.
2. ESTIMATE YOUR BUDGET:
What resources – in terms of time and money – is it going to take for you to do this? if you have a 980 laser, you’ll still need to purchase a tumescent infusion and suction pump which can run about $10,000. if you don’t have a laser box, and are going to offer laser lipolysis or VASER, you’ll have to make a significant financial investment.
3. ALLOCATE THE TIME/HOURS NEEDED:
Upfront research and training is essential. i spent countless hours before i made the decision to move ahead and followed up with many hours scrubbing in with plastic surgeons.
4. INVEST IN MARKETING:
You must address the question: How am i going to get patients for these new services? Advertising is expensive. Phlebology patients won’t ask for these services as it’s not really a natural fit. i did invest substantial dollars in advertising, including radio and television ads. Be aware that it’s still a difficult time to attract patients for elective, cash procedures in this economy.
5. BE COLLEGIAL WITH PLASTIC SURGEONS:
Develop collegial ties with local plastic surgeons a d establish cross referral relationships. i will still refer out to these surgeons if laser lipolysis isn’t the right solution for a specific aesthetic patient (or in cases where the patient that wants more cosmetic services with their laser lipo).
In summary, I hope I have conveyed my cautionary per-spective about the wide range of things that you must con-
sider before adding this to your practice. It’s not simple and not a quick return on your investment. For me, adding laser lipolysis has not brought a significant increase in net revenue to my practice. I continue to emphasize cardiology and veins, and in truth, the bulk of my new patients are in phlebology.
For more information on Dr. Sanchez and his practice, go to www.veinscenter.com.