Lasers, cash machine?

[Dr McSteamy]

how many pcp's do you know that have lasers in their office?

I know fraxel has been around for some time, and each 30 minute session costs $1000 or more. lessen acne scars, remove age spots and hyperpigmentation, etc.

a lot of times, the doctor doesn't even perform the laser procedure. the nurse or tech does.

if you look at videos of fraxel, they just wave the handheld gizmo like a Nintendo Wii remote.

Bam! $1000. pay up!


$200k salary? i don't see why not......

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[JaggerPlate]

how many pcp's do you know that have lasers in their office?

I know fraxel has been around for some time, and each 30 minute session costs $1000 or more. lessen acne scars, remove age spots and hyperpigmentation, etc.

a lot of times, the doctor doesn't even perform the laser procedure. the nurse or tech does.

if you look at videos of fraxel, they just wave the handheld gizmo like a Nintendo Wii remote.

Bam! $1000. pay up!


$200k salary? i don't see why not......

I really don't belong in this forum (see pre-med tag), but I saw your question and thought I'd give a quick opinion ... first, it is probably a good way to make cash, HOWEVER ... I heard a derm attending tell me one time that he opted to leave the laser out of his practice because they are extremely expensive and you need to have a constant stream of patients to make it profitable after buying or continutally leasing one of these beasts. Not to mention that in order to have this constant stream, you'll need to keep up on the newest lasers ... ie, more $. Seems like injectable fillers may be easier.

 

[MOHS_01]

I really don't belong in this forum (see pre-med tag), but I saw your question and thought I'd give a quick opinion ... first, it is probably a good way to make cash, HOWEVER ... I heard a derm attending tell me one time that he opted to leave the laser out of his practice because they are extremely expensive and you need to have a constant stream of patients to make it profitable after buying or continutally leasing one of these beasts. Not to mention that in order to have this constant stream, you'll need to keep up on the newest lasers ... ie, more $. Seems like injectable fillers may be easier.

Your derm attending was spot on. Lasers, without an already established, reliable patient base, do not constitute a pathway to riches. They are quite expensive and their technological half-life, on average, is often quoted to be 18 months. Leasing is good if you want to dabble, but leasing fees eat up much of your revenue, you will not perform enough to become knowledgeable or proficient, etc.

Find what you're good at, get better at it, and everything else will work itself out.

 

[1viking]

I see it first-hand. My attending has some lasers, and he says it was a terrible decision.

 

[Dr McSteamy]

i didn't know lasers had such a short life?

i thought that if a laser had proven results, there would be no need to switch up.

I've read that the laser machine can cost from $50k-100k.

On average, fraxel patients spend $2500. The doc would need 40 pts to break even.

i guess botox is still the better choice in cosmetics huh.

 

[Doowai]

Yeah start up expense is a killer with anything like that.

one of my classmates dropped out of the whole residency thing to go back to acupuncture - $50 cash per treatment and aims for 50 visits a week. His overhead is $2K per month. He seesn roughly 4 patients an hour. Acupuncture needles are $5 a hundred or so.

Not that I am recommending acupuncture to everyone - the point is how fast can you hit the profit margin. If you owe big monthly payments its much more work before you start hitting money

Freezing actinic keratoses with liquid nitrogen - ~ $210 per first 3 lesions from Medicare, better with other insurances, last time I checked a few years ago

Trigger point injections with Lidocaine - I think it was about $130 for 3 spots a few years ago

These are the things I think of when my concern is money - low cost, high profitability.

 

[Doowai]

I see it first-hand. My attending has some lasers, and he says it was a terrible decision.

Also, if you have a belief in it, the A4M type of material can be very lucrative.

 

[MOHS_01]

Yeah start up expense is a killer with anything like that.

one of my classmates dropped out of the whole residency thing to go back to acupuncture - $50 cash per treatment and aims for 50 visits a week. His overhead is $2K per month. He seesn roughly 4 patients an hour. Acupuncture needles are $5 a hundred or so.

Not that I am recommending acupuncture to everyone - the point is how fast can you hit the profit margin. If you owe big monthly payments its much more work before you start hitting money

Freezing actinic keratoses with liquid nitrogen - ~ $210 per first 3 lesions from Medicare, better with other insurances, last time I checked a few years ago

Trigger point injections with Lidocaine - I think it was about $130 for 3 spots a few years ago

These are the things I think of when my concern is money - low cost, high profitability.

Ummm... no. Google "medicare physician fee schedule look up". The code for AK destruction is 17000. The add on code is 17003. Do the math. Not $210.... probably still over reimbursed, but approx half your number in my state.

 

[Doowai]

Ummm... no. Google "medicare physician fee schedule look up". The code for AK destruction is 17000. The add on code is 17003. Do the math. Not $210.... probably still over reimbursed, but approx half your number in my state.

Yeah...hmmm. I am not sure why the number $210 is what I remember. Maybe I was factoring in an E&M code and something else : like patient presents for follow up for headache and hypertension, AK on forehead noted; blood pressure check - chiropractic adjustment - and AK destroyed psshhhh (sound of liquid nitrogen being sprayed) - takes under 15 minutes total. I don't know, but still ~$70 to go psshhh psshhhh psshhh (5 seconds total) with liquid nitrogen is pretty good money compared to hanging sheet rock.

 

[deleted87716]

~$70 to go psshhh psshhhh psshhh (5 seconds total) with liquid nitrogen is pretty good money compared to hanging sheet rock.

More like $28, net. Unlike the sheet rock guy, your overhead would likely be around 60%, like most other primary care physicians.

 

[Doowai]

I remember where I got the $210 number - and that was that if you just added 3 AK services a day on top of the usual services you would be adding $50,000 a year.

~$70 collections, $28 net etc whatever - the point is its quick, easy and does not add the overhead a laser does (and overhead is largely a matter of how sharp your business acumen is). Adding liquid nitrogen, especially if you use a cotton tip applicator the way I have seen some doctors use, is virtually no expense to add to the clinic services. Overhead is going to be roughly 50% regardless - its just an example of one of those things you can add that takes seconds to do.

If you have a decent senior base you have AK's walking in every day. No real cost to them if they have medicare, takes seconds, only mildly uncomfortable (I did it to myself just to see what it feels like), and is reimbursed well - can easily be added on top of current scheduling with no conflict - easy to add to a hypertension follow up etc - as opposed to laser treatments which require special time slots built into the appointment schedule. When you have the nitrogen ready, you just look for the opportunity (people with AK's) and include it on a regularly scheduled visit - nothing special, just another $70 that is missed without having nitrogen in the office.

You schedule someone for a laser treatment and they don't show and your cost is 100% overhead... because you are paying for the entire overhead they do not show - rent, staff, power and electricity etc. On the other hand you can't have a patient scheduled for a routine follow up visit and just say "Hey why don't we do a laser treatment while you are here...okay?" You have to make special appointments for it. On the other hand, its easy to be doing a follow up visit on a patient and just notice some AK's on their forehead or ears or hands and cook them off in literally a few seconds. Without distrupting your schedule or any special appointments you can add $50K a year to you services with that one thing if you do 3 a day. This area has a HUGE retirement population and so its very reasonable to do.

But there are other services like that - the main point being very very very very low overhead (compared to a laser) - basically just the existing overhead , very quick and requires no special scheduling for the extra service, very low malpractice (in some states ANYTHING cosmetic with the face adds ALOT to your malpractice as people are very likely to sue if you F up their face).

2 or 4 quick low overhead services like that and you can add $100-150K per year. Especially if you do them yourself.

Blue dog - just out of curiosity, are you in private practice?

 

[deleted87716]

Blue dog - just out of curiosity, are you in private practice?

Yep.

I freeze stuff all the time. Do all kinds of biopsies and minor skin procedures, too. Reimbursement is generally okay, but you need to be efficient and know how to document and code things properly. You've also got to know what you're doing, as mucking around with potential skin cancer can lead to certain medical-legal issues.

 

[Doowai]

Yep.

I freeze stuff all the time. Do all kinds of biopsies and minor skin procedures, too. Reimbursement is generally okay, but you need to be efficient and know how to document and code things properly. You've also got to know what you're doing, as mucking around with potential skin cancer can lead to certain medical-legal issues.

Do you shave any lesions or solely punch biopsies?

Regarding AK, my simplistic thinking is if it looks like an AK you freeze it, but if it comes back it may not be and then you send it to the dermatologist. Too simplistic?

 

[deleted87716]

Do you shave any lesions or solely punch biopsies?

Depending on the lesion type and location, I'll either do a shave, punch, or excision.

Regarding AK, my simplistic thinking is if it looks like an AK you freeze it, but if it comes back it may not be and then you send it to the dermatologist. Too simplistic?

I'll only cryo obvious localized AK's or inflamed SK's. If there's any concern that it's something else, based either on appearance or history, I'll biopsy it first.

 

[MOHS_01]

Listen to Blue.

I shaved what looked all the world like an ISK two weeks ago.... I am excising the 0.35mm crusted melanoma with ulceration and regression tomorrow. Surprised the living sh** out of me -- I only shaved it because it looked a little thick to freeze without hurting too much. Even simple stuff can prove difficult and surprising sometimes; just remember that few will fault you for performing a non-mutilating biopsy on a growth. Don't get caught up on the biopsy technique too much -- DIAGNOSIS trumps PROGNOSIS -- and a deep shave through a melanoma is preferable to punching into a large melanocytic tumor and missing the area that contains definitive melanoma.

 

[DD214_DOC]

I think this thread is the perfect example of the lack of business acumen of most primary care docs. Could a laser provide another good source of positive cash flow? Sure. Can it also provide a source of negative cash flow? Sure. It depends on your patient demographics. I surmise a lot of docs don't really look into this aspect of it (otherwise they would not have purchased the machines to begin with)

I worked with a doc who was planning to add an aesthetic component to his practice. The majority of his patients are middle-aged smokers who REALLY could use the work. Unfortunately, I don't think he's considering the fact that the majority of these patients are poor and either are on medicaid or nothing at all.

Then again, I wouldn't be surprised if someone is willing to pay $60 for a botox injection but not $50 for their BP med

 

[piggie]

business acumen is key to any specialty
i personally know a solo optho who is not doing so well
and a solo IM trained primary care who is only 40 years old now owns 5 houses
so...... business acumen is key

 

[maxheadroom]

Then again, I wouldn't be surprised if someone is willing to pay $60 for a botox injection but not $50 for their BP med

$60 worth of Botox is almost nothing.

 

[DD214_DOC]

$60 worth of Botox is almost nothing.

True, but I couldn't remember the going rate per ml from my plastics rotation. I thought botox injections were a giant waste of money and time so I didn't pay it much attention. It seemed much more cost-effective to pony up the cash up front for Juvaderm or one of the other latest collagens. (And I think Juvaderm is actually pig collagen?)

 

[maxheadroom]

True, but I couldn't remember the going rate per ml from my plastics rotation. I thought botox injections were a giant waste of money and time so I didn't pay it much attention. It seemed much more cost-effective to pony up the cash up front for Juvaderm or one of the other latest collagens. (And I think Juvaderm is actually pig collagen?)

This is precisely why Plastic Surgeons and Dermatologists get irritated with "other" providers who use Botox and fillers. Juvederm is a hyaluronic acid product, produced by bacteria. It lasts anywhere from 6 to 18 months.

Botox is fantastic -- it works very well. When used apporpriately, I think it is much more useful than a filler.

Not to start a flame war, but please think carefully before you take a weekend course on lasers, Botox, or fillers. If this isn't something that you've had training in, you won't just learn how to do it from doing it over a weekend in Orlando. There is a PCP guy a couple of towns over who bought a laser and decided to use it to do tattoo removal. Unfortunately, it wasn't the right wavelength to take off several of the pigments that people wanted removed. His answer? Crank the joules. I've treated several patients who have full thickness burns. The tattoo is gone, but the result is pretty awful.

If you're going to be a Family Medicine doc, put all of your energy into doing that well and serving your patients in that capacity. If you want to open a Medi-Spa (not a great idea in this climate), commit a substantial amount of time to getting appropriate training before you practice on patients.

 

[MOHS_01]

This is precisely why Plastic Surgeons and Dermatologists get irritated with "other" providers who use Botox and fillers. Juvederm is a hyaluronic acid product, produced by bacteria. It lasts anywhere from 6 to 18 months.

Botox is fantastic -- it works very well. When used apporpriately, I think it is much more useful than a filler.

Not to start a flame war, but please think carefully before you take a weekend course on lasers, Botox, or fillers. If this isn't something that you've had training in, you won't just learn how to do it from doing it over a weekend in Orlando. There is a PCP guy a couple of towns over who bought a laser and decided to use it to do tattoo removal. Unfortunately, it wasn't the right wavelength to take off several of the pigments that people wanted removed. His answer? Crank the joules. I've treated several patients who have full thickness burns. The tattoo is gone, but the result is pretty awful.

If you're going to be a Family Medicine doc, put all of your energy into doing that well and serving your patients in that capacity. If you want to open a Medi-Spa (not a great idea in this climate), commit a substantial amount of time to getting appropriate training before you practice on patients.

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