Medical Spas: Where Medicine and Luxury
Meet in the Middle

T his is not your father’s dermatology clinic. Instead of utilitarianism, luxury reigns. Instead of time spent in a waiting room, promptness is the watchword. And instead of the traditional lineup of dermatology procedures intended to cure the sick, the services make the healthy feel even more vital. These are medical spas, which dot today’s dermatologic landscape from Manhattan to the West Coast. You may have heard of them, perhaps even seen one in a nearby town or your own community. And you may wonder whether one of these facilities might make a worthwhile addition to your practice. In this article, we’ll provide a look at these sometimes glamorous facilities. We’ll discuss how medical spas evolve and offer practical tips on establishing one. First, let’s define our terms. Physician Oversight Ask clinicians and others to define “medical spa” and you’ll get a patchwork quilt of answers. The definition involves a combination of who provides the services, the types of services offered, and who is getting the services and why, suggests Philip Werschler, M.D., Spokane Dermatology Clinic and Aesthetic Image Medical Spa, Spokane, WA. The thread that ties those answers together is physician oversight and involvement. Medical spas run by dermatologists are typically associated with a traditional dermatology office, which can be in the same building or located remotely. They combine luxury with the security of having a doctor nearby. Besides physicians, a medical spa can involve a range of professionals, including estheticians, massage therapists and registered nurses. In a true medical spa, a physician supervises the estheticians, says Ron Shelton, M.D., The New York Aesthetic Center, LLP, New York City. Services include, but aren’t limited to, facials, body wraps, microdermabrasion, endermologie, laser hair removal, collagen and Botox treatments. Dr. Werschler stresses that a medical spa focuses on “desire dermatology” as opposed to “disease dermatology.” Patients are healthy and the procedures are elective. The services provided “generally fall under the purview of a licensed medical facility versus a licensed cosmetology facility,” he says. For Michael Gold, M.D., Gold Skin Care Center and Advanced Aesthetics Medi Spa, Nashville, TN, a medical spa “incorporates physician-based practices and concepts into its treatments.” Besides those who simply want to feel good, the medical spa treats patients with skin concerns such as acne and dry skin. The setup “at least gets them in the door of some sort of medical environment,” he says. Emerging Growth Trend The term medical spa became part of the vocabulary about 5 years ago, according to Carol Phillips, president, Spa-Med Consulting Group, Manassas, VA. They’ve evolved, says Dr. Werschler, from an “anecdotal curiosity” to a big-city style of practice to an “emerging growth trend” — though still not a dominant trend, he says. The numbers suggest medical spas are set to take off. Of the roughly 5,700 spas in the United States in August 2000, only 162 were medical spas, says the International Spa Association in its 2000 Spa Industry Study. In 1999, medical spas had 1.1 million visits, compared with 63.5 million for day spas, which led in this regard. But medical spas are among the fastest growing spa types, the study reports. The spa industry’s cumulative growth in number of locations from 1995 to 2000 has been driven by growth in medical spas (133%) and day spas (127%). If you suspect that this growth is fueled mainly by the well-to-do, think again. Using a spa isn’t solely the province of the independently wealthy, suggests Dr. Werschler. “This is very much a real phenomenon of middle America,” he notes. Those users are, though, likely to be female. For laser hair removal, his spa sees about 70% women and 30% men, estimates Bruce Katz, M.D., of the Juva Skin and Laser Center and Juva MediSpa in New York City. Most other treatments, he estimates, are 80% female. Dr. Katz says that his three most popular treatments are antiaging facials, microdermabrasion and laser hair removal. Dr. Shelton lists much the same rundown: facials, superficial peels and microdermabrasion and laser hair removal (though the last is seasonal). Not Just Dermatologists With such growth lurking on the horizon, dermatologists aren’t the only ones interested in getting in on the action. “This isn’t just a dermatology phenomenon,” says Dr. Werschler. Other clinicians participating in the medical spa market include plastic surgeons, ophthalmologists, oralmaxillofacial surgeons, and even family physicians. Each particular physician is likely, says Dr. Werschler, to leave his or her imprint on the spa. For instance, plastic surgeons may emphasize procedures such as liposuction and face lifts. Dermatologists are more likely to stress skin care, laser hair removal, Botox, collagen, and similar procedures. (See “How to Set Your Medical Spa Apart from the Competition.") With a residency in ophthalmology and postgraduate work in cosmetic surgery, Santa Rosa, California-based ophthalmologist Swati Singh, M.D., director of aesthetic services at LaserVue Medical Associates, offers such services as Botox, collagen, microdermabrasion and skin peels. She doesn’t have a medical spa, instead performing these treatments in her regular office. But she has given thought to opening a medical spa. Tracing The Evolution The glamorous settings of some medical spas belie their humble heritage. Dr. Katz’s Juva MediSpa can trace its lineage back to one esthetician performing laser hair removal in a Manhattan dermatology office. Needing more space, Dr. Katz pursued the medical spa concept in the mid 1990s. In April 1999, he opened Juva Skin and Laser Center and Juva MediSpa in midtown Manhattan. Two-thirds of the 5,000-square-foot facility is given over to the medical skin and laser center; the six-room spa takes up the remainder. While there is no one formula for setting up a medical spa, starting slow represents a viable approach. Dr. Gold says to “start slow and grow as needed.” A conservative approach has been a key to success for Dr. Shelton’s medical spa. He and his partner had the foremost concern of simply making a successful practice. For him, quality of care is paramount: “I’m concerned,” he notes “when things grow too quickly.” Dr. Werschler discusses one typical evolution. The process starts with an esthetician using a room in a dermatology office part time to provide such services as facials and peels. Next, paraprofessional estheticians might take over a corner of the office and a waiting area, and start to offer a schedule different from the medical facility’s (Saturday hours, for instance). Next, the office next door or across the hall becomes the spa, providing new services, such as endermologie or massage — though the emphasis is still on skin care. Finally, the spa grows into a full-service, dedicated, freestanding facility or much larger addition to the current facility. Services now also include traditional spa/salon services such as hair, nails and make-up. But the medical spa might still be different from the spa down the street because it might also provide medical services such as Botox, collagen, physician-depth chemical peels, and products such as cosmeceuticals. (Or the spa might refer patients to the associated dermatology clinic for those procedures.) Ultimately, you’ve become “a blend of the elective components of a dermatology practice in conjunction with a full-service day spa,” says Dr. Werschler. Not a Retirement Plan With declining Medicare reimbursements and other pressures, opening a medical spa might seem like a good way to bring additional revenues to your practice. While that argument has merit, some physicians caution against regarding a medical spa as a cash cow. “This isn’t designed as an income generator more than it is to fulfill a void,” Dr. Shelton says. “I always tell people,” says Dr. Gold, “you don’t make a lot of money in the spa business.” Dr. Gold says he’s happier making sure the spa makes some money and clients know he provides services as a dermatologist. “I always look at the spa as an adjunct to my practice. I’m not looking to retire from my spa.” Still, Dr. Katz estimates that his spa experiences a 15% to 20% annual increase in revenue growth. His staff sees 30 to 35 patients per day in the medical spa. To make it worth physicians’ while, a spa has to “feed the clientele that allows them to do higher remunerative elective, cash-basis services,” says Dr. Werschler. You can’t use the medical clientele to support the spa; rather, the spa has to be self-supporting, he advises. Because of the labor-intensive nature of the spa business, cosmeceutical expert Jan Marini, president and CEO of Jan Marini Skin Research, Inc., San Jose, CA, suggests that selling products represents the way to generate revenues and provides an “unprecedented revenue potential.” She quotes figures suggesting that a spa can net $1 million in 3 years if four patients each day spend $195 each on skincare products. Every woman, she argues, will spend more money in her lifetime on skincare products than cosmetic surgery. Pluses to Consider A well-run, well-planned medical spa provides a range of benefits for both patients and providers. Consider the following: • Quick access to medical care. Having access to a dermatologist means that patient problems can be dealt with quickly. “Doctors are on site and we can check things right away,” according to Dr. Katz. “There are just numerous situations where an esthetician might do a facial and be concerned about a lesion on the person’s face,” says Dr. Shelton. They can refer the patient to the dermatology office on the same day. “So it works beautifully to have several different specialists and estheticians under one roof.” • “One-stop shopping.” Linked to this idea is the concept that patients can get all their skin care needs met under one roof. They can get a facial, buy their skin care products, and more. • “Cross-pollination.” The medical side and the spa side of the facility can work in tandem -– offering “cross-pollination,” as Dr. Katz says. A patient might visit the dermatology office, see the spa, and decide to have a massage. Or, a spa client might need traditional dermatology care, as with a suspicious lesion. “One feeds the other often in terms of facilities,” says Dr. Katz. • Effective use of time. If a patient needs to learn how to apply a cream, referring him or her to an esthetician instead of teaching the patient himself is a more effective use of the physician’s time, says Dr. Shelton. He can treat another patient while the first patient feels that another staff member is taking time to show him or her the proper application. Keys to Success Despite these attractions, don’t underestimate the resources it takes to create a successful medical spa. You’ll need investments in time, staff and finances. The trend is clearly to an increase in the number of medical spas, but also to “more regulation, more supervision and higher quality,” according to David J. Goldberg, M.D., J.D., clinical professor of dermatology and director of laser research and Mohs surgery at Mount Sinai School of Medicine and adjunct professor of law at Fordham Law School in New York City. (Regulations regarding who can perform various cosmetic procedures vary from state to state.) “It sounds great on paper,” says Dr. Katz, “but it’s a very difficult endeavor, very high-end service business. It’s also medical so you have to make sure both are being done all the time.” Do’s and Don’ts With these cautions, here are some do’s and don’ts that can help a medical spa flourish: • Don’t think opening a medical spa is just like opening another office. The word to keep in mind is “pamper.” Lighting, equipment, even smells must tell the client that she or he is in a relaxed environment, not a medical setting. This approach even plays into such areas as scheduling. For one thing, a medical spa patient who’s coming for a facial isn’t going to wait long for an appointment. And you may have to be sensitive to the timing of appointments in another way. For instance, Dr. Shelton’s office and medical spa share a common waiting area. His staff needs to be sensitive when he’s actively engaged with skin cancer surgery to ensure patients waiting for a spa appointment won’t become anxious by seeing a patient heavily bandaged and swollen. It doesn’t work, says Dr. Werschler, to “have a mix of disease dermatology and desire dermatology patients sharing a waiting room in an office.” Dr. Gold also tries not to walk into the spa. If he comes in wearing his white lab coat, “then I change the environment,” he says. Instead, he’ll have patients who need to be seen brought to the clinic. • Do hire individuals experienced with spas. Some haven’t succeeded, says Dr. Goldberg, “because they’ve tried to run the spa the way they run the medical office; however, they’re two very different animals.” Make sure, says Dr. Shelton, that estheticians have good resumes and spend time training them properly. If you don’t, he warns, you won’t realize the rewards you want. (See Hiring an Esthetician.) • Do careful background checks and make sure that individuals are licensed, says Paula Filler, managing partner, Ascent Healthcare LLC, Maplewood, NJ. The credentials and history of cosmetologists and estheticians are just as important, she says, as those of more highly paid clinicians. • Do expect bumps in the road. “Be prepared for a lot of ups and downs at the beginning because it’s not an easy process to get going,” says Dr. Katz. “You’re going to make mistakes; don’t make them twice,” says Dr. Gold. Expanding Services While no one knows the ultimate form a medical spa may take, Dr. Werschler points to an emerging, consumer-driven model that provides the full breadth of services. Ultimately, you wind up with a medi-day-spa, he suggests. Whatever shape it assumes, the phenomenon holds the promise of expanding the range of services dermatologists provide. Younger dermatologists, especially, suggests Dr. Werschler, are eager to get in on the ground floor of this movement. “In the end,” says Dr. Gold, “it’s been a wonderful addition to what I do.”