Selling Your Soul to Practice Dermatology

I’ll start by saying that this rant about increasing prices may seem grumpy, but it is something that troubles me significantly for several reasons. While I always appreciate innovation and feel that, without it, there is no future for our specialty, lately, any innovation I have seen is modest (and I say this generously) and overpriced. At the most recent Cosmetic Surgery Forum, discussions centered around new and useful laser platforms and how they can integrate into a dermatology practice. I was struck by the remarkably high price tags for each of these machines and can’t even imagine how a new dermatologist, let alone an established one, could possibly afford one or several of these tools. Some of the mechanisms of action also seemed questionable. (Do we want to promote muscle growth with devices or decrease it with neurotoxins, and do we really feel that microcores on neck tissue are safe and won’t lead to scarring?)

Is it possible that these price tags and the attendant risk of purchasing a machine that could underperform may, sadly, be the reason that newly minted dermatologists are being priced out of private practice? Are starting dermatologists joining corporations where they must sell their soul for access to these tools and other “essential” components of a practice?

The end result of these incredibly pricey elements of a dermatology practice could be a shift in the ability to utilize these tools in our specialty, thus placing them in the hands of larger corporations/medspas or private equity-owned practices and out of the hands and pocketbooks of most dermatologists and right into the hands of unqualified individuals (rarely core-cosmetic physicians or physicians at all). It is entirely disagreeable to see pricing that hits the stratosphere for all aspects of a practice, thereby forcing a shift in practice options if dermatologists want to have access to these.

The innovations that are being offered also seem to be weaker than those in the past. Perhaps most of what is discoverable has been discovered, and we are just wading into less fertile areas. It may be the next RF/toner machine can now do the face in addition to the buttocks, the next BBL device is packaged with some other minor laser, or the next tattoo laser can theoretically deliver quicker results, but it is always about $300,000 plus/minus for entrée into the “club.” Plus disposables.

When I started practice in 1992, it was a big deal to spend $2,000 on an autoclave. I still remember the agony of whether to purchase regular needle holders or gold-tipped, with the attendant increase in costs—and I was dealing with $100 or less price differences. Now, we have lasers and devices that cost well over $300,000 for something that has questionable results even in skilled hands. Some of these are second-generation devices, where the same lecturers who said they were great in Gen One are now saying they work in Gen Two, but they really didn’t work in the previous generation. No kidding. I think I may wait until Gen Three.

And, for the record, the first laser that I ever purchased (in 1994) was a CO₂ laser that cost the princely sum of $52,000. This laser worked its tail off, and there was absolutely no question that it was effective. In fact, people still come back to me and thank me for the results that have had until this day. Oh, and the laser is still in my office and in operation 28 years later.

In contradistinction to my ancient laser, now, there is the ongoing cost of disposables with all of these devices, something that apparently happens mainly in the United States, while other countries have figured out a way to go back in time to the days when “disposables” and “lasers” were words that meant “no-sale.” I don’t see the benefits of US cosmetic physicians underwriting the financial well-being of all the laser and other device companies for elective procedure patients in other countries. Whether it is right or wrong, there is perhaps an argument to be made when the wealth of the United States underwrites HIV drugs for Sub-Saharan countries, but should my overseas colleagues benefit from my largesse so they can inject fillers less expensively? I think not.

Then there is the question of service warranties for these products. In the “good old days,” these were included in the cost of the laser for at least 2 or 3 years after the sale. And they came with stellar service that came within a day or 2, and, if not, a loaner unit appeared magically within 24-48 hours. Those days are over, and the price of these warranties is eye-popping.

As for the cost of other injectables, with the addition of presumably longer-term neurotoxins such as daxibotulinumtoxinA (even though the package insert still says it lasts such as onobotulinumtoxinA), we have the potential for a more expensive and longer-lasting toxin that will likely be substituted for less expensive toxins in the medspas that proclaim to have $7 a unit neurotoxins. And those same medspas, if they do actually use the real thing, will dilute it out or misuse it such that people will just end up with longer-lasting ptosis, which sours them on the product altogether. To add insult to injury, the company’s proposition that, in order to sell this new neurotoxin, you must be an active purchaser of their other product, a filler, is a strong-arm technique that falls flat on me. While I have used both products, having performed the FDA clinical trials on them, I don’t like to be told I have to purchase one thing in order to purchase something else. It seems to me like something a used-car salesperson would do, not a professional company catering to dermatologists and other cosmetic surgeons. So far, I am resisting the urge to purchase in this scheme, though I would like to try it out at some point in the future once I don’t have a biblical Rachel and Leah proposition in order to gain access.

The pandemic and its related financial tsunami for medical and cosmetic practices have made me more careful with my expenses and more deliberate when it comes to these purchases. That doesn’t mean that I won’t bite the bullet and purchase one of these “must-have” lasers (you can never have too little fat, too little cellulite, or too much overhead expense, apparently), but I will be withering in my negotiations and hold off for as long as possible so that perhaps Gen Six of the machine will do what it was supposed to do in Gen One!