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The spa quandary
Medical spas are a fast-growing but undefined industry with few regulations in place
By Markian Hawryluk / The Bulletin
Published: November 05. 2009 4:00AM PST
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More medical than a day spa, more luxurious than a doctor's office, medical spas, such as this one at Bend Memorial Clinic, exist in the gray area between medical practice and cosmetology.
Dean Guernsey / The Bulletin
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Plastic surgery and other medical treatments that improve appearance were once largely the domain of the rich and famous. New technologies have changed that, bringing a host of less invasive cosmetic procedures within the financial reach of a much larger swath of the population.
The demand for services such as Botox injections, chemical peels and laser abrasions — and the willingness to pay out of pocket for them — has also made them an attractive option for physicians. At a time when many doctors are struggling with lower payments from public and private insurers, cash-only medical spas have become an increasingly popular way of relieving the financial pressures.
But as the medical spa industry continues to expand at a breakneck pace, oversight of these facilities is lagging behind. New cosmetic procedures and devices are increasingly blurring the line between the practice of medicine and the field of cosmetology — and putting some patients in the hands of less-qualified individuals.
Emerging field
The medical spa concept began about a decade ago, according to Hannelore Leavy, executive director of the International Medical Spa Association. When the group formed as a spinoff from the Day Spa Association in 2002, it had about 45 members. By 2004, its ranks had grown to 450, and today the group has 5,000 medical spas listed in its database.
“What is driving this growth is the baby boomers,” Leavy said. “They don't want to get old and the technology is moving so fast that it enables us to do this, to change our appearance, to look younger instantly.”
In Central Oregon, at least five medical spas have opened in the past five years. These spas vary in their offerings but differ from standard day spas by also providing the more complex, more clinical services that can only be performed by medical personnel.
“Medical spas can offer medical-grade products, which are only offered under a doctor's supervision,” said Kathleen McDonald, an aesthetician with NorthWest Medi Spa in Bend. “Medical spas are more results oriented with more of a medical atmosphere. It's everything you would get in a normal spa and then you also get a little bit more on the medical side.”
The same facility may offer waxing and facials in one room, and botox injections and laser resurfacing of the skin in the next. While most medical spas are owned or supervised by a doctor, it's not necessarily the doctor providing those services.
NorthWest Medi Spa, for example, is owned by Dr. Rebecca Nonweiler, who works primarily offsite as an anesthesiologist. A nurse performs all of the injections and other invasive procedures, while aestheticians do the cosmetic work.
“I do work under the umbrella of the doctor, as far as my insurance and protection,” McDonald said.
Regulatory cracks
Because medical spas bring so many different licensed professionals under one roof, they present a challenge for state regulators who must balance public demand for services against public safety.
“Medical spas — there's no real definition of what that means,” said Randy Day, complaint resource officer for the Oregon Medical Board. “This could be somebody who has set up a practice to do aesthetics, plastic surgery, any number of things.”
The medical board licenses physicians and steps in when it hears of people providing medical services without a license. But many of the services at medical spas are provided by nurses, who are licensed by the Board of Nursing, or aestheticians, licensed through the Board of Cosmetology.
“Physicians also have some latitude to delegate some things that could be construed as medicine,” Day said. “That's where it starts getting gray.”
The medical board, for example, considers the use of lasers to be the practice of medicine but has allowed doctors to train medical assistants to perform laser procedures. Aestheticians are permitted to use lasers to remove hair, but not to perform more invasive laser treatments.
Day also stresses that when physicians delegate medical tasks to other, they are still responsible for the outcomes.
“If a physician assumes responsibility, they have the responsibility,” he said. “They can delegate authority, they cannot delegate responsibility.”
Other states, including California and Washington, have clearly defined what sort of treatments must be done by a physician and what can be delegated to others. But Oregon has not, leaving open to interpretation what should be considered the practice of medicine and what qualifies as cosmetology or aesthetics.
“Certainly reasonable people could argue over where that line is,” Day said.
Kraig Bohot, communications officer for the Oregon Health Licensing Agency, said state officials have concluded the cosmetology board has jurisdiction over aestheticians and nail technicians who might work at a medical spa, but that primary oversight of such facilities falls to the medical board.
“Medical spas really should have some sort of physician involved,” Bohot said. “Ostensibly it falls under the medical board.”
Bohot said the cosmetology board could step in only if an aesthetician or a nail technician was providing services outside of his or her scope of practice without the supervision of a doctor. But he also admitted to a gray area between medicine and cosmetology.
Oregon officials have tried to draw the dividing line between invasive and non-invasive procedures, allowing aestheticians to perform laser hair removal and some weaker chemical peels.
“They can't use any chemical that works on live tissue. That's really the demarcation point,” he said. “They can slough off dead skin cells or use a microderm laser. I've seen a demonstration of that, and it's pretty innocuous.”
States with a high number of medical spas, including California, Florida and Massachusetts, have started to formalize the medical spa category. California's effort has been bogged down in debate for years. In Massachusetts, legislators created a task force on medical spas, which proposed a three-tier classification for services. Level I would include practices that were clearly cosmetic in nature, such as hair or nail care, while Level III would include treatments that were clearly medical. Level II procedures would require a nurse or another type of licensed professional. But the task force suggested a standing committee would be needed to classify new procedures as they emerged.
Florida passed a law placing limits on how many satellite offices physicians could supervise and how far they could be from the main office. The law also requires medical spas to be supervised by a dermatologist or a plastic surgeon.
Crossing specialties
Medical spas might be a natural offshoot for those specialties. Many of the procedures offered in medical spas are also provided by dermatologists and plastic surgeons in their office settings. But increasingly, other types of doctors — family physicians, gynecologists, even neurologists — have opened their own medical spas.
“Doctors are struggling to cover their expenses, so aesthetic medicine is a cash cow for them,” Leavy, of the medical spa association, said.
Dr. Peter Bernardo, president of the Oregon Medical Association, argues that physician interest in medical spas is a sign of the pressures that many physicians face.
“It's a symptom of the stress that's out there,” he said. “They are tired of their regular workload, and in the case of primary care doctors, it's a way to do some different business, to make some different money. A lot of that work is cash up front, not paid by insurance companies. It's not a bad life.”
Bernardo also said it's not unusual for doctors to expand their scope of practice or to change their specialty. And as long as doctors are getting the additional training in cosmetic medicine, there's no problem in having specialists other than dermatologists and plastic surgeons opening medical spas.
“It is a way to supplement declining income,” said Suzanne Maitland, administrator of Bend Dermatology Clinic and its Dermaspa. “Because with cosmetic procedures, you don't have to bill insurance. You have cash-money up front, and your overhead is decreased, so you have a decent cash flow. That's the impetus for a lot of people.”
Maitland said the dermatologists at the practice had been offering many of the cosmetic services in their practice, but in 2007, they opened a new building that now houses the medical spa and hired more aestheticians, a nurse practitioner and a physician assistant.
She expressed concern, however, that as equipment used in medical spas has come down in price and complexity, less-qualified people may be attracted to what can be seen as easy money.
“Any time you use a light source, whether it's a laser or a pulse light, you can cause damage. And yes, the manufacturers are constantly doing things to make them foolproof, so they're really reducing the risk,” she said. “But unfortunately, we're finding people who don't know enough about it are getting into the market, and that's where the real risk comes in.”
Maitland said in other areas of the country, physicians have franchised out their medical directorship allowing unlicensed people to open spas.
Maitland advised consumers to ask questions about who runs the medical spa and what training the personnel have. She also said there's some security to choosing a spa that's closely tied to a medical practice.
“We have a very good reputation here in town as medical providers and as dermatologists, and anything we do on the cosmetic side is attached to that,” she said. “We're only going to offer things that we know are safe. They're being administered by people who know what they're doing so that you can get the result you want. Because if you're not happy with your cosmetic procedure or anything that happens in the spa, that's going to reflect on the medical side as well.”
Some spas, she said, seem to be more concerned about selling the product or service than whether it will work for the patient.
Alyssa Abbey, a physician assistant with Bend Memorial Clinic, said their medical spa clients also benefit from having the dermatologists on hand. If an aesthetician sees a suspicious lesion or other potential problem, they can pull in the doctor and have it examined on the spot. And staff at the medical spa, she said, are more likely to know what they are looking for than staff at a regular spa.
“We have patients who tell us they come here specifically for cosmetic treatments because of the security in knowing what's going to happen or who's going to be here when it happens,” she said.
Abbey said Bend Memorial Clinic opened its medical spa in 2007 in response to patient demand for the services, and patients generally pay for the services themselves.
She said the spa trends more clinical, focusing more on the procedures and services than on luxury.
“I don't think you'll find as much of the pampering as you would find in a traditional spa,” she said. “We don't serve tea or offer massages.”
But the BMC medical spa, like others in the area, does offer traditional spa services such as facials and waxing, in addition to its medical treatments. Critics have cautioned that providing both types of services under one roof may be blurring the line between medicine and cosmetics, which could confuse patients into thinking that cosmetic services have the same level of effectiveness as clinical procedures.
“Lending one's status as a physician to the sale of unproven products in a medical setting is ethically questionable, especially since consumers look to their physicians and health care professionals as more authoritative than an aesthetician or clerk at a cosmetic counter,” Dr. Lionel Bercovitch, a dermatology professor at Brown University wrote in a physician education piece on medical spas for the American Medical Association.
Maitland said that can be a problem if medical spas are run primarily as businesses rather than medical facilities.
“If people have set this up as just a way to make money, then I definitely think it blurs the line,” she said. “If I invested $10,000 into a laser and my business model says I have to do 10 patients a day to pay for this laser, then everybody who walks through the door, I'm going to try to sell them this procedure.”
Abbey said it's unlikely that any patients at BMC's spa would confuse what's medical and what's cosmetic.
“I think the lines are clear,” she said. “If a patient would like a cosmetic procedure then we set them up with a consultation, typically with myself, and then we determine the best course of treatment.”
Often patients come in for a medical appointment and express an interest in some of the cosmetic procedures done at the spa.
“Obviously none of this is necessary. It's optional, and they are made aware of it,” Abbey said. “So anything you can do above and beyond prevention and necessary treatment for skin cancer is completely optional.”
Markian Hawryluk can be reached at 541-617-7814 or mhawryluk@bendbulletin.com.
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