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Ancillary Services in Primary Care

October 8, 2008 |

Many of today’s physicians are battling declining reimbursements by bringing ancillary services into their practices, according to the Medical Group Management Association’s (MGMA) 2008 annual Cost Survey Report, which notes a 3-year increase in physician use of ancillary services. This sea change in the scope of traditional practice can infuse new life and revenue into primary care offices.

“Ancillary services are definitely a trend, and doctors have found that some of them can be very profitable,” says Edward J. Enos, president of the New York Medical Group Management Association (NYMGMA). “Many services require cash-in-advance payment from patients, and those that are reimbursed by insurance may pay very well.”

Botox and Cosmetic Injectable Fillers

Approximately 4.1 million Botox (botulinum toxin type A; Allergan; Irvine, California) procedures were performed in 2006, according to the American Society of Plastic Surgeons. Botox injections are currently the most popular cosmetic procedure in the United States. These services yield excellent profit margins, but primary care physicians enter tricky territory when they offer aesthetic treatments. Doctors should be especially cautious of subjecting patients to sales pitches and prioritizing cosmetic interventions above providing medical care.

“Initially, some patients mentioned that they thought I was going to stop doing regular medicine and that they were frightened by all of the new activities,” notes IAPAM member Christopher B. Paronish, MD, of Patton Family Medical Center and Advanced Skin Care, both in Carrolltown, Pennsylvania. “But now I hear nothing but good responses.”

Botox is a purified protein derived from the bacterium Clostridium botulinum. It blocks nerve impulses that trigger wrinkle-causing muscle contractions, thus creating a smooth appearance. Botox is FDA-approved for use on glabellar lines (known as the 11’s) between the eyebrows for men and women 18-65 years of age. A Botox treatment lasts 1-6 months, and most patients desire ongoing treatments.

“Doctors get paid cash in advance for Botox treatments, so you don’t have to wait for reimbursements,” says Jeff Russell, executive director of the International Association for Physicians in Aesthetic Medicine (IAPAM). “Risk for the physician is low, and it requires little cash investment.”

A vial of Botox contains 100 units and costs $525. “You’ll generally use 20 units for crow’s feet and from 30 to 50 for glabellar lines. Men require about twice as much as women,” says Russell. The national average fee for a Botox procedure was $492 in 2006, according to the American Society of Plastic Surgeons. Paronish generally bills $12 per unit of Botox used.

Injectable dermal fillers serve the same purpose as Botox but work differently. The leading injectable fillers, made of hyaluronic acid (HA) dermal filler, include Juvéderm (Allergan), Restylane (Medicis Pharmaceutical; Scottsdale, Arizona), and Radiesse (BioForm Medical; San Mateo, California). When you inject the malleable gel into the skin, it plumps up moderate-to-severe facial wrinkles and folds so that the skin looks smooth. Treatments last from 6 months to about a year, which typically translates to return visits. The national average fee for injectable filler treatments is $585.

The procedures are fairly uncomplicated to perform, but providers will also need to learn how to deal with possible complications. Some independently run organizations offer a 2- or 3-day aesthetic medical symposium covering Botox, injectable fillers, lasers, chemical peel, and the business of aesthetic medicine, although many plastic surgeons and dermatologists argue that these symposia do not provide adequate training.

Many physicians turn these procedures over to their nurse practitioner or an aesthetician. Check with the state board to determine whether one is permitted to do so.

STRATEGIC TIP:Botox and dermal fillers are retail procedures, so there will be price competition. Stay aware of what’s being charged in your market,” says Russell.


  •   Patients pay cash in advance
  •   Little investment; excellent profit margin
  •   Potential for scheduled return visits


  • Offering services may erode patient trust
  • Requires patients willing to pay cash for cosmetic procedures
  • Requires marketing to generate continuous stream of patients
  • Retail cosmetic procedure may be highly price-competitive
  • Waiting room or exam room may require updated décor for retail cosmetic service
  • Must learn to deal with complications

Laser Hair Removal and Other Laser Procedures

“Doing laser procedures is a large expenditure of time and money, especially if you already have a very busy practice, which we do,” says Dr. Paronish. “But the rewards of a cash-based business and the rapid outcomes and gratitude can be well worth it.” Paronish does about 12-15 laser procedures a week.

To maximize their investment, many doctors who start with laser hair removal often expand into other laser procedures, such as removal of freckles, age spots and sun spots; wrinkle treatment; leg and facial vein treatment; and skin tightening.

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