Guest guest Posted November 20, 2006 Report Share Posted November 20, 2006 $3,000 - $5,000 profit on flu shots? Wow, how many flu shots do you give? We only went through 4 0r 5 vials this year. > > > Date: 2006/11/18 Sat AM 09:13:33 EST > To: < > > Subject: RE: Branching out > > Responses: > 1) Agreed, but flexibility is important as well. If I have 100 > patients change from an insurance that pays $100 per visit to an > insurance that pays $90 per visit, is it better to try and find another > 100 patients or just try and work without the extra $10/visit? > 2) Sounds good, but we only book ½ the patients ahead of time and > these typically come in pretty well. For some reason, a fair number of > the same day patients no show (go figure) but this does not affect the > payment per visit. About the -25 modifier. I have only found one > insurance in this area that will pay for the physical and the E & M with > the modifier. The others will pay the lesser of the codes (likely the > 99213/4) and write off the difference so I will actually make less money > than if I had just coded for the physical. Yes, I could spend hours on > the phone arguing this, but then I lose money because I’m on the phone > and not seeing patients. This is likely a regional issue. > 3) I just dropped UHC (which was the poorest payor here). > Actually, they dropped me because I refused resign their contract. As I > only had 25 or so patients of theirs, I was just going to keep seeing > them, but UHC wanted me to take more. No way. Most of the other insurers > are clumped around Medicare reimbursement rates. I could drop some of > these, but then I am losing a lot of patients and I am moving away from > one of my original concepts which was to try and provide care to Hilton > Village (my neighborhood) and not discriminate based on insurance. I > realize this is idealistic, but I would like to at least continue > trying. > 4) In adding more procedures I look at it from as many angles as > possible. Is it going to increase my malpractice? How much extra billing > time/training is it going to take? How often am I going to use it? Does > it take up space? How long does doing the procedure take? What is the > cost of the supplies vs. return on investment? Currently, I offer joint > and trigger point injections, small skin stuff including suturing, > immunizations (only slightly profitable when the injection fee is > included), rapid strep tests, u/a dips, and pregnancy tests. But that is > one reason I wanted to look at some other form of income. Every year, I > look forward to the flu shots because I know I will make $3000-$5000 > extra over the months of October, November and December. Imagine if I > could make that every month without changing the flow of the practice. > That is the attraction to me. > > > Re: Branching out > > RE Branching out and increasing revenue in solo/ultra-solo practices > > 1) Volume dependent -- if you have enough pt flow, then you have the > choice of alternative care or changing your demographics ie better payor > insurance. > > 2) Be sure you are doing all you can for each pt -- reminders for > follow up, well care with -25 modifier. > > 3) Stop giving care to pts with insurance that is poorest payor. > > So if you have the max number of pts in a fixed time period, I'd look > very closely at the insurer class, and consider dropping the poorest > payor. You may catch up a few pts who will see you out of network, but > I'd bet this depends on the pts you see and the competition in the area. > > I'd also seriously look at the number of additional procedures and other > services you provide. > My example is that probably next year, I'll start to offer flu shots > again, after looking at cost per shot, as well as reimbursement per > shot. We will ask pts to " preregister " so we will be absolutely sure of > their payor class prior to visit, and insist on payment on receipt up > front where those pts have no coverage. > > Good luck on your new venture. > > Dr Matt Levin > Solo east of Pittsburgh, PA > FP > > Branching out > > Group, > I wanted to let everyone know that after months of contemplation I have > decided to start offering aesthetics in my practice. I have purchased a > McCue Ultra VPL and will begin offering permanent hair reduction, > photofacials, and spider vein removal in mid-December. I wanted to share > my thought processes as to why I decided to go in this direction in case > others are interested. > Why aesthetics? As of the end of September, I had billed for $16,000 > more and had seen about 200 more patients this year than last. > Unfortunately, I had collected about $500 less. When researching why, I > found out I was making between $7-$9 less per claim this year even > though the breakdown of the E & M codes and the CPT codes were similar. > So, the insurances are either paying me less or my population has > shifted to a lower paying insurance or both. At the same time, I have > come to the conclusion that I don’t want to be busier in the office. > Since the beginning of the year, my schedule has been relatively full. I > would say that we usually run at 80% capacity and have had to swell to > 100% periodically to meet demand during busier times. Financially, we > are making ends meet, but we certainly could not afford it if anything > went wrong (ex. I got sick and missed a week, etc). So the question is > how can I bring in more income without getting much busier? I obviously > cannot rely on insurances to keep me afloat as they have never even kept > up with the cost of living. I don’t want to charge a retainer fee as I > am concerned about the legality of it and I fear the loss of my > patients. And so, I decided to look at aesthetics. > What is the cost? The way the system will work in my office is that my > nurse will do the initial consultation and perform the actual procedure. > (I plan to quickly introduce myself to the patient and glance at any > moles or other lesions prior to any procedure to make sure there is > nothing worrisome). If she is doing a treatment (average <30 minutes), I > will do my best to continue seeing scheduled patients and answer the > phone. As my office is in a renovated house, we already have an unused > room upstairs which will serve as a perfect aesthetics room. The VPL was > not cheap ($65,000) but financed over 60 months equates to about > $1400/month. So, total cost is really only the cost of the machine as > the room is already there, there is no billing, I will continue seeing > patients as before and my one employee is excited about doing the > procedures which do not take a huge amount of time. > Can you make that much per month? Although I have not yet figured out my > fee schedule, most people I have talked to who do this said that they > average $300/treatment. So, given this is up front cash, only 5 > treatments a month would be necessary to break even. Also remember that > most people need 3-5 treatments, so really only about 20 people/year (5 > people being treated each month for 3 months X 4 cycles of 3 months > each) are needed to break even. I already have been open for 3.5 years, > and when I sent out a newsletter to my patients stating that I was > thinking of doing this, I got 11 patients who stated they were “very > interested.” I also have 2 patients who own salons and both state they > have a lot of clients who they are sure would want to have one of these > procedures done, but they have not had anyone to refer them to. In > short, I can’t imagine not having 20 patients interested in the next > year. > Is it Anti-IMP? Actually, I don’t think so. My overhead is definitely > increased, but, assuming the machine pays for itself, the time I spend > with the patient and the quality of care I can offer should remain the > same as it has been over the past 3.5 years. If anything, I am > approaching this as an alternative way of financing the rest of my > practice in order to insulate it from the whims of the insurance world. > We might even be able to generate enough income to get a part time > chronic care nurse which would actually improve the quality! > Anyway, as of next month, I am starting at zero patients in my > aesthetics practice and I will keep everyone abreast of how it develops. > I know Tim is doing this already (so I am not alone in my quest to see > if this works), but I think he started off with both the aesthetics and > the IMP practice. My IMP practice is closed to new patients, but will > hopefully be able to feed the aesthetics practice. We will see how/if > this works. > As always, I look forward to your comments! > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 20, 2006 Report Share Posted November 20, 2006 We have given 280 so far and will likely give another 50-60. The cool thing is that we had a walk-in flu shot clinic (advertised to our patients through a newsletter) on October 26th and in 4 hours we gave about 130 shots. We also offer flu shots to nearby businesses (we’ll come to your office and give flu shots for $30 each) and then we give them to all high risk patients. Re: Branching out > > RE Branching out and increasing revenue in solo/ultra-solo practices > > 1) Volume dependent -- if you have enough pt flow, then you have the > choice of alternative care or changing your demographics ie better payor > insurance. > > 2) Be sure you are doing all you can for each pt -- reminders for > follow up, well care with -25 modifier. > > 3) Stop giving care to pts with insurance that is poorest payor. > > So if you have the max number of pts in a fixed time period, I'd look > very closely at the insurer class, and consider dropping the poorest > payor. You may catch up a few pts who will see you out of network, but > I'd bet this depends on the pts you see and the competition in the area. > > I'd also seriously look at the number of additional procedures and other > services you provide. > My example is that probably next year, I'll start to offer flu shots > again, after looking at cost per shot, as well as reimbursement per > shot. We will ask pts to " preregister " so we will be absolutely sure of > their payor class prior to visit, and insist on payment on receipt up > front where those pts have no coverage. > > Good luck on your new venture. > > Dr Matt Levin > Solo east of Pittsburgh, PA > FP > > Branching out > > Group, > I wanted to let everyone know that after months of contemplation I have > decided to start offering aesthetics in my practice. I have purchased a > McCue Ultra VPL and will begin offering permanent hair reduction, > photofacials, and spider vein removal in mid-December. I wanted to share > my thought processes as to why I decided to go in this direction in case > others are interested. > Why aesthetics? As of the end of September, I had billed for $16,000 > more and had seen about 200 more patients this year than last. > Unfortunately, I had collected about $500 less. When researching why, I > found out I was making between $7-$9 less per claim this year even > though the breakdown of the E & M codes and the CPT codes were similar. > So, the insurances are either paying me less or my population has > shifted to a lower paying insurance or both. At the same time, I have > come to the conclusion that I don’t want to be busier in the office. > Since the beginning of the year, my schedule has been relatively full. I > would say that we usually run at 80% capacity and have had to swell to > 100% periodically to meet demand during busier times. Financially, we > are making ends meet, but we certainly could not afford it if anything > went wrong (ex. I got sick and missed a week, etc). So the question is > how can I bring in more income without getting much busier? I obviously > cannot rely on insurances to keep me afloat as they have never even kept > up with the cost of living. I don’t want to charge a retainer fee as I > am concerned about the legality of it and I fear the loss of my > patients. And so, I decided to look at aesthetics. > What is the cost? The way the system will work in my office is that my > nurse will do the initial consultation and perform the actual procedure. > (I plan to quickly introduce myself to the patient and glance at any > moles or other lesions prior to any procedure to make sure there is > nothing worrisome). If she is doing a treatment (average <30 minutes), I > will do my best to continue seeing scheduled patients and answer the > phone. As my office is in a renovated house, we already have an unused > room upstairs which will serve as a perfect aesthetics room. The VPL was > not cheap ($65,000) but financed over 60 months equates to about > $1400/month. So, total cost is really only the cost of the machine as > the room is already there, there is no billing, I will continue seeing > patients as before and my one employee is excited about doing the > procedures which do not take a huge amount of time. > Can you make that much per month? Although I have not yet figured out my > fee schedule, most people I have talked to who do this said that they > average $300/treatment. So, given this is up front cash, only 5 > treatments a month would be necessary to break even. Also remember that > most people need 3-5 treatments, so really only about 20 people/year (5 > people being treated each month for 3 months X 4 cycles of 3 months > each) are needed to break even. I already have been open for 3.5 years, > and when I sent out a newsletter to my patients stating that I was > thinking of doing this, I got 11 patients who stated they were “very > interested.” I also have 2 patients who own salons and both state they > have a lot of clients who they are sure would want to have one of these > procedures done, but they have not had anyone to refer them to. In > short, I can’t imagine not having 20 patients interested in the next > year. > Is it Anti-IMP? Actually, I don’t think so. My overhead is definitely > increased, but, assuming the machine pays for itself, the time I spend > with the patient and the quality of care I can offer should remain the > same as it has been over the past 3.5 years. If anything, I am > approaching this as an alternative way of financing the rest of my > practice in order to insulate it from the whims of the insurance world. > We might even be able to generate enough income to get a part time > chronic care nurse which would actually improve the quality! > Anyway, as of next month, I am starting at zero patients in my > aesthetics practice and I will keep everyone abreast of how it develops. > I know Tim is doing this already (so I am not alone in my quest to see > if this works), but I think he started off with both the aesthetics and > the IMP practice. My IMP practice is closed to new patients, but will > hopefully be able to feed the aesthetics practice. We will see how/if > this works. > As always, I look forward to your comments! > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 20, 2006 Report Share Posted November 20, 2006 Good marketing on your part it seems. I would be too afraid I would end up throwing out a few vials. Re: Branching out > > RE Branching out and increasing revenue in solo/ultra-solo practices > > 1) Volume dependent -- if you have enough pt flow, then you have the > choice of alternative care or changing your demographics ie better payor > insurance. > > 2) Be sure you are doing all you can for each pt -- reminders for > follow up, well care with -25 modifier. > > 3) Stop giving care to pts with insurance that is poorest payor. > > So if you have the max number of pts in a fixed time period, I'd look > very closely at the insurer class, and consider dropping the poorest > payor. You may catch up a few pts who will see you out of network, but > I'd bet this depends on the pts you see and the competition in the area. > > I'd also seriously look at the number of additional procedures and other > services you provide. > My example is that probably next year, I'll start to offer flu shots > again, after looking at cost per shot, as well as reimbursement per > shot. We will ask pts to " preregister " so we will be absolutely sure of > their payor class prior to visit, and insist on payment on receipt up > front where those pts have no coverage. > > Good luck on your new venture. > > Dr Matt Levin > Solo east of Pittsburgh, PA > FP > > Branching out > > Group, > I wanted to let everyone know that after months of contemplation I have > decided to start offering aesthetics in my practice. I have purchased a > McCue Ultra VPL and will begin offering permanent hair reduction, > photofacials, and spider vein removal in mid-December. I wanted to share > my thought processes as to why I decided to go in this direction in case > others are interested. > Why aesthetics? As of the end of September, I had billed for $16,000 > more and had seen about 200 more patients this year than last. > Unfortunately, I had collected about $500 less. When researching why, I > found out I was making between $7-$9 less per claim this year even > though the breakdown of the E & M codes and the CPT codes were similar. > So, the insurances are either paying me less or my population has > shifted to a lower paying insurance or both. At the same time, I have > come to the conclusion that I don’t want to be busier in the office. > Since the beginning of the year, my schedule has been relatively full. I > would say that we usually run at 80% capacity and have had to swell to > 100% periodically to meet demand during busier times. Financially, we > are making ends meet, but we certainly could not afford it if anything > went wrong (ex. I got sick and missed a week, etc). So the question is > how can I bring in more income without getting much busier? I obviously > cannot rely on insurances to keep me afloat as they have never even kept > up with the cost of living. I don’t want to charge a retainer fee as I > am concerned about the legality of it and I fear the loss of my > patients. And so, I decided to look at aesthetics. > What is the cost? The way the system will work in my office is that my > nurse will do the initial consultation and perform the actual procedure. > (I plan to quickly introduce myself to the patient and glance at any > moles or other lesions prior to any procedure to make sure there is > nothing worrisome). If she is doing a treatment (average <30 minutes), I > will do my best to continue seeing scheduled patients and answer the > phone. As my office is in a renovated house, we already have an unused > room upstairs which will serve as a perfect aesthetics room. The VPL was > not cheap ($65,000) but financed over 60 months equates to about > $1400/month. So, total cost is really only the cost of the machine as > the room is already there, there is no billing, I will continue seeing > patients as before and my one employee is excited about doing the > procedures which do not take a huge amount of time. > Can you make that much per month? Although I have not yet figured out my > fee schedule, most people I have talked to who do this said that they > average $300/treatment. So, given this is up front cash, only 5 > treatments a month would be necessary to break even. Also remember that > most people need 3-5 treatments, so really only about 20 people/year (5 > people being treated each month for 3 months X 4 cycles of 3 months > each) are needed to break even. I already have been open for 3.5 years, > and when I sent out a newsletter to my patients stating that I was > thinking of doing this, I got 11 patients who stated they were “very > interested.” I also have 2 patients who own salons and both state they > have a lot of clients who they are sure would want to have one of these > procedures done, but they have not had anyone to refer them to. In > short, I can’t imagine not having 20 patients interested in the next > year. > Is it Anti-IMP? Actually, I don’t think so. My overhead is definitely > increased, but, assuming the machine pays for itself, the time I spend > with the patient and the quality of care I can offer should remain the > same as it has been over the past 3.5 years. If anything, I am > approaching this as an alternative way of financing the rest of my > practice in order to insulate it from the whims of the insurance world. > We might even be able to generate enough income to get a part time > chronic care nurse which would actually improve the quality! > Anyway, as of next month, I am starting at zero patients in my > aesthetics practice and I will keep everyone abreast of how it develops. > I know Tim is doing this already (so I am not alone in my quest to see > if this works), but I think he started off with both the aesthetics and > the IMP practice. My IMP practice is closed to new patients, but will > hopefully be able to feed the aesthetics practice. We will see how/if > this works. > As always, I look forward to your comments! > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 21, 2006 Report Share Posted November 21, 2006 I took a course at the Scientific Assembly which cost $180. Overall, I would say it was helpful as they went over how to mix up the botox, where to put the injections, and how much to inject. At the end of the course, we all got certificates of training so we could buy botox from the manufacturer. It really does not look that difficult, but I have not done any injections myself, so I could be wrong. As suggested by others, I would certainly check with your malpractice carrier before doing this as it may impact your premium. Re: Branching out I have several chronic pain people that I think would benefit from botox injections, but they don't want to drive 45 minutes to get them. I have thought about getting the training to do them. At the same time, I figure, if I'm already buying botox, I might as well extend into the asthetics market and have actually talked with a spa in town about the possible demand. Where have people gone for training? I already stick needles in trigger points and medium and large joints. Pfenninger's intro course is over $1000 and looks as if one should also take the following one (also >$1000). Help! Anyone doing this? Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 21, 2006 Report Share Posted November 21, 2006 No, in Ohio I’m certain my malpractice would go through the roof if I started doing Botox. Is Botox technically FDA approved for things like chronic pain, etc? Not that we don’t already do things that are not FDA approved, but Botox just sounds like more pushing the boundaries to me. My carrier actually said I should not do trigger points because it would also raise my rates significantly. Re: Branching out I have several chronic pain people that I think would benefit from botox injections, but they don't want to drive 45 minutes to get them. I have thought about getting the training to do them. At the same time, I figure, if I'm already buying botox, I might as well extend into the asthetics market and have actually talked with a spa in town about the possible demand. Where have people gone for training? I already stick needles in trigger points and medium and large joints. Pfenninger's intro course is over $1000 and looks as if one should also take the following one (also >$1000). Help! Anyone doing this? Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 29, 2006 Report Share Posted November 29, 2006 Forgive the late reply, but I'm just getting back to my email, after the list somehow kicked me off for about 2 wk. I have been injecting Botox for about 2.5 yr now. For one yr before, I hounded the botox people to train me, let me go to someone's office, send me a video, etc. At that pt AAFP wasn't running their course. I finally got a 10 min video from the Pfennigers book, that I mailed away for. In that procedure book, it's fairly complete anyway. After those 2 things, I just started ordering, and doing it. It is way easier than most of the other things we do as procedures in FP. At it's most basic it's 5 shots, 4-8 u at each, and done. After I started re-ordering, botox finally sent my some info on a class they were having locally at a hotel, for non-plastic and dermatology MD's. At least in this state, that's the problem. The local Allergan reps used to have a deal with these doctors societies to keep us primary care doctors out of the market. I went to their course with Dr Kaplan, and the Spokane cosmetic derm, and it was amazing. Much better than the point and shoot that I got in the video. It's all about disabling some muscles to let other's pull more, in beneficial directions. The local Allergan rep told me that once I had gone to a cosmetic training, they would then set me up in local offices to precept with doctors doing the specific chronic pain things I wanted to learn. That is because their FDA approval at that time was only for glabellar wrinkles, everything else was off label. I did go to a Rehab doctors office in Bellevue, and learned how to give the injections in the palms, soles and axilla for hyperhydrosis, but never actually did it. My patient who wanted it was a Massage therapist, and it does weaken hand strength somewhat, esp first wk. She decided against, and actually had a nerve clipped in her arms, to stop the sweating. Just goes to show how miserable people are from something we think of as only an inconvenience. After that, I never did get to the neurologists to learn how to inject for migraines, that was actually my original goal, but found since most people could get relief from Triptans, and the insurance wouldn't cover for migraines, it just wasn't worth it. I didn't have the right mix of patients willing to pay out of pocket to prevent them with botox, but I'm sure others would. After going to the above, the AAFP Dermatology course came to Seattle, and I went and did go to the Botox thing. It was a nice review, and very adequate to get started. But there is alot better info out there. I now get notified by the local allergan rep about 2x a yr on either workshops or talks for the "non-cosmetic" MD's. The workshops are usually done by a local trainer, Sheila , who works for the Allergan, and REstylane folks as a private trainer. For $1000, plus the cost of the Restylane, she will come to your office, and help you inject your patients with restylane. I found it a little harder to learn, but more fun. It's much more artistic, requires hand skills, and thought. It's also more to buy it, and keep on hand, but makes more, and is stable on shelf for 3 yr. I don't know if she trains privately for Botox, or what it would cost, but could send you her phone number or email if you are interested. My bottom line is, if you have been to the AAFP course you have had as much training as you are going to get at first, for the least cost. Now you just have to practice. Since I felt very uncomfortable about that at first, I actually lowered my price, to cost, and had a local aesthetician send me clients I could "train" or practice on for about 1 mo. They were people mostly new to botox, but some had had before, just looking for a cheaper deal. After doing about 5 -8 people, I really felt ready to move on. Most people want their glabella done, it's the easiest, and most complication free area. Contact your local allergan rep, and ask for local training, free or for cost, and keep asking. My feeling in the last yr, is that they have become way more helpful now that they have a competing product. As I have posted before, my malpractice carrier, TDC, basically told me as long as I was the one doing the injections, that it wouldn't raise my rates at all, "because it's temporary". In other words, by the time someone would decide to sue, their botox would be worn off. However, TDC is a California company, and I am in Washington, not Ohio. -------------- Original message -------------- I took a course at the Scientific Assembly which cost $180. Overall, I would say it was helpful as they went over how to mix up the botox, where to put the injections, and how much to inject. At the end of the course, we all got certificates of training so we could buy botox from the manufacturer. It really does not look that difficult, but I have not done any injections myself, so I could be wrong. As suggested by others, I would certainly check with your malpractice carrier before doing this as it may impact your premium. -----Original Message-----From: [mailto: ] On Behalf Of Lynette IlesSent: Monday, November 20, 2006 6:58 PMTo: Subject: Re: Branching out I have several chronic pain people that I think would benefit from botox injections, but they don't want to drive 45 minutes to get them. I have thought about getting the training to do them. At the same time, I figure, if I'm already buying botox, I might as well extend into the asthetics market and have actually talked with a spa in town about the possible demand. Where have people gone for training? I already stick needles in trigger points and medium and large joints. Pfenninger's intro course is over $1000 and looks as if one should also take the following one (also >$1000). Help! Anyone doing this? Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the se nder immediately and delete it from your computer. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 29, 2006 Report Share Posted November 29, 2006 My thought: Botox is temporary if you inject it properly, but not if you stick it into a nerve or a blood vessel. Or, is it just nearly impossible to do that? I know that my malpractice carrier did say my rates would go up if I did trigger point injections or newborns circumcisions, so I assume it as well with Botox. RE: Re: Branching out Forgive the late reply, but I'm just getting back to my email, after the list somehow kicked me off for about 2 wk. I have been injecting Botox for about 2.5 yr now. For one yr before, I hounded the botox people to train me, let me go to someone's office, send me a video, etc. At that pt AAFP wasn't running their course. I finally got a 10 min video from the Pfennigers book, that I mailed away for. In that procedure book, it's fairly complete anyway. After those 2 things, I just started ordering, and doing it. It is way easier than most of the other things we do as procedures in FP. At it's most basic it's 5 shots, 4-8 u at each, and done. After I started re-ordering, botox finally sent my some info on a class they were having locally at a hotel, for non-plastic and dermatology MD's. At least in this state, that's the problem. The local Allergan reps used to have a deal with these doctors societies to keep us primary care doctors out of the market. I went to their course with Dr Kaplan, and the Spokane cosmetic derm, and it was amazing. Much better than the point and shoot that I got in the video. It's all about disabling some muscles to let other's pull more, in beneficial directions. The local Allergan rep told me that once I had gone to a cosmetic training, they would then set me up in local offices to precept with doctors doing the specific chronic pain things I wanted to learn. That is because their FDA approval at that time was only for glabellar wrinkles, everything else was off label. I did go to a Rehab doctors office in Bellevue, and learned how to give the injections in the palms, soles and axilla for hyperhydrosis, but never actually did it. My patient who wanted it was a Massage therapist, and it does weaken hand strength somewhat, esp first wk. She decided against, and actually had a nerve clipped in her arms, to stop the sweating. Just goes to show how miserable people are from something we think of as only an inconvenience. After that, I never did get to the neurologists to learn how to inject for migraines, that was actually my original goal, but found since most people could get relief from Triptans, and the insurance wouldn't cover for migraines, it just wasn't worth it. I didn't have the right mix of patients willing to pay out of pocket to prevent them with botox, but I'm sure others would. After going to the above, the AAFP Dermatology course came to Seattle, and I went and did go to the Botox thing. It was a nice review, and very adequate to get started. But there is alot better info out there. I now get notified by the local allergan rep about 2x a yr on either workshops or talks for the " non-cosmetic " MD's. The workshops are usually done by a local trainer, Sheila , who works for the Allergan, and REstylane folks as a private trainer. For $1000, plus the cost of the Restylane, she will come to your office, and help you inject your patients with restylane. I found it a little harder to learn, but more fun. It's much more artistic, requires hand skills, and thought. It's also more to buy it, and keep on hand, but makes more, and is stable on shelf for 3 yr. I don't know if she trains privately for Botox, or what it would cost, but could send you her phone number or email if you are interested. My bottom line is, if you have been to the AAFP course you have had as much training as you are going to get at first, for the least cost. Now you just have to practice. Since I felt very uncomfortable about that at first, I actually lowered my price, to cost, and had a local aesthetician send me clients I could " train " or practice on for about 1 mo. They were people mostly new to botox, but some had had before, just looking for a cheaper deal. After doing about 5 -8 people, I really felt ready to move on. Most people want their glabella done, it's the easiest, and most complication free area. Contact your local allergan rep, and ask for local training, free or for cost, and keep asking. My feeling in the last yr, is that they have become way more helpful now that they have a competing product. As I have posted before, my malpractice carrier, TDC, basically told me as long as I was the one doing the injections, that it wouldn't raise my rates at all, " because it's temporary " . In other words, by the time someone would decide to sue, their botox would be worn off. However, TDC is a California company, and I am in Washington, not Ohio. --------- Re: Branching out I have several chronic pain people that I think would benefit from botox injections, but they don't want to drive 45 minutes to get them. I have thought about getting the training to do them. At the same time, I figure, if I'm already buying botox, I might as well extend into the asthetics market and have actually talked with a spa in town about the possible demand. Where have people gone for training? I already stick needles in trigger points and medium and large joints. Pfenninger's intro course is over $1000 and looks as if one should also take the following one (also >$1000). Help! Anyone doing this? Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the se nder immediately and delete it from your computer. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 29, 2006 Report Share Posted November 29, 2006 Even if you inject it into a blood vessel, you are using such small doses it doesn't do anything. The lethal dose per the company is about 10,000 units. RArely does anyone get more than about 50-70 even if they are having multiple areas inject. The nerves in the forehead are so small and the needle is so small I haven't even heard of hitting a nerve as an issue. You make them use the muscle, and aim into the big lump of the muscle. It's meant to be an IM injection. It's just in some areas the muscle is so small, thin, you give it as a bleb just under the skin. Never assume what these irrational carriers will say. Just ask, it doesn't hurt to ask. They may want some certificate of training, the AAFP one works, as does the one from the company. -------------- Original message -------------- My thought: Botox is temporary if you inject it properly, but not if you stick it into a nerve or a blood vessel. Or, is it just nearly impossible to do that? I know that my malpractice carrier did say my rates would go up if I did trigger point injections or newborns circumcisions, so I assume it as well with Botox. -----Original Message-----From: [mailto: ] On Behalf Of magnetdoctorcomcast (DOT) netSent: Wednesday, November 29, 2006 1:22 PMTo: Subject: RE: Re: Branching out Forgive the late reply, but I'm just getting back to my email, after the list somehow kicked me off for about 2 wk. I have been injecting Botox for about 2.5 yr now. For one yr before, I hounded the botox people to train me, let me go to someone's office, send me a video, etc. At that pt AAFP wasn't running their course. I finally got a 10 min video from the Pfennigers book, that I mailed away for. In that procedure book, it's fairly complete anyway. After those 2 things, I just started ordering, and doing it. It is way easier than most of the other things we do as procedures in FP. At it's most basic it's 5 shots, 4-8 u at each, and done. After I started re-ordering, botox finally sent my some info on a class they were having locally at a hotel, for non-plastic and dermatology MD's. At least in this state, that's the problem. The local Allergan reps used to have a deal with these doctors societies to keep us primary care doctors out of the market. ; I went to their course with Dr Kaplan, and the Spokane cosmetic derm, and it was amazing. Much better than the point and shoot that I got in the video. It's all about disabling some muscles to let other's pull more, in beneficial directions. The local Allergan rep told me that once I had gone to a cosmetic training, they would then set me up in local offices to precept with doctors doing the specific chronic pain things I wanted to learn. That is because their FDA approval at that time was only for glabellar wrinkles, everything else was off label. I did go to a Rehab doctors office in Bellevue, and learned how to give the injections in the palms, soles and axilla for hyperhydrosis, but never actually did it. My patient who wanted it was a Massage therapist, and it does weaken hand strength somewhat, esp first wk. She decided against, and actually had a nerve clipped in her arms, to stop the sweating. Just goes to show how mise rable people are from something we think of as only an inconvenience. After that, I never did get to the neurologists to learn how to inject for migraines, that was actually my original goal, but found since most people could get relief from Triptans, and the insurance wouldn't cover for migraines, it just wasn't worth it. I didn't have the right mix of patients willing to pay out of pocket to prevent them with botox, but I'm sure others would. After going to the above, the AAFP Dermatology course came to Seattle, and I went and did go to the Botox thing. It was a nice review, and very adequate to get started. But there is alot better info out there. I now get notified by the local allergan rep about 2x a yr on either workshops or talks for the "non-cosmetic" MD's. The workshops are usually done by a local trainer, Sheila , who works for the Allergan, and REstylane folks as a private trainer. For $1000, plus the cost of the Restylane, she will come to your office, and help you inject your patients with restylane. I found it a little harder to learn, but more fun. It's much more artistic, requires hand skills, and thought. It's also more to buy it, and keep on hand, but makes more, and is stable on shelf for 3 yr. I don't know if she trains privately for Botox, or what it would cost, but could send you her phone number or email if you are interested. My bottom line is, if you have been to the AAFP course you have had as much training as you are going to get at first, for the least cost. Now you just have to practice. Since I felt very uncomfortable about that at first, I actually lowered my price, to cost, and had a local aesthetician send me clients I could "train" or practice on for about 1 mo. They were people mostly new to botox, but some had had before, just looking for a cheaper deal. After doing about 5 -8 people, I really felt ready to move on. Most people want their glabella done, it's the easiest, and most complication free area. Contact your local allergan rep, and ask for local training, free or for cost, and keep asking. My feeling in the last yr, is that they have become way more helpful now that they have a competing product. As I have posted before, my malpractice carrier, TDC, basically told me as long as I was the one doing the injections, that it wouldn't raise my rates at all, "because it's temporary". In other words, by the time someone would decide to sue, their botox would be worn off. However, TDC is a California company, and I am in Washington, not Ohio. -------------- Original message -------------- From: " Brady, MD" <drbradythevillagedoctor (DOT) hrcoxmail.com> I took a course at the Scientific Assembly which cost $180. Overall, I would say it was helpful as they went over how to mix up the botox, where to put the injections, and how much to inject. At the end of the course, we all got certificates of training so we could buy botox from the manufacturer. It really does not look that difficult, but I have not done any injections myself, so I could be wrong. As suggested by others, I would certainly check with your malpractice carrier before doing this as it may impact your premium. -----Original Message-----From: [mailto: ] On Behalf Of Lynette IlesSent: Monday, November 20, 2006 6:58 PMTo: Subject: Re: Branching out I have several chronic pain people that I think would benefit from botox injections, but they don't want to drive 45 minutes to get them. I have thought about getting the training to do them. At the same time, I figure, if I'm already buying botox, I might as well extend into the asthetics market and have actually talked with a spa in town about the possible demand. Where have people gone for training? I already stick needles in trigger points and medium and large joints. Pfenninger's intro course is over $1000 and looks as if one should also take the following one (also >$1000). Help! Anyone doing this? Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the se nder immediately and delete it from your computer. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 29, 2006 Report Share Posted November 29, 2006 Regarding blood vessels, the most serious complication would be bruising. This can be avoided by taking your time injecting, and if you do " hit " a superficial vessel, apply direct pressure for 5-10 minutes and then move on with your next injection. Also most injections tend to be superficial (no need to " hit bone " and pull back method). I know my malpractice rates did go up either. I had similiar experience with Restylane. Never heard from a rep in the last one year. Now that Juvederm is coming out from Allergan, we get a call from a rep. and she provided in office " advanced " training and even brought the restylane to practice with rocky --- Brock DO wrote: > My thought: Botox is temporary if you inject it properly, but not if > you > stick it into a nerve or a blood vessel. Or, is it just nearly > impossible > to do that? I know that my malpractice carrier did say my rates > would go up > if I did trigger point injections or newborns circumcisions, so I > assume it > as well with Botox. > > > > > > > > RE: Re: Branching out > > > > Forgive the late reply, but I'm just getting back to my email, after > the > list somehow kicked me off for about 2 wk. > > I have been injecting Botox for about 2.5 yr now. For one yr before, > I > hounded the botox people to train me, let me go to someone's office, > send me > a video, etc. At that pt AAFP wasn't running their course. I > finally got a > 10 min video from the Pfennigers book, that I mailed away for. In > that > procedure book, it's fairly complete anyway. After those 2 things, I > just > started ordering, and doing it. It is way easier than most of the > other > things we do as procedures in FP. At it's most basic it's 5 shots, > 4-8 u at > each, and done. After I started re-ordering, botox finally sent my > some > info on a class they were having locally at a hotel, for non-plastic > and > dermatology MD's. At least in this state, that's the problem. The > local > Allergan reps used to have a deal with these doctors societies to > keep us > primary care doctors out of the market. I went to their course with > Dr > Kaplan, and the Spokane cosmetic derm, and it was amazing. Much > better than > the point and shoot that I got in the video. It's all about > disabling some > muscles to let other's pull more, in beneficial directions. The > local > Allergan rep told me that once I had gone to a cosmetic training, > they would > then set me up in local offices to precept with doctors doing the > specific > chronic pain things I wanted to learn. That is because their FDA > approval > at that time was only for glabellar wrinkles, everything else was off > label. > I did go to a Rehab doctors office in Bellevue, and learned how to > give the > injections in the palms, soles and axilla for hyperhydrosis, but > never > actually did it. My patient who wanted it was a Massage therapist, > and it > does weaken hand strength somewhat, esp first wk. She decided > against, and > actually had a nerve clipped in her arms, to stop the sweating. Just > goes > to show how miserable people are from something we think of as only > an > inconvenience. > > After that, I never did get to the neurologists to learn how to > inject for > migraines, that was actually my original goal, but found since most > people > could get relief from Triptans, and the insurance wouldn't cover for > migraines, it just wasn't worth it. I didn't have the right mix of > patients > willing to pay out of pocket to prevent them with botox, but I'm sure > others > would. > > After going to the above, the AAFP Dermatology course came to > Seattle, and I > went and did go to the Botox thing. It was a nice review, and very > adequate > to get started. But there is alot better info out there. I now get > notified by the local allergan rep about 2x a yr on either workshops > or > talks for the " non-cosmetic " MD's. The workshops are usually done by > a > local trainer, Sheila , who works for the Allergan, and > REstylane > folks as a private trainer. For $1000, plus the cost of the > Restylane, she > will come to your office, and help you inject your patients with > restylane. > I found it a little harder to learn, but more fun. It's much more > artistic, > requires hand skills, and thought. It's also more to buy it, and > keep on > hand, but makes more, and is stable on shelf for 3 yr. I don't know > if she > trains privately for Botox, or what it would cost, but could send you > her > phone number or email if you are interested. > > My bottom line is, if you have been to the AAFP course you have had > as much > training as you are going to get at first, for the least cost. Now > you just > have to practice. Since I felt very uncomfortable about that at > first, I > actually lowered my price, to cost, and had a local aesthetician send > me > clients I could " train " or practice on for about 1 mo. They were > people > mostly new to botox, but some had had before, just looking for a > cheaper > deal. After doing about 5 -8 people, I really felt ready to move on. > Most > people want their glabella done, it's the easiest, and most > complication > free area. Contact your local allergan rep, and ask for local > training, free > or for cost, and keep asking. My feeling in the last yr, is that > they have > become way more helpful now that they have a competing product. > > As I have posted before, my malpractice carrier, TDC, basically told > me as > long as I was the one doing the injections, that it wouldn't raise my > rates > at all, " because it's temporary " . In other words, by the time > someone would > decide to sue, their botox would be worn off. However, TDC is a > California > company, and I am in Washington, not Ohio. > > --------- Re: Branching out > > I have several chronic pain people that I think would benefit from > botox > injections, but they don't want to drive 45 minutes to get them. I > have > thought about getting the training to do them. At the same time, I > figure, > if I'm already buying botox, I might as well extend into the > asthetics > market and have actually talked with a spa in town about the possible > demand. Where have people gone for training? I already stick needles > in > trigger points and medium and large joints. Pfenninger's intro course > is > over $1000 and looks as if one should also take the following one > (also > >$1000). Help! Anyone doing this? > > Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible > Family > Care 'Modern medicine the old-fashioned way' This e-mail and > attachments may > === message truncated === Rakesh Patel MD Arizona Sun Family Medicine, P.C. 633 East Ray Road, #101 Gilbert, Arizona 85296 www.azsunfm.com PLEASE NOTE: Email is not a secure form of communication. It should not be used for urgent or sensitive messages. Email may be done securely through our web portal. If you have a medical emergency go to an Emergency Room or call 911. Quote Link to comment Share on other sites More sharing options...
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