(Bloomberg Businessweek) — This is the third installment of The Nurse Will See You Now, a series documenting how the increasing reliance on nurse practitioners may be imperiling US patients. Read part one here. Read part two here.
The patient popped a painkiller, a Xanax, something for allergies, another pill for nausea—a pharmaceutical cocktail meant to replace general anesthesia. Thirty minutes later she was on an operating table under the care of Karen Jean Anderson, a nurse practitioner who’d trained for 40 hours with a medical device distributor in performing liposuction. The patient was undergoing a breast augmentation and fat removal, and she was wide awake.
The pain was searing. She was handed a stress ball and a blindfold. Anderson and the other employee in the room asked the patient if she wanted them to stop, but she’d invested $10,000 in the procedures and was midsurgery, so she decided to see it through.
“We want to hear your breathing, not your voice,” one of the providers told the patient, according to a Statement of Allegations filing from Utah’s Division of Professional Licensing (DOPL), which investigated Anderson. (The patient was not identified in the documentation from the investigation.) In the filing, from May 2022, the division alleged that Anderson violated a variety of health-care regulations. The state Board of Nursing, which operates under the DOPL, conducted a two-day hearing into the allegations, and recommended that Anderson be cleared of the counts against her, with the exception of one pertaining to her procedures in prescribing drugs. The director of the licensing division disagreed. He filed an order of adjudication determining that the nurse practitioner “unlawfully practiced medicine by performing ablative cosmetic procedures.”
In that order, Anderson was banned from performing the surgery, fined $10,000 (later reduced to $5,000) and ordered to take a continuing education class related to the drugs she’d prescribed. The patient later sued both Anderson and the medical spa at which she performed the procedure, Belle Medical, for malpractice. That suit was settled in November, but that didn’t settle all the issues. Anderson has sued the state of Utah, saying that the law does in fact allow her to perform liposuction, as, she said in the suit, she has done safely more than 1,100 times—and as nurse practitioners do at medical spas nationwide. The case has been heard by the state’s Supreme Court, which will likely issue a ruling next year.
In an emailed statement, Belle Medical, which operates nine medical spas in four states, said it is “committed to high-quality patient outcomes, patient safety, and complying with all laws and regulations” and that it “contracts with qualified and highly trained medical professionals, including board certified surgeons and APRNs [advanced practice registered nurses].” Anderson referred questions to an attorney, who didn’t comment, citing the pending litigation.
The Belle Medical patient is among the millions of Americans who’ve sought treatment at medical spas, often called med spas. The name refers generally to offices that sell cosmetic procedures. Some of their services, such as body scrubs and chemical peels, aren’t medical in nature. But plenty are—Botox injections, dermal fillers and weight-loss injections, to name a few. Some med spas offer liposuction and fat grafting. Some offer vampire facials, a procedure in which the practitioner draws a small amount of blood from a patient and separates out the plasma. The plasma is then injected into the patient’s face, typically with microneedles. There’s not much evidence this is effective, according to the American Academy of Dermatology Association.
Today the med spa industry generates an estimated $17 billion annually, according to the largest US industry group, the American Med Spa Association, or AmSpa. More than 10,000 medical spas are in business nationwide, according to AmSpa, and an additional 1,000 are expected to open next year. Some med spas are small shops with a narrow specialty. Others are multisuite, multilocation operations that offer a variety of services and branded merchandise and help set up loans for clients who want especially costly care.
Despite the size and rapid growth of the industry, it occupies a regulatory gray area. Med spas rarely accept health insurance, so they’re of no interest to insurance regulators. Surgical auditors don’t have to accredit them, and the government regulators that oversee the businesses vary from state to state. In effect, no one is watching.
A minority of med spas offer liposuction, and those that do typically advertise it without using the word. They favor the term “sculpting” and describe the procedure as “minimally invasive.” Lipo can be costly at a med spa—procedures can reach the low five figures—but is generally less expensive than the version done by a plastic surgeon. At Belle Medical, Anderson conducted what is called tumescent liposuction. One of the six liposuction techniques recognized by the American Society of Plastic Surgeons, this involves the infusion of lidocaine and epinephrine into saline, which is injected under the skin as fat is loosened and removed. Med spas sometimes treat this light anesthetic regime as a selling point, boasting of “awake lipo” and “twilight lipo.” In an outpatient surgical suite, by contrast, a plastic surgeon usually opts to use general anesthesia, which incurs an additional cost and involves another physician.
Alex Thiersch, head of AmSpa, says his organization advises its 4,000 members against doing liposuction. “We typically exclude liposuction from the list of services that med spas should be performing,” he says. “This is more of an invasive procedure beyond what med spas do. Most of the med spas aren’t doing lipo.”
Liposuction at med spas is typically performed with what are called power-assisted devices. The business end is a roughly footlong metal wand called a cannula. Inserted beneath the skin, it vibrates at thousands of strokes per minute to separate and remove fat. The procedure usually lasts several hours. These devices have become synonymous with treatments such as the “mommy makeover,” which aims to break down stubborn belly fat, and “influencer arms,” where fat in the upper arms is removed. Sometimes fat is redistributed into another area, as in the Brazilian butt lift, or BBL. Liposuction tools are expensive, at around $30,000 each, but they can pay for themselves quickly. The US Food and Drug Administration approves such devices, but it doesn’t police who uses them.
AmSpa said in a 2023 report that 43% of the businesses it surveyed offer body contouring, a broad term covering both surgical and nonsurgical procedures. The report said 17% of annual med spa revenue among those surveyed came from energy-assisted devices, a wide-ranging category that, in addition to body contouring devices, includes lasers and services such as microneedling and tattoo removal.
The med spa is a relatively new phenomenon, born out of a combination of regulatory change, cultural acceptance and entrepreneurial spirit. Over the past decade, cosmetic procedures have become more normalized, in no small part because of the Kardashian family and their televised chronicling of the many changes to their bodies. At the same time, nurse practitioners have gained full practice authority—the ability to practice, within the scope of their license, without physician oversight or with limited oversight—in more and more states. (There are now 27.) These health-care providers, many of them young women—like the customer base of the med spa industry—saw a booming business opportunity and rushed to open their own clinics.
“Fifteen years ago there weren’t really medical spas. There were these services offered inside a dermatology practice or surgical practice,” says Michael Byrd, a health-care lawyer who specializes in med spa compliance. “There has always been a little bit of a perception issue because of the retail elective nature of this. Expectations are more like they’ve just gotten a spa treatment—unless something goes wrong, and then that changes.”
About two-thirds of medical spas have a single owner; among those, about a third are operated by physicians. The rest of the single-owner operations are run by nonphysician, nonsurgeon health-care providers, such as nurse practitioners, physician assistants or registered nurses, according to a 2023 AmSpa report on the industry.
Doctors are becoming scarce in med spas. While other jobs in the business have seen a boom in hiring, physician supervisors have fallen out of favor, according to AmSpa. In 2021, the group found, 25% of med spas had a supervising or collaborative physician on staff. Two years later, only 16% had one. Doctors are expensive; they demand higher salaries and have costlier malpractice coverage.
AmSpa’s report found an average annual revenue of about $1.4 million at med spas, and because insurers rarely cover cosmetic procedures, it’s often a cash business. The average patient comes in repeatedly and spends around $500 per visit, according to AmSpa’s market-research report. Traffic is often driven by the social media hype cycle: More clinics means more customers means more social media posts means more customers means more clinics. Twice as many med spas have social media managers as have doctors, according to AmSpa. Ninety-five percent are on Instagram.
Thomas Terranova, CEO of Quad A, a nonprofit, nongovernmental surgical industry accreditor, says that in large part because of social media, med spa clients tend to see themselves as customers and not patients. “This treatment has been trivialized to the point that patients no longer see it as health care,” he says. Quad A was born out of the early days of outpatient plastic surgery, in the late 1970s and ’80s, during which some clinics ran wild while others wanted to differentiate themselves as safer and thus more appealing to patients, even at a higher price. They opted to have Quad A accredit their practices, and today some state legislatures mandate this kind of third-party review to allow cosmetic practices to operate.
“The state of the industry is just wide open,” Terranova says. “I don’t know when or how that trigger comes that says we need to get our hands around it.”
The majority of practitioners in a med spa haven’t formally studied the services they’re providing. They aren’t able to—there are few programs for this specialized training. The Dermatology Nurse Practitioner Certification Board says only 37 NPs were certified in dermatology in 2023, out of the tens of thousands who graduated from NP programs. Those 37 had to work with patients for 3,000 hours before they could take the certification exam. Nurse practitioners in the med spa industry are most often educated as family practitioners.
The educational gap for NPs in med spas is filled by the cosmetic industry itself, through training companies. For $10,000 the Los Angeles-based American Association of Aesthetic Medicine and Surgery will teach a nurse practitioner how to perform liposuction over the course of three days. For $2,450 it offers a self-guided 6½-hour online class. Empire Medical Training Inc., based in Fort Lauderdale, Florida, teaches courses in injectable buttock enhancement to physicians, nurses and even dentists. The Elite Nurse Practitioner offers a variety of online courses for cosmetic procedures, taught by NPs to NPs, with no in-person option. None of these businesses responded to requests for comment for this story.
Influencers have a powerful effect on the beauty business, and med spa nurses have become influencers within their industry. Since 2021 the federal government has required drugmakers and medical device manufacturers to disclose their financial ties to nurse practitioners. Those payments rose to more than $135 million last year, up about 70% from two years earlier, as NPs took on a wider role in US health care, a Bloomberg Businessweek analysis of a Centers for Medicare & Medicaid Services database shows. Much of that went from the aesthetics industry to NPs, some of whom teach other NPs how to inject drugs like Botox.
Leslie Fletcher, among the most prominent nurse-fluencers, has received more than $1 million in payments from pharmaceutical companies making aesthetics-related drugs, according to the database. “#1Allergan Trainer 2019-2024,” she says in her Instagram bio, referring to Allergan Inc., the maker of Botox and dermal fillers. “Pharma is definitely going the non-MD route with the majority of their training, more than likely due to the fact that 80-85% of all aesthetic treatments are performed by non-MD’s and so nurses/PA’s are their target customer,” Fletcher said in an email. Over the past five years she’s trained more health-care professionals for Allergan than anyone else in the country, averaging 175 sessions annually. In a statement, Allergan said it is “committed to providing world-class training and education for licensed aesthetics professionals, including nurse practitioners, who provide professional care to their patients.”
The standards and regulations that apply to med spas vary widely from state to state. They can be hard to parse and are sometimes challenged in court, as Anderson opted to do. Her suit contends that the statutes do allow her to perform liposuction, and during the oral argument before the state Supreme Court, both sides noted that ablative cosmetic procedures are routinely performed by nurse practitioners in Utah. Anderson’s attorneys also argued for the safety of the procedure. “APRNs worldwide thus perform hundreds of thousands of procedures with the Vibrasat Power each year, and the procedures are highly successful,” they wrote in a brief.
A spokesperson for the Utah Department of Commerce said that the fine has been stayed but that Anderson remains banned from performing liposuction pending the court’s decision. In its statement, Belle Medical said, “Anderson and Belle Medical have worked with and complied with DOPL’s rulings throughout the entirety of this process despite great financial costs which impair the company’s ability to service its obligations.”
Quad A plans to roll out accreditation rules for med spas next year. As it tries to get the industry to take this effort seriously, the organization has an ally: private equity, which has begun to buy med spa practices. There’s a strong business case for accreditation. It could decrease malpractice costs, which could mean bigger and more reliable profits for investment companies.
The rollup is in its infancy: About 3% of med spas have been acquired by private equity firms. But the deals that have been done are attention-getting. Ever/Body, a New York-based chain with 10 locations, has raised more than $100 million since 2019, including an investment from Tiger Global Management LLC. Princeton Medspa Partners LLC, which operates 14 locations in 10 states, raised $120 million, with growth capital coming from BC Partners Credit. Skytale Group, the health-care mergers-and-acquisitions advisory firm, has dubbed med spas “healthcare’s hottest investor market.”
Belle Medical gained a private equity backer in 2021, Peterson Partners. The fund lauded the clinic chain for providing “non-invasive cosmetic surgery, leveraging technology that is less aggressive on the body and far safer than traditional liposuction.” That same year, Anderson performed the procedure that led to her hearing. Peterson Partners didn’t respond to requests for comment for this story.
After the patient left Belle Medical, she said in her malpractice claim, she experienced several months of hardness in her breasts. Alarmed, she went to plastic surgeon Mark Jensen, who later testified at Anderson’s hearing. He said he drained a baseball-size cyst from the patient’s breast, filling a bowl with the fluid, a photograph of which was admitted as an exhibit. In his testimony, Jensen didn’t take issue with the use of the liposuction device itself, but with everything around it. He was concerned, based on photographs of the office where the procedure was done, about sterility. (Anderson said the office was sterile, according to the state’s order of adjudication.) There was no access to emergency support for the patient. And the fat graft itself was too large compared with the size of the patient’s body. Jensen was also concerned about the credentials of the spa’s employees. Liposuction, he said, is among the riskier procedures he performs.
Sara Nethercott, a patient of a Belle Medical facility in Idaho Falls, Idaho, says she didn’t realize she’d signed up for liposuction at all. “They just make it sound so much softer than what it actually is,” she recalls of her February 2019 procedure, which she underwent in an effort to slim her love handles. She’d seen a promotion for “3D body contouring” and had been impressed with the before-and-after photos the med spa showed of other patients. She says she signed up using a credit card, got a prescription for some pain medicine, and the next morning was back in the office to be sculpted.
Nethercott says that the day of the procedure, as she sat in an exam room wearing paper undergarments, she was pitched additional treatment on her upper back. The spa employees suggested she take advantage of a sale and add it to her tab. Feeling self-conscious, and at least somewhat affected by the painkiller she’d been prescribed, Nethercott yielded to what she now feels was a high-pressure sales tactic. After that, she was taken into another office suite to meet the provider for the first time. She says she assumed she’d be meeting a surgeon.
The provider was a nurse practitioner, who performed the liposuction across Nethercott’s sides and back while she, like the Utah patient, was fully awake. The health-care workers spoke with her, asking her to flip so they could work on her other side. “That was the most pain I’ve ever felt,” she says.
After the procedure, she says, she developed an infection and visited an urgent-care facility, where she was informed that the 3D sculpting procedure she’d undergone was in fact liposuction. That was noted in one of the medical forms she signed in advance of surgery, but she says she didn’t see it. “They never said, ‘It’s not surgery,’” Nethercott says. “They didn’t have to—because they never mentioned it could be surgery! So it just seemed like a beauty procedure.”
Citing patient privacy, Belle Medical said that it couldn’t comment on Nethercott’s account but that it complies with regulations and is committed to patient safety. “The medical providers, both board certified surgeons and mid-levels, use their medical training to decide what to prescribe for each given case and patient,” the company said.
The liposuction was about $6,500. Nethercott says she paid an additional $3,500 toward IV antibiotics, administered twice a day for two hours, to clear the infection from her system.
“It looks like a bullet hole,” she says today, reflecting on her scars. “Belle Medical. Medical—it sounds like you know what you’re doing.” —With Caleb Melby and Noah Buhayar
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