Like the SuperBowl ads, its always interesting to see which celebrity is the latest CoolSculpting spokesperson! It looks like television personality on Bravo’s “The Real Housewives of New York City”, Sonja Morgan is in. What does this mean to you? Well, with all the marketing money Allergan® has spent across the nation, it is very likely that you have had or will have patients ask about Coolsculpting®. Before you spend +$150,000 on a CoolSculpting® machine (including handpieces) and $10,000’s annually to use it, you need to know the Cold Hard Truth about CoolSculpting®.
This article is not about whether CoolSculpting® is an effective treatment, it absolutely works. I have had CoolSculpting® in my practice for +4 years, and we have many happy patients. This article is about the true cost of owning and operating a CoolSculpting® machine in a medical practice. Most owners are silent in their feelings about the exorbitant costs of running the machine because they want to continue to get practice marketing support (the commission sales person they provide to clinics), however, the truth needs to be told and this is my story. Please feel free to comment below, either for or against, I promise I won’t take it personally!
As many physicians have learned the hard way, investments in lasers and other expensive practice equipment often do not turn out to be as profitable as the sales representatives lead you to believe. Is CoolSculpting® any different?
Well, yes and no. Yes, in that the procedure does work on the right patients. And no, in the fact they gloss over the real costs of owning, and more importantly, operating a CoolSculpting® machine. One thing the reps gloss over is the cost of running a CoolSculpting® machine – the very high consumable costs will drive you crazy. In fact Allergan® made over $148 million in consumable card sales in the first nine months of 2019! They actually made more money in consumable sales then in selling the actual machines.
You are used to paying Allergan® half your money when you perform a Botox® injection, well, now not only did you pay $150,000+ for a CoolSculpting® machine, you are going to need to pay Allergan® $330 per area treated. An interesting fact is when I first bought my CoolScultping® machine I was paying $125 per area, so it has increased 2.5x’s in the last 4 years! If you didn’t already know, every time you treat a CoolSculpting® patient’s targeted body area (multiple treatments are usually required for each patient, on average 4-6 treatments per patient), you need to pay this $330 per area. So making the equipment purchase is not a one-time event, they have now become a partner in your practice! You are now going to be paying Allergan® half your money every time you treat a CoolSculpting® patient. When you look at other competing machines, some do not offer significant consumable costs (ie BTL’s Vanquish has a $0 consumables).
Here is a quick example of how much you will pay CoolSculpting® to treat your patients with their “Treatment to Transformation™” package they recommend you sell to patients. The package typically includes: 6 small treatments @ $330/ea + 1 large treatment at $330, which is a cost of $2,310/patient to your practice. If you see 8 patients a month, after a year, you will be writing Allergan® a check for $221,760! And it does not end there, every year after, you need to write them more checks!
10 patients a month = $221,760 in CoolSculpting® consumable costs
10 patients a month = $0.00 in BTL Vanquish consumable costs
* Both of the machines above promote 25% fat cell adiposis in their clinical research.
But the sales rep says “You will get your co-op marketing expenses reimbursed!”. Actually in the above case, if you bought your cards as you needed them, you would only receive a maximum reimbursement of $1,000/quarter ($4,000/year), so yes, if you spent $24,600 in marketing for a quarter, they are going to give you $1,000 back! (If you spend more than $25,000/quarterly, they increase it to $6,000/quarter, so they really want you to pay for 6 months of patients in advance.) Spending $221,760/year on a full-time marketing person and an advertising campaign that not only promotes CoolSculpting®, but all my procedures may be a better option to spend my money!
Let’s begin with some education on the CoolSculpting® procedure.
What is CoolSculpting®?
The CoolSculpting® System is a portable thermoelectric cooling and heating device that applies controlled cooling or heating to a treatment site. The device is indicated for cold-assisted lipolysis (breakdown of fat) of the submental area, thigh, abdomen, and flank, or “love handles” in individuals with a Body Mass Index (BMI) of 30 or less. The procedure is intended to change the appearance of the treatment area by delivering controlled cooling at the surface of the skin to break down fat cells that are just beneath the skin. The procedure is non-invasive and is not a treatment for obesity or weight-loss solution and does not replace traditional methods such as diet, exercise or liposuction.
How Does CoolSculpting® Work?
As with any medical equipment, you are going to see endless photos of successful procedures. I have to say with my experience offering CoolSculpting® procedures for the last 3 years, we have certainly seen many great results. However, we also have seen not so impressive results. It is critical with this and other similar fat elimination equipment that you always take before and after photos of all your patients. Based on how CoolSculpting® works, the patients need to wait at least 3 months before they see their final results. It is also important to take their weight and measurements.
Coolsculpting® is a procedure that is used to destroy fat cells using controlled cooling (near 4 Celsius) to gently and effectively target the fat cells underneath the skin without apparent damage to the overlying skin. The treated fat cells are crystalized (frozen), then die and leave the body through the body’s natural elimination process, thus reshaping the body contours. The results are long-term.
For the right patients, CoolSculpting® certainly works. But since it is such an aggressive procedure, you are also more likely to have discomfort during and after the procedure, which will be covered in the next section.
What are the complications and side effects of CoolSculpting®?
Most patients will have a loss of feeling in the treated area. We had one patient where we used the large abdominal handpiece and they did not have any feeling in the abdomen for 6 months. This length of time is unusual, but it can certainly happen. Most patients will have neurogenic pain in the affected areas for between 2-6 weeks.
There have been many adverse events registered with the FDA in relation to the CoolSculpting® procedure.
- Patient experienced extreme pain after procedure, by day 3 had a high level of pain. The patient was not given any meds at the doctor’s office. The patient stated the procedure was a waste of money and the second treatment was not performed due to the pain. (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=2334988)
- Male patient received coolmax applicator on his lower abdomen. Over a short period of time the patient noticed his abdomen was larger. Upon his second treatment the bulge decreased but then increased again within 6 to 8 weeks. The patient required surgical intervention as the condition could not resolve on its own. (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=3023853)
- Male patient received coolmax applicator on his mid-abdomen centered on the umbilicus. Three months post-treatment the patient noticed lump and went for follow up visit to the treating office. They said it was “tissue stiffing” in the treated area. A CT scan diagnosed the lump as fat and the patient begun accent ultra treatments. (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=2950096)
- Patient had treatment on lower and upper abdomen, with 2 small devices in 2 separate sessions. The patient experienced intense burning in lower abdomen and sharp occasional stabbing pains and tender area to touch. Doctor’s office told patient the result was unusual. (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=2593139)
- Coolsculpting treatment on male patient’s left flank became enlarged 2 months after treatment and his weight increased. Patient underwent an ultrasound and diagnosis was possible lipoma and he will be undergoing a liposuction procedure to correct condition. (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=2878976)
- Clinician experienced issues with coolsculpting machine while treating patients left abdomen, skin was assessed and determined to be normal. The clinician successfully treated the right side. The patients left area was re-attempted two times and experienced two more system messages and treatment was stopped. Again the skin was assessed and determined to be normal. Review of the device revealed no abnormalities. On follow up appointment patient had skin discoloration on the left side and was prescribed Silvadene. Patient continued to have issues with skin on left side with redness and the skin then peeled off. Clinician gave the patient triple action cream, aquaphor and was also prescribed tret/kojic/hc and epicream. The patient completed medlite laser treatments and skin was improving. (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=2281208)
- Male patient received two coolsculpting treatments on the lower abdomen. Three months post treatment showed increased fat in lower abdomen. Four month follow up visit, the area was firm and Zeltiq recommend diagnostic treating. The patient underwent an ultrasound and the report stated “increase in volume, thickness and density of the described lower abdominal fat not associated with collections or mass. There is no eventration.” Liposuction was recommended by a plastic surgeon. (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/detail.cfm?mdrfoi__id=2802334)
The Aesthetic Surgery Journal also published a case report of a 29-year-old man presented with an enlarging adipose collection on his lower abdomen following cryolipolysis with CoolSculpting® (https://asj.oxfordjournals.org/content/35/7/NP218#sec-6). It was determined that “Paradoxical hyperplasia of fat following cryolipolysis occurs infrequently, usually only after multiple cycles of cryolipolysis. The condition should be identified early and treated with liposuction, not another round of cryolipolysis.”
In a recent article of The Aesthetic Surgery Journal on Paradoxical Adipose Hyperplasia and Cellular Effects After Cryolipolysis (https://asj.oxfordjournals.org/content/36/1/NP6) recommends that “Additional studies are needed to better understand the mechanism of cryolipolysis and how it affects the interstitial cells and vasculature.” This complication has been added to their patient consent forms.
What your patients can expect with a CoolSculpting® treatment?
Uneven results are quite common, and you must tell all patients that you may need to retreat some of the areas. In this study (https://asj.oxfordjournals.org/content/early/2015/03/30/asj.sju069) there were “4 initially dissatisfied patients who were re-treated” and then they were satisfied. The study was conducted for 528 consecutive patients from January 2010 to December 2012.
The “CoolSculpting® Treatment Considerations Form” provided by Zeltiq® gives you an idea of the possible complications:
- Excessive fat removal in the treatment area, resulting in an unwanted indentation. The indentation may be improved through corrective procedures (ie surgery)
- Darker skin color
- Discrete nodules
- Frostbite (local injury due to cold)
- Hernia or worsening of existing hernia. Surgical intervention may be required to correct hernia formation. (unfortunately for us, this was added after we observed our first hernia, we have certainly seen several hernias protruding through the patients abdominal wall)
How CoolSculpting® (Allergan®) Make Money?
As mentioned above, not only does Allergan® make money on the one-time equipment purchase price (~$150,000), they generate an additional $5-9,000/year by providing a service warranty on the device (which is critical, our machine broke down after only 5 months of use, and needed to be replaced). The most lucrative money they make is from the physicians themselves.
The structure at Allergan® is you have your sales rep, and then when you buy the machine you are assigned a “Practice Development Manager” to help develop your practice. Sounds like a great idea, however there are some significant issues with this role. First and foremost, this is a commission sales role and their job is to sell you cycles so you can use your machine, in which they earn a commission. Secondly, you can be assured that everything you tell them about how you do business will be shared with all your competitors. We have seen our website content, promotions, and ads all copied by local competitors. As well, they have certainly shared what our competitors are doing with us. The only person who wins in this situation is the Practice Development Managers with their commission checks, certainly not your practice! We have learned, albeit the hard way, not to share anything we are doing with our rep.
Another way they make money is by requiring you to have a different type of card for each of the handpieces, which causes you to have excess cycles sitting on your shelves. For example, I have $11,000 worth of cycles in my practice, which is $11,000 cash. I would rather spend that money on marketing my practice, rather than inventory sitting on my shelves. If you have all the handpieces, you would need to inventory 5 different cards in your practice! I should point out that a cycle is one patient treatment, and a card typically contains between 16-24 cycles.
How much money are we talking about? At the time of this writing (and I have heard Zeltiq® is planning a pricing increase very soon), this is what it will cost to treat a patient (also add the mandatory FedEx shipping fee):
CoolMini/Advance – $330/each
CoolCard – $330/each
CoolCard Max – $330/each
CoolSmooth Pro – $330/each
CoolSmooth – $330/each
To make matters more complicated, the new handpieces now require $330/cycle cards. Here Allergan® is making even more money since cards for the old handpiece will not work in the new handpieces. If the handpiece takes new cards (which they all do), you then have to wait 4 weeks after you receive your new handpiece before you can start the cycle exchange program. To help you, they will sell you more cycles (you don’t need) until you get the new replacement cycles 4 weeks later.
What does this mean to a typical practice? A busy practice will see closer to 15-20 patients a month, and the average patient does approximately 6 treatments. With an average cost of $330/cycle, you will need to pay Allergan® +$475,000 (+ shipping) to treat those patients. If you used a competitor that did not require consumables (cards), the cost to you would be $0.
In addition, ever since Allergan® purchased CoolSculpting® from Zeltiq®, we have seen our patients (and practice revenues) drop by 30-50% mainly due to the flood of new machines the vast number of Allergan® reps are selling. Is the market saturated with CoolSculpting machines? Absolutely! I am certainly hearing this in every major city. Once you had 30-40 machines, now you are seeing 80-120 machines in the same area! This is good news for Allergan®, however their 4th quarter financial results showed a decrease in CoolSculpting sales of 37.6% over the previous year.
Support that Allergan® Provides
So you have just spent $475,000 in one year buying cycles so you can treat patients. What are you getting for that nearly half a million dollars? (At this level, we will assume you have reached the “Diamond” level of their Crystal Rewards program, which is now on its way out).
- They will reimburse you up to $50,000/year for CoolSculpting® marketing (in which the requirements change every quarter, so what was approved the previous quarter will not necessarily get approved in the next).
- You get 95% off your annual equipment warranty (this is a great benefit).
- You have a Practice Development Manager who will continually try and sell you more cycles, and tell your competition how you made it to Diamond, and they can to!
Sorry, but I would rather take that $475,000 hire a brilliant marketing manager, create a comprehensive marketing program that covers not only CoolSculpting®, but all of the procedures I provide, like Botox®, dermal fillers, lasers, etc.
Allergan® also has a CoolSculpting® University, and for a hefty fee (+ hotel and airfare), you can send your staff to this program which is located at either their head office in Pleasanton, California or in Reston, Virginia.
The Final Truth
The intention of this blog was to give you all the facts Allergan® does not tell you before adding CoolSculpting® to your practice. I have had CoolSculpting® in my practice for +4 years, so I’m sharing my experience, in addition, I have incorporated the feedback of many owners through my role as the Executive-Director of the IAPAM. The fact is the CoolSculpting® procedure is not a sham; it certainly works on the right patients. Hopefully, you now have some hard questions to ask your rep before you make this huge investment. Do not forget the investment is not only the machine but the onerous consumable costs that are associated with these procedures. When you do the math, it may make more sense to buy a machine without these expensive “cycles.”
If you think I was too harsh, and you would like a more positive, advertorial style article on how great CoolSculpting® is, please check out this article, “Fat Chance Building a Better Body the Cool Way” that appeared in Prime magazine. It’s full of quotes from CoolSculpting® and all the positives. My suggestion is to read that article as well, then you will have a much better understanding of the big picture and clearly understand the pros and cons of offering CoolSculpting® to your patients.
What Are The Benefits of CoolSculpting Training
In order to perform CoolSculpting®, specific training is essential to make sure the treatment offered is state of the art and meets standards that patients expect from their healthcare professional. Below are a few aspects that must be considered when training to perform CoolSculpting.
1. Background knowledge – It is important to know when cool sculpting can be offered to patients. In other words, a good background knowledge will arm the practitioner with the information they need to make an expert decision on whether cool sculpting is the treatment that will be of benefit to the patient.
2. Understanding equipment – The equipment used to perform cool sculpting is state of the art. The procedure is developed by Allergan®, and currently, the FDA has only approved this CoolSculpting® machine for cryolipolysis.
3. Procedural skills – The theory behind CoolSculpting® is clear – breakdown of fat cells by reducing the temperature to below freezing, while protecting the skin and other tissues. This requires a degree of skill, and training programs will aim at ensuring these skills are developed or at least introduced by the time the course is complete.
4. Risks and side effects – This is another important aspect that must be covered in training programs. Having a good knowledge of the risks and side effects means that the treating practitioners will know how to manage them in the event of them occurring.
5. Benefits – There is no doubt that patients undergo CoolSculpting® in order to experience the benefits that it offers. It is good to have a detailed knowledge of the benefits that patients can obtain from this procedure. It is essential to realize that treatments will only start to show positive effects after a few months, and repeat treatments will sometimes be needed. This aspect will need to be discussed with the patients, and therefore a good knowledge will make this process easy.
CoolSculpting® is emerging as a much sought after treatment for fat reduction. Adding it to your service will require that you undergo specific training. This way, patients can experience the most out of this safe and effective procedure.
If you are a current owner of a CoolSculpting® machine, we want to hear from you! Please feel free to post any comments below, I’d love to hear from other owners.
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