By Valerie Monroe
If you’re interested in feeling happier about your appearance—especially as you age—you might like reading what she has to say about it. For more of her philosophical and practical advice, subscribe for free to How Not to F*ck Up Your Face at valeriemonroe.substack.com.
“ASK VAL” answers your urgent questions, “Deep Throat” edition.
Yes, you—with the reporter’s notebook—looking very skeptical in that handsome Trilby. Would you mind putting out the cigar?
Q: Why are dermatologist office procedures so pricey? What are we paying for? Is the cost of ingredients in Botox or Restylane, or whatever, really that high? Do pharmaceutical companies jack up prices even though the ingredients cost pennies? Are doctors charging 10x the cost of the product, plus whatever they charge for their skill, time, experience . . . and house in the Hamptons? It doesn’t seem possible that those tiny vials are so expensive.
A: You asked a mouthful, friend. I spoke with a trusted, very thoughtful dermatologist to get the inside scoop on pricing markup and the strategy behind it.
First, and most important, DT (as I’ll affectionately call them) points out that “buying” neuromodulator or filler is not like buying a bottle of ketchup. You might be thinking, Right, for obvious reasons, but . . . maybe not so obvious. Because you’re not paying for a product but a procedure. Confusion about that distinction has led to horrendous stories about people trying to inject themselves with filler and neuromodulator.
At the doctor’s office, what you’re really paying for is, as you suggest, skill and experience. A person should not be performing a procedure, no matter how low-risk, if one isn’t fully prepared to manage a complication, says DT. If you choose to have a procedure without a physician present—or at least with a physician’s assistant and an MD within screaming distance—you are making maybe not such a good choice. Another thing about avoiding the doctor’s office for a less expensive venue, like a medi-spa: Though the price listed for your injectable might be lower, there’s the possibility that you will be over-injected—blessed with more product than you need—in order for the medi-spa to charge you a larger amount. Not necessarily, but just sayin’.
Onto pricing. Every few months, product prices change, points out DT. To determine pricing, doctors take into consideration whether the product is a consumable—something that will be used up, like a neuromodulator or filler—or something reusable, like some devices. The list price the doctor pays for a 100-unit vial of neuromodulator is roughly $600 ($6 per unit) while you, the patient, are probably paying roughly $20/unit—about a 300% markup. (All prices are for New York City and, therefore, somewhat high.) Does that sound like a lot? DT notes the price of a procedure is also based on the downtime required; if the doctor expects you may need follow-up care with multiple visits and/or time on the phone, they will factor that into the cost. Many dermatologists will answer questions you might have about your skin before, during, or after a procedure. (After asking about a skin issue, I’ve never had a dermatologist say to me, “I don’t know what that is,” and leave the room. If you have, I hope you never went back.) Even a quick-ish procedure for Botox, say, when you factor in time for numbing cream, photos, vein mapping (to avoid bruising), injections, maybe a little arnica, and then a conversation, might require 30 minutes of a doctor’s time.
The question is: What is that worth to you?
Here’s an interesting tidbit. The more product a doctor’s office buys, the better the price they get. For example, they might say to a drug rep, “If we order more filler, can we get 20 free Restylanes?” That means an office might push one brand of filler or neuromodulator onto patients because it’s good for their balance sheet. If the physician you see carries only one or two brands of neuromodulator or filler (no, they’re not all the same), you’ll get what they have—whether it’s the best one for you or not. DT’s office carries all major brands; they tell patients that they would like to make the decision about which to use; if the patient has a preference, they will try to work with it.
I haven’t been successful yet finding pharmaceutical production costs. Abbvie, the company that bought Allergan, which produces Botox, had (if I read this right) global net revenues of $1.142 billion from their aesthetics portfolio in the fourth quarter of 2020. That’s a lotta meatballs! For a weird and maybe unhelpful contrast, I checked out the physician yearly salary report for 2021 by specialty to see where on the golden ladder of wealth dermatologists sit. Unsurprisingly, plastic surgeons occupy the catbird seat (which adds credence to DT’s advice to see a dermatologist rather than a plastic surgeon for most non-surgical skin issues). It turns out that dermatologists are the ninth most highly paid. The lowest earners? Public Health and Preventive Medicine, Family Medicine, and, finally, Pediatrics. If that doesn’t tell you something about our culture, I don’t know what does.
So. You found some spare change in the sofa cushions and you’ve decided you want some minor face-fiddling. (Before you fiddle, please read this for a thought-provoking perspective.)
Here’s DT’s best advice: Call around to three dermatologist offices for prices and ask if they carry a variety of brands of neuromodulator and filler. The range you might expect to pay for enough neuromodulator for the forehead and crow’s feet (but please take my advice and don’t mess with the latter) is between $650 and $850. You might pay less if the dermatologist has a high volume of patients or offers a package deal. For filler, you might expect to pay anywhere from $800 to $900 for a syringe—you’ll likely need one or two syringes depending on what you’re plumping up. Sometimes a second syringe is discounted, says DT. If a treatment is sold as a package (like for laser hair removal), expect that one treatment isn’t going to solve your issue.
One more point, notes DT. Because some procedures have a higher risk, they’re more expensive. For example, filler under the eye typically costs more than filler elsewhere on the face, which is why some offices charge by “area,” while others charge per syringe.
You can always ask if the price you’re quoted includes a complimentary touchup. (DT’s office will re-treat a patient—once—if he or she thinks the result is too subtle.) And keep in mind that most injectables are not forever (except the ones you probably want to avoid), so you’ll need to factor in maintenance costs if you think you’ll travel further down this road. Ask your doctor how long you should expect results to last.
Bottom line: Who’s getting rich? Sure, your doctor is likely pocketing a nice profit after around 12 years of school, training, and possibly student debt. But I think it’s safe to say who’s getting really rich. Big Pharma. And that’s whose Hamptons spread I’d like to see.