On March 4, 2025 HB 3749 was introduced in the Texas House of Representatives seeking to significantly restrict NPs and PAs working in medical spas in the state. The following is the full text of a letter from AmSpa founder and CEO Alex Thiersch, JD, to the bill’s chief sponsor, Representative Angelia Orr. For more information on this and other bills currently active in the Texas statehouse that would affect medical aesthetics, see our Texas Med Spa Legislation Action Center.
 

Representative Angelia Orr
Room E1.220
P.O. Box 2910
Austin, TX 78768

Re: HB 3749

Dear Representative Orr,

On behalf of the American Med Spa Association (AmSpa), I would like to submit the following in relation to HB 3749. We applaud the efforts to address unlicensed and unsupervised medical spas and IV clinics, an increasingly troublesome issue that our industry is grappling with not only in Texas but across the country.
Ultimately, we can’t support the bill, not because we don’t support the desire to make the industry safer, but because we don’t believe the bill achieves that purpose. This bill, while undoubtedly well-intentioned, makes medical spas less safe by removing qualified oversight that every other health care clinic maintains, while not addressing the actual problems this industry faces. I look forward to discussing this further.

Three points need to be made here:

• First, under current Texas law, medical spas are medical clinics and are regulated by the same standard as any other doctor’s office. Med spas are already required to adhere to the same strict physician oversight and safety protocols as any other physician office and are required to only used trained and experienced medical providers. Because of this, most medical spas are extremely safe with complication rates less than other areas of medicine.
• Second, while there are undoubtedly problems with a certain segment of the medical spa industry, those are overwhelmingly caused by medical spas who lack any physician supervision, use unlicensed and untrained personnel, and operate in a noncompliant and unlicensed fashion. In other words, those medical spas are illegal right now, and it’s doubtful that they will suddenly follow new laws that are implemented. As such, the proposed bill punishes safe and compliant med spas while allowing the bad actors to continue unabated.
• Third, current Texas law addressing medical aesthetic treatments is already one of the most robust regulatory frameworks in the country and more than adequately prevents the types of tragedies at issue here. The Jenifer Cleveland tragedy likely never would have happened had current law been more widely known and, importantly, enforced. The proposed bill strips away clinical protections that bad actors don’t pay attention to in the first place, while making the “good” med spas less common.

AmSpa and the Medical Spa Industry

The American Med Spa Association (AmSpa) is the largest trade group in the medical spa industry. Consisting of over 4,000 members, including close to 1,000 in Texas, AmSpa is dedicated to ensuring the non-invasive aesthetic industry is safe and that its practitioners are trained, qualified, and compliant. AmSpa’s goal since its founding in 2013 is to ensure the aesthetic industry understands and complies with the myriad health care regulations put in place to ensure the public is protected. It is in our best interests to rid the industry of unqualified practitioners and unsupervised medical spas.

Partnered with ByrdAdatto, the leading aesthetic health care law firm in the United States (headquartered in Dallas), as well as some of the top clinical providers in the industry, AmSpa has developed a database and corresponding legal analysis of the medical spa laws in all 50 states. We have also created comprehensive practice guidelines that will not only address the circumstances contemplated in the current bill, but also ensure that all Texas med spas commit to and comply with minimum standards and requirements widely accepted as safe.

How Safe (and Most) Medical Spas Work:

Medical spas are considered medical practices, and therefore the medical laws and regulations of each state govern medical spas in that state. In Texas, while medical spas’ minimum requirements are the same as any medical office, the Texas Medical Board has adopted additional regulation governing delegation and supervision of nonsurgical medical cosmetic procedures (22 TX Admin Code § 169, “Rule 169”). Medical spas are already more heavily regulated than other medical practices.

Most med spas adhere to the strict medical framework of a traditional medical practice, which make compliant med spas very safe. Reports of complications and side effects are rare, despite an explosion in treatments in recent years. Evidence of this exists in the cost of professional insurance policies for medical spas, which remain far below national averages. The numbers of lawsuits and malpractice claims is also far lower than other areas of medicine.

While medical spas are designed to have a more patient-centered experience (i.e. not as clinical and sterile as a typical doctor’s office), the patient treatment process is the same:

• All patients are examined by qualified and experienced physicians, or, with proper documentation and training in place, qualified and experienced Physician Assistants or Nurse Practitioners.
• Following this initial examination, treatments can only be delegated to providers that the delegating physician confirms are trained and qualified in the procedures being offered, and only if properly supervised.
• Proper protocols and procedures for addressing side effects, complications and emergency situations must be in place.
• Informed consent must be obtained, including the patient being informed that they are being seen and treated by a non-physician, if that is the case.
• Practicing within HIPAA and OSHA standards.
• Providing up-to-date and thorough standard operating procedures (SOPs).
• Physicians are well-trained in every procedure offered; and
• Nurse practitioners, physician assistants, and registered nurses are licensed in good standing, and well-trained in every procedure offered.

Current Texas Law, If Enforced, Would Have Prevented Jenifer Cleveland’s Death

It must be noted that these regulations, had they been followed, would almost certainly have prevented the Jenifer Cleveland tragedy from happening. The clinic at issue should have had a physician or properly licensed NP or PA providing an initial exam before treatment, there should have been written protocols in place and a physician available for immediate consultation in the event of a complication, and there should have been a trained providers on site to deal with complications. In short, had the current laws been followed and enforced, we wouldn’t be having this debate right now.

We encourage the Committee to review Rule 169, and we would be happy to provide specific legal guidance from health care regulatory counsel as to its applicability to med spas.

HB 3749 Will Make Med Spas Less Safe and Increase Unsafe Practices:

We do not wish to sweep what happened to Jenifer Cleveland under the rug, nor do we want to ignore any issues that exist in medical spas in Texas. Our primary goal is the same as yours: to ensure that medical spas are safe and that patients are protected. But we also know that the vast majority of med spas are safe, and they operate in accordance with strict medical regulations that are already in place. By abruptly changing those regulations, the current bill would make the good med spas less safe by taking away medical oversight they have employed for years, and that every other medical practice area currently employs, while not addressing the real problem we’re dealing with as an industry – the operation of illegal, unlicensed med spas.

For example:

• HB 3749 makes medical spas less safe by removing trained and qualified advanced practitioners (NPs and PAs) from assessment and supervisory roles. NPs and PAs are advanced clinicians who are permitted to assess, diagnose, prescribe, and treat conditions provided they are working under a physician with a written agreement and protocols in place. The physician is responsible for ensuring that the NP/PA is experienced and qualified in the procedures being offered, and, if so, the physician may delegate to the NP/PA services that allow the physician freedom to perform more complicated medical procedures. In medical spas, this means that NPs and PAs can perform initial assessments, diagnose, and treat non-surgical aesthetic patients (i.e. Botox, fillers, IV treatments) provided the physician in his or her judgement has determined they are qualified and experienced enough to do so. The current bill takes this feature away, which will lead to more unlicensed and unsupervised treatments, not less. It will also punish physicians who operate safe, compliant med spas because they will no longer be able to utilize PAs and NPs as they did, forcing many to shut down.
• Further, HB 3749’s requirement that every med spa have a physician, not an NP or PA, “immediately available … to be present” at the facility is unfairly punitive to the majority of med spas operating in Texas. NPs and PAs, in a compliant relationship with a physician, can and do provide oversight services without this requirement in other private healthcare settings. Most physicians who run med spas rely on PAs and NPs to provide an advanced level of medical oversight while the physician is not in the immediate vicinity (i.e., at another location doing a more advanced procedure). The physician is already required to be immediately available for consultation under Rule 169. Forcing them to be on-site – which this requirement would surely do, and which is not required in any other area of medicine – would force most med spas to shutter and, again, increase the number of unlicensed, untrained services being provided. And given how safe med spas are, this is completely unnecessary.
• Other than curtailing NP and PA authority, HB 3749 doesn’t meaningfully improve the current law in Texas. Texas’ current aesthetic regulatory framework is far more definitive, provides more specific guidance, and offers more patient protection than HB 3749. HB 3749 is a vague repetition of the current law, and its only material change removes safeguards that were in place beforehand: the involvement of NPs and PAs.
• Finally, HB 3749’s IV provisions seem to have none of the safety or supervision requirements that it proposes for medical spas: there is no patient assessment required for IV treatment, no immediate supervision required for IV treatment and, no requirement that anyone trained in basic life support be onsite. And the bill takes the unusual step to grant registered nurses the ability to prescribe IV treatments, something RNs cannot do in any other health care setting.

The Problem is Bad Med Spas, Not Good Med Spas

There are bad actors and bad situations in this industry that must be addressed, and we know exactly where they originate. The problems are caused by unlicensed, noncompliant, untrained providers doing treatments they shouldn’t be doing. In other words, unlawful practices blatantly operating contrary to well-established law and medical regulation.

The bad actors in our industry are violating existing laws – laws that, if enforced, would prevent the very problems we all want to solve. The current bill will punish ethical providers and hardworking professionals, punishing all med spas for problems caused by those already breaking the law. HB 3749 doesn’t make the industry any safer. It just shuts down the safe med spas and creates more unsafe, uncompliant ones in its place.

Conclusion

What happened to Jenifer Cleveland was unconscionable. It was also illegal. While, as mentioned before, many elements in HB3749 are not objectionable and are, in fact, already the law, the provisions cited above will do little to advance patient safety. Rather they will cause almost all med spas in Texas to shut down and put thousands out of work.

AmSpa welcomes the opportunity to work with all stakeholders on this issue. We have been researching, training, and educating the industry for over ten years, and we have access to advisors and professionals that have been in the space for over 20 years. AmSpa supports well-informed, practical regulations that ensure patient safety while avoiding reactive legislation that overreaches or harms an already safe industry, and we are committed to rejecting any so-called "medical spas" that fail to follow the laws and regulations of medical practice or engage in unsafe and/or unethical practices.