What does this even mean?
The awkward title refers to On-Demand, Direct-To-Consumer, prescription drugs…sold by “telemedicine” companies that use a blend of Internet and traditional marketing to attract visitors to their web sites and call centers.
Who are these companies? What are they selling? Is it legal?
The recent issue of JAMA published a short summary of these companies and the kinds of products they sell. Well-known examples include hims.com, keeps.com, and getroman.com.
They first place you “in contact” with a licensed physician, where contact could mean voice, video, or even text/messaging. After a brief consultation and a medical history, the physician prescribes a medication, which is then filled and shipped directly to the patient/consumer.
Prescription filling and dispensing certification is provided by LegitScript.com.
To date, these products are limited to prescription solutions to medical problems such as acne, erectile dysfunction, and hair loss. However, some of these companies are branching out into more serious conditions, such as sleep, performance anxiety, and benign prostatic hypertrophy (BPH).
Benefits
These companies are, in their unique way, providing our industry with a business model that can lower prescription delivery costs. Mail order delivery of generic drugs directly from company warehouses eliminates complex layers in the distribution channel, thereby reducing costs.
And, this approach may drive people to seek medical attention who would not otherwise do so due to concerns over cost or embarrassment. Indeed, their prices for prescription drugs like sildenafil are unbelievably low. Importantly, these are real prescription drugs, not the “weird tricks” that we see in our Spam folders.
These companies claim their services can also benefit patients living in remote areas without easy access to physicians. But whether or not this is a legitimate issue for these conditions is an open question.
So what's the problem?
We see a few potential problems with this model:
Excessive Medicalization – For decades, Pharma has been accused of creating medical conditions in order to sell therapies to treat them. A few decades ago, early criticisms of minoxidil and sildenafil were focused on this point. But at least these candidates went through clinical trial and regulatory processes.
Can this model “create” conditions that require prescription medication? Perhaps.
The authors give a great example in the prescribing of propranolol for performance anxiety. While the internet is full of articles touting the benefits of propranolol for performance anxiety, at least one meta-analysis concluded “… the quality of evidence for the efficacy of propranolol at present is insufficient to support the routine use of propranolol in the treatment of any of the anxiety disorders.”
To be clear, we are in favor of physicians having the freedom to prescribe off-label. And if a physician feels low-dose propranolol can be helpful, then so be it. But do we want patients using prescription drugs to treat nervousness secondary to public speaking? Is this really a condition that usually requires medical intervention? And what about drug-drug interactions?
More importantly, is the prescriber undertaking a thorough examination and diagnosis? Via text?
Misdiagnosis & Misprescribing – For 20 years, sildenafil other drugs of their class have been the source of innumerable jokes. However, this entire class of medications has driven more men to see their physicians than any other drug class. That’s great, considering most men are loath to discuss their intimate, personal problems with physicians…or anyone for that matter.
This is important because a physician discussion about ED can uncover underlying conditions, such as depression, trauma, and even diabetes.
Can erectile dysfunction secondary to diabetes be successfully diagnosed via text?
Probably not.
And therein lies the problem.
We want men to see their physicians to talk about their health issues. This can lead to the early diagnosis of underlying conditions which can be dealt with if identified early. DTC telemedicine models essentially run counter to this.
But let us suppose for a moment that the diagnosis is correct. These telemedicine companies do not have a full portfolio of drugs to choose from. Given its low cost as generic, it makes sense to start there. But is sildenafil the right choice for every patient? What if it doesn’t work?
Let’s consider oral contraception, where the choices are more complex? What if an IUD makes more sense instead of an oral contraceptive? How will this distinction be made via text? Will the prescribed decline to prescribe/sell the product in hand because another option is better for this patient? And, again, how can this nuance be understood via text?
Missed Drug-Drug Interactions – One of the reasons pharmacies exist is to provide one central hub for all prescriptions flowing from multiple physicians. This is a great model for catching drug-drug interactions in cases of polypharmacy via multiple prescribers.
DTC Telemedicine is like having a second pharmacy dispensing drugs. Will drug-drug interactions be missed if the primary pharmacy is not notified of other active prescriptions? Possibly. To be fair, the drugs being dispensed by these companies have relatively few drug-drug interactions. But what if their formulary expands?
Moving forward, it is likely that these companies will entirely avoid medications with potential drug interactions. It is the logical thing to do. Yet, a narrowly-defined formulary is not in the best interest of patients.
Where do we go from here?
Earlier this year, Hims received a $100 million investment at >$1 billion premoney valuation. They also started a brand for women (cleverly named “Hers”).
That needle will have to be moved, which means that this company (and their competitors) will expand, both in terms of marketing spend and product lines. They are not going anywhere anytime soon because their investors will want a return (likely via acquisition; Amazon.com, are you reading this?). Areas for expansion may include smoking cessation, contraceptive patches, cough and cold, and others.
We concede that cost reduction and increased access to medical care is generally a good thing. But the potential for incorrect diagnoses and other problems remain, and may grow as their formularies expand.