Direct-to-consumer telemedicine services have attracted plenty of attention from investors and patients alike, due in part to their lower costs and ease of use. From a medical standpoint, however, these business models introduce a number of departures from traditional care that deserve serious concern and investigation, argue the authors of an editorial published Friday in JAMA.

“DTC telemedicine companies are focused on improving convenience within a health care system that many patients find overly complex,” the authors, all of whom are affiliated with Harvard Medical School, wrote. “An important issue is whether this convenience comes at the cost of lower-quality patient care.” 

There are some clear benefits to the DTC model of Hims, Roman and others that shouldn’t be overlooked, they wrote. Looking beyond patient convenience, DTC questionnaires provided to every patient introduce diagnostic consistency, and can greatly streamline clinicians’ workloads so that they can treat more cases.

“In addition, these companies may increase access to care for patients in rural areas lacking availability of clinicians, patients without insurance, and patients who feel uncomfortable talking about sensitive health issues, such as erectile dysfunction and contraception, in person,” the authors wrote.

Chief among the Harvard team’s concerns, however, is the directed, solutions-oriented approach these services employ. Unlike a standard in-person visit — or even the one-on-one virtual consultations offered by Teladoc, American Well or others in the telemedicine space — these companies don’t necessarily seek the best possible treatment for a patient’s condition, but rather screen for those who should not be taking the specific prescription being offered. This approach can also lead customers to seek and receive medication for conditions that would not normally warrant an intervention.

“One company, for instance, advertises off-label use of propranolol for performance anxiety with the following headline on its website: ‘With cold season always in bloom, loud roommates that keep you up, and nerves that come creeping before an important presentation — life can throw you some curveballs,’” they wrote. “Companies are trying to increase their consumer base by recruiting new patients who may not have previously looked to treatment for these issues.”

In contrast to the uniformity provided by user questionnaires, the authors worried that these D2C telemedicine services could lead to fragmented or inconsistent care. In terms of the former, they noted that not every service offer to send treatment information to the patient’s primary care physician. For the latter, they highlighted the variability between each state’s telemedicine licensing and policies, not to mention the grey area in which they operate regarding prescription drug distribution.

“For example, the [FDA] regulation against marketing off-label drugs has not applied to these companies, and surveillance of approved drugs appears inconsistent given reports of prescriptions mailed to patients without safety warning labels,” they wrote. “To our knowledge, no study to date has investigated the prevalence of adverse events related to the sale of prescription drugs by DTC drug telemedicine companies.”

WHY IT MATTERS

Consumer awareness of these kinds of telemedicine services has spiked within the last year, thanks in no small part to an expansive advertising push permeating social media, public transportation and numerous other high-traffic avenues. And while the treatments these services carry are generally limited to wellness, sexual health, cosmetics and common infections, continued success could drive the business model into a broader selection of treatments and conditions.

“It is clear that the companies want to expand to more complex acute care and disease management; for example, Lemonaid Health has expanded to include laboratory testing,” the authors wrote. “Some companies envision a transformation of their platforms into one-stop shops for comprehensive care. For example, the Hims founder stated his intention for the company to become a holistic source of health care not only for prescriptions, but also for ‘information, advice, and comfort.’ As DTC telemedicine companies continue to expand, it will be imperative for physicians, other health care professionals, and policy makers to monitor these new treatment options to ensure convenience does not come at the expense of quality.”

THE LARGER TREND

Just this year alone, D2C heavyweights Hims and Ro enjoyed major funding rounds pegged at $100 million and $85 million, respectively, while competitor Nurx announced earlier this month that it was adding mail-order STI tests to its repertoire. On the other hand, Nurx endured a bit of bad publicity in the wake of a New York Times article reporting that the company was “cutting corners” on its birth control prescribing policy, and last week’s JAMA editorial is certainly not the first to highlight the business model’s flaws.