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A secret shopper survey conducted by researchers at Yale University and published this week in the Journal of the American Medical Association offers an alarming, if unsurprising, glimpse into the world of telehealth purveyors of GLP-1 medicines. It confirms what doctors have worried about for years: The popular obesity drugs are being cavalierly prescribed. It should be yet another wake-up call for regulators
Virtual clinics are popular with patients who have become frustrated by the often monthslong wait for an in-person appointment or whose insurance won’t cover obesity medicines. But as these telehealth purveyors rapidly expand, regulators must make sure they’re offering the comprehensive care people deserve — and not just capitalizing on consumer desperation
Yes, GLP-1s are incredibly effective at helping people lose weight. Yes, they can address a host of medical conditions associated with obesity. And yes, access and affordability have been problems almost from the moment Novo Nordisk’s Wegovy and Eli Lilly & Co.’s Zepbound were approved, pushing consumers to go outside of the conventional healthcare system to find them. But GLP-1s also ought to be prescribed with care — as with any other treatment
The secret shopper study made clear that often, they aren’t. The researchers created a profile for a theoretical patient who fit the criteria for a GLP-1 and sought care at 49 online providers. Although the vast majority asked about the basics, like existing medical conditions, there were also some alarming gaps. Nearly half the telehealth providers neglected to ask about the patient’s diet and physical activity, and 45% failed to broach the topic of eating disorders. That’s a critical concern for medicines that could worsen or activate someone’s condition.
The study also revealed how some telehealth companies are hanging on to customers despite the Food and Drug Administration’s recent crackdown on compounded GLP-1 drugs. As a reminder, this online marketplace bloomed because regulators allow compounding of medicines that are in shortage. And though Lilly and Novo have long since brought on enough manufacturing to meet the swell of demand for Wegovy and Zepbound, and the FDA has warned telehealth companies against selling compounded versions of the drugs, that gray market has persisted.
The Yale researchers found companies’ workaround involved asking patients leading questions to establish a reason for a personalized version of the drug. A provider might probe, for example, if a patient wanted to prevent nausea or wanted vitamins, or would prefer a mode of administration that differs from the injectables. The answer to those questions would technically permit them to sell a “customized” GLP-1
At first blush, the report had one silver lining: About a quarter of the telehealth companies required a video visit between a physician and patient before prescribing an obesity medicine. In theory, that should allow the doctor to go beyond the standard forms to make sure they’ve understood someone’s full medical history and answer patients’ questions — not to mention get visual confirmation that a patient is being honest about their weight
But the Yale researchers found most of those meetings to be perfunctory at best — more like a box-checking exercise than a real evaluation, says Reshma Ramachandran, the Yale physician and health services researcher who led the study
In one particularly egregious incident, a physician who seemed to work at multiple telehealth companies wrote a prescription for the secret shopper across three platforms, including one that required a video visit. The doctor either didn’t notice they were dealing with the same patient three times or didn’t care
Both scenarios are disturbing. The former suggests there aren’t enough safeguards in place to ensure drugs are being appropriately prescribed; the latter suggests an utter disregard for patient safety
“All of this just indicated the telehealth platforms are not necessarily there to provide high-quality care, but just to prescribe,” Ramachandran says
This issue of questionable care from virtual clinics isn’t necessarily limited to GLP-1s. An earlier, smaller secret shopper study found that direct-to-consumer platforms targeting men seeking testosterone were similarly liberal with the prescription pad. In other areas where telehealth has flourished — say, women’s health or aging — anecdotal evidence suggests some might be similarly lax
The question, of course, is how to fix this. The FDA’s ramped-up efforts to wrangle the market for compounded GLP-1s are a good first step, but the agency also needs more help
One possibility would be to toughen the rules around compounding. Traditionally, compounding has been a service that can fill a supply gap or address an individual patient’s particular needs. Yet as Ramachandran points out, online pharmacies have taken advantage of loopholes to pivot to mass distribution of compounded medications. One proposed bill would limit the number of times a particular pharmacy could create a personalized version of a particular product or risk losing their designation as a compounder.
Pharma companies, too, should ensure their partners are acting responsibly. More than half of the telehealth sites involved in the survey offered branded products in addition to compounded drugs, or sent prescriptions to the companies’ direct-to-consumer platforms
Consumers, too, should be more circumspect when considering these telehealth sites. They might provide an easier or cheaper avenue to a medicine, but there are hidden costs — namely, the kind of high-quality care and accountability that all patients deserve
Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry
