The changing face of care
DermWorld discusses digital pharmacies and direct-to-consumer (DTC) teledermatology platforms.
By Ruth Carol, Contributing Writer, February 1, 2023
Patients have more ways than ever to obtain medications and “care” to treat dermatologic conditions as digital pharmacies and direct-to-consumer (DTC) teledermatology websites continue to proliferate. First and foremost, these options offer patients convenience. But at what price does it come? Can dermatologists learn from these evolving business models to provide safe and effective care to their patients in a more convenient manner?
“We live in a digital age. People have become accustomed to ordering products and services online from streaming services to food to clothes, and health care is no exception,” stated Abraham M. Korman, MD, FAAD, a dermatologist at The Ohio State University Wexner Medical Center, and clinical assistant professor of dermatology at The Ohio State University in Columbus. “Patients have expectations of immediate treatment plans and don’t want to have to wait to come into the office and have a detailed conversation about the treatment plan,” said Stephanie Fabbro, MD, FAAD, core faculty for the Riverside Methodist Hospital Dermatology residency program in Columbus, Ohio, and a private practice dermatologist with Buckeye Dermatology. She believes that today’s “convenience-oriented world that minimizes the importance of in-person interaction” was fueled by the COVID-19 pandemic.
Digital pharmacies replace brick-and-mortar stores
Like many aspects of health care, the way in which patients can obtain prescriptions has changed. Historically, patients made an appointment to see the physician who prescribes a medication that they pick up at a brick-and-mortar pharmacy. Then mail-order pharmacies affiliated with insurers, such as UnitedHealth’s OptumRX, began offering patients the convenience of having their prescriptions delivered to the house with the added bonus of potentially paying less than using a retail chain pharmacy. Next, digital pharmacies, such as Capsule, BlinkRX, and Amazon Pharmacy, came on the scene. They accept major insurance and offer free home delivery on prescriptions. While BlinkRX claims to provide the lowest prescription prices, Amazon Pharmacy offers PillPack, a service that sorts medications into packets by date and time.
Convenience is the No. 1 advantage for using digital pharmacies. “People don’t have to travel to a pharmacy and wait for a prescription,” noted Lemrey “Al” Carter, MS, PharmD, RPh, executive director for the National Association of Boards of Pharmacy. Using an online pharmacy can increase access to prescriptions for people who live far away from a pharmacy or have obscure prescription needs.
Patients also can “price shop” their medications easily using digital pharmacies. “Some online pharmacies offer a cash price that can be cheaper than purchasing a prescription using insurance at a brick-and-mortar pharmacy,” Carter said. More recently, digital pharmacies, such as the Mark Cuban Cost Plus Drug Company and Skin Medicinals, are attempting to combat the rising cost of prescriptions.
But there is a downside to using digital pharmacies. When patients need a prescription immediately, they can’t get it from a mail-order pharmacy, noted John S. Barbieri, MD, MBA, FAAD, chair of the AADA Drug Pricing and Transparency Task Force. Cost Plus, for example, doesn’t offer a complete formulary because it provides only medications it can obtain at a substantial cost savings, he said. To date, Cost Plus carries more than 700 of the most commonly prescribed generic medications and continues to add more drugs to its inventory, but it does not currently carry brand or specialty drugs. In comparison, a mail-order pharmacy, such as Cigna’s Express Scripts, can fill pretty much any medication a doctor prescribes, Dr. Barbieri added.
Additionally, digital pharmacies can’t offer prescriptions that require refrigeration or special packaging or handling, Carter said. When patients buy some medications online and some at their local pharmacy, not all the medications show up in their medical record. Finally, it can be difficult to distinguish between a valid compliant online pharmacy and an illegal one, he said.
DTC telemedicine websites proliferate
The latest player to enter the online marketplace are DTC teledermatology websites, such as Curology and Hims & Hers. These business models enable patients to schedule virtual consultations with a provider and have a prescription sent to their house.
Among the factors that spurred the growth of these platforms are a shortage of dermatologists, improved technology, and rising health care costs, stated Jules B. Lipoff, MD, FAAD, a dermatologist in Philadelphia and a clinical associate professor (adjunct) in the Lewis Katz School of Medicine at Temple University, Department of Dermatology. Drug patent expirations have contributed to the rise of DTC companies as they can buy generics in bulk and sell them at a profit, added Dr. Lipoff, who co-authored an analysis of these platforms published in the April 2022 issue of Cutis.
DTC websites appeal to patients’ desires to get treated immediately, noted Carrie Kovarik, MD, FAAD, a dermatologist in Philadelphia and a professor of dermatology, dermatopathology, and infectious diseases at the University of Pennsylvania. “These sites were growing before COVID-19, but the pandemic gave them a push because people became more familiar with telemedicine and now many don’t want to leave their house to get care,” she added. Dr. Fabbro is dealing with the opposite — an influx of patients who eschewed their routine follow-up visits because of safety concerns revolving around the pandemic and didn’t have any urgent concerns but are now ready to re-establish care. Patients have expressed frustration with the higher-than-normal wait times to be seen in the office, which she believes have pushed them to explore DTC teledermatology.
Convenience is arguably the most significant advantage for patients to use DTC telemedicine websites. Access could play a role for some, as well. “Patients who might not otherwise contact a dermatologist to make an appointment will use this type of platform,” Dr. Barbieri said. Patients seeking care for certain conditions, such as hair loss, might prefer not to have an in-person discussion with a physician, Dr. Korman noted. But he does not believe that DTC teledermatology increases access to underserved populations, as some have suggested. In fact, evidence suggests that people who use these websites tend to be younger and live in wealthier, urban communities, Dr. Korman said. With rising deductibles and co-pays, DTC websites could cost less than more traditional models of care.
“Entrepreneurs recognize the potential and are developing companies to meet that need,” Dr. Lipoff said. While the goal behind the DTC teledermatology platforms — to make medications or physician visits more accessible to patients — is a noble one, he is concerned that increasing access in this way may decrease quality of care.
Illicit digital pharmacies: A significant problem
While many digital pharmacies are licensed and require prescriptions, the National Association of Boards of Pharmacy (NABP) estimates there are between 30,000 and 40,000 active illegal online pharmacies operating at any one time, said Lemrey “Al” Carter, MS, PharmD, RPh, NABP executive director/CEO. These illegal online pharmacies claim to sell prescription medicines at deeply discounted prices, often without requiring a prescription. “They are really selling unapproved or counterfeit medicines that are unsafe, ineffective, or of poor quality,” said Sangeeta Chatterjee, PharmD, deputy director of the Office of Drug Security, Integrity, and Response in the Center for Drug Evaluation Research at the FDA.
The NABP discovers about 200 new websites operating illegally each week, Carter said. As soon as one illegal online pharmacy is shut down, another opens. They are targeting people looking for COVID-19 and mpox treatments, antibiotics, as well as abortion pills being restricted in some states or any other drug that has received publicity and is difficult to get, he noted. “This is a huge problem that is only getting worse as more people turn to the internet for drugs,” Carter said.
“The FDA continues to take a multipronged approach to maximize the scope of its efforts to shield patients from potentially dangerous prescription drugs sold online,” said Dr. Chatterjee. This includes outreach to consumers and health care professionals and engaging with law enforcement, federal, and international partners. The FDA also issues warning letters to operators of unsafe online pharmacies that violate the Food, Drug, and Cosmetic Act, including those that sell a prescription drug without a prescription.
To help educate the public about the significant problem of illegal online pharmacies, the NABP hosts the Buy Safely website. The NABP’s Healthcare Merchant Accreditation program provides patients with information about the credentials of online pharmacies. Internet pharmacies that have received this accreditation are deemed safe to use because they have met state licensure requirements as well as other NABP criteria.
Similarly, the FDA’s BeSafeRx program educates the public about the dangers of buying prescription drugs from unsafe online pharmacies, how to identify them, and how to find safe online pharmacies. The FDA has also developed resources for health care professionals to educate and support patients who may be using or considering an online pharmacy for buying medications.
Impact on quality
People treated through DTC telemedicine websites were often unable to choose a clinician or be provided with the clinician’s credentials, according to a study published in the July 2016 issue of JAMA Dermatology (doi:10.1001/jamadermatol.2016.1774). The most concerning finding for Dr. Kovarik, who is a co-author of the study, is that some of the doctors weren’t even licensed to practice medicine in the United States. Only 26% of the sites disclosed information about clinician licensure, making it difficult for patients to know who is treating them. “It’s unclear who is behind the screen, whereas when you walk in the office, it’s obvious in most cases, who is sitting in front of you,” she said. In fact, lack of transparency is the most frequent comment Dr. Kovarik hears from patients who attempted to use these websites.
Overall, the care provided by DTC teledermatology platforms is siloed, leading to fragmented care, Dr. Kovarik said. Only 23% of the websites in the study asked patients for their existing primary care physician’s name, and only 10% offered to send medical records to an existing clinician. Many of the DTC websites didn’t offer a referral for follow-up care even when patients were given a serious diagnosis, she added. Ideally, a dermatologist would be affiliated with a DTC teldermatology website, allowing patients to have the option for an in-person visit, if needed, Dr. Lipoff said. “But most of them are not run by doctors, with a couple exceptions,” he added. This lack of care coordination goes beyond dermatology issues. As an example, when Dr. Barbieri has patients with mental health issues related to their skin condition, he can refer them to a mental health clinician at his health care system. “At these sites, coordination of care is much more challenging or even non-existent,” he added.
While many patients were prescribed oral or topical medications in the study, only one-third of them were told about potential side effects, Dr. Kovarik said. Among those were women of child-bearing age, who were neither asked if they were pregnant or told about pregnancy risks associated with medications, she said. When DTC telemedicine websites don’t capture basic medical history, comorbidities, and other medications they are taking, patients could experience drug-to-drug interactions, Dr. Barbieri added. It can be difficult to provide good follow-up care for these patients because the medications they were prescribed are not in their medical records, Dr. Kovarik noted. When the medication in question is compounded by the site, it can be even more challenging to figure out what is in it and determine what the patient has tried and worked or not worked, Dr. Barbieri said.
Sixty-five percent of patients were given prescriptions by DTC telemedicine website providers in the JAMA Dermatology study. Physicians bill for the evaluation and management and procedures, if any, performed during an office visit, Dr. Lipoff said. Prescribing a medication in a traditional visit has much less impact on how much money the doctor makes from the encounter compared to a DTC visit. “Since DTC models are predominantly based on pharmaceutical sales — because many have their own pharmacies — there’s an inherent conflict of interest.”
When the prescribing of medications is financially motivated and incentivized it can lead to medications being inappropriately prescribed to drive profits, Dr. Korman stated. Not all medical problems require medicine. Unfortunately, the DTC models rely on prescribers keeping the prescriptions flowing, he added. It’s different than when dermatologists sell skin care-related products in their office because those products are independent to the patient’s medical management. Furthermore, dermatologists typically sell over-the-counter medicines in their office that hold lower risks of side effects. If they do sell prescription medicines, they are able to directly evaluate the patient to ensure there are no contraindications to the therapy, Dr. Korman said.
Some DTC teledermatology websites have a limited algorithm of services and/or a set number of medications in the formulary they offer, Dr. Barbieri noted. They may not, for example, have the correct prescription strength the patient requires or the appropriate treatment. “If there are five treatments for a patient’s disease/condition, but the site only offers three, the patient may not get the best treatment or may get a substandard treatment that doesn’t address the problem,” he said.
Many DTC telemedicine companies are selling “the wellness trend,” Dr. Lipoff said. They offer supposedly personalized products, making it sound like the products are designed specifically for the consumer. The reality is that these products are commonly prescribed by dermatologists. Some people are paying an exorbitant amount of money for medications, such as finasteride or minoxidil, on a subscription service that he could prescribe for much less money. “When I explain that to patients, they usually switch,” Dr. Lipoff said. But for others, the convenience may be worth the higher price tag.
Because these DTC websites typically offer limited treatments, patients are often surprised when they learn about additional treatments and the nuances regarding them, Dr. Fabbro said. “I hope these discussions that go into more detail about each individual patient’s goals and expectations help to emphasize the importance of an in-person patient-physician relationship,” she added.
The JAMA Dermatology study also noted that major diagnoses were repeatedly missed. Inaccurate diagnoses given patients by DTC website company providers inspired Drs. Korman and Fabbro to write about the topic for the Ethics Journal Club in the October 2021 issue of the JAAD. They discuss an inaccurate diagnosis of androgenetic alopecia, which was really scarring alopecia. “When all you have is a hammer, everything looks like a nail,” Dr. Fabbro said. These providers are supposed to tell patients when the conditions they have are not amenable to the therapies they offer, she said, but they get around that by using superficial questionnaires to screen-out ineligible patients and poor-quality photos sent in by patients. “When patients come to see us, we do our due diligence to work them up using the broader armamentarium of tools at our disposal, but patients may have already suffered from adverse outcomes, such as scarring,” Dr. Fabbro added.
The bottom line is that patients don’t really know what they’re getting into when they approach DTC websites, Dr. Kovarik said. “There is no way for them to know whether a site has good intentions or doesn’t. Some of them even require consumers to sign up for payment plans before getting a consultation,” she said, adding, “It’s not transparent that it’s a transaction rather than a patient-doctor relationship.”
Dr. Lipoff noted that “Silicon Valley’s motto ‘move fast and break things’ doesn’t work when it comes to health care because the potential downside is much higher.” It’s okay to be transactional if that’s what the patient wants and the problem warrants it, he said. “But I think most patients don’t want that.” On the other hand, if more transactions result in seeing twice as many people, which is a greater good? Dr. Barbieri summed it up best. “It doesn’t mean that these platforms are inherently good or bad,” he said, “but there are risks associated with getting care through them.”
Buying drugs safely on the internet
Dermatologists can help educate their patients about illegal online pharmacies by recommending they:
Check NABP’s safe pharmacy website to determine if the pharmacy website is a licensed pharmacy in good standing.
Don’t purchase drugs that are not approved by the FDA.
Don’t purchase medications from sites that do not require a prescription nor provide access to a registered pharmacist to answer questions.
Talk to a physician before using any medication for the first time.
Report a suspicious site to the FDA.
“Dermatologists should tell their patients to stick with a licensed accredited pharmacy,” Carter said. “If the deal looks too good to be true, it often is.”
Lessons from these business models
What, if anything, can dermatologists learn from these business models? “Patients want to access care from more settings and without having to go to the doctor’s office,” Dr. Barbieri said. “As dermatologists, we should be thinking about how to meet those patients’ needs in a way that is safe and effective.” Some skin diseases/conditions lend themselves to using alternative models of care. Some diagnoses are easier to make than others and maybe those can be done in a virtual format, he said. And some patients are better at self-diagnosing than others; it all depends on the clinical scenario. Once a diagnosis is made, studies have shown that managing chronic skin diseases, such as psoriasis and atopic dermatitis, can be done through telemedicine with equivalent outcomes, improved patient satisfaction, and maybe lower overall costs than using the traditional in-person visit, Dr. Barbieri added.
“We need to hear our patients loud and clear that they like these services and many patients would be able to follow up more regularly if we offered telehealth appointments for established patients.”
Many dermatologists offered expanded telehealth services during the height of the COVID-19 pandemic, but since then have either scaled back or completely stopped doing telehealth, Dr. Fabbro noted. “We need to hear our patients loud and clear that they like these services and many patients would be able to follow up more regularly if we offered telehealth appointments for established patients.” Dermatologists currently not offering teledermatology might want to consider introducing it, Dr. Kovarik said. While she believes that it’s important to make care as accessible as possible, the convenience aspect must be balanced with safety. Physicians are still the gatekeepers for seeing patients and monitoring their medications and overall health, Dr. Kovarik said, adding, “We don’t want to turn health care into a drive-thru experience.”