OP-ED

How Telehealth May Be Promoting Fraud and Abuse

flying cadeuciiI recently called my primary care physician (PCP) for the first time in years to get my immunization records, and encountered a strange message saying he was not currently seeing patients. My mom had apparently encountered the same message weeks ago. “Maybe he retired,” she suggested.

I did a quick google search of my PCP’s name to find an alternate contact number, and instead found a shocking article from the local newspaper. Apparently my PCP has been indicted for falsifying tax returns and participating in an online pharmacy organization that provided prescription drugs without an in-person physician examination.

Remote Prescribing: Lucrative, Pervasive, and Very Illegal

I did a quick search online and confirmed that the practice of offering prescription drugs through a “cyber doctor” prescription, relying only on a questionnaire is indeed very illegal.

It is also very pervasive. The National Association of Boards of Pharmacy (NABP) reviewed 10,700 websites selling prescription drugs and found that 97% of them were “Not Recommended”. Of these, 88% do not require a valid prescription and 60% issue prescriptions per online consultation or questionnaire only.

What struck me was how this appeared to be a case where the market came together to produce a “triple win” for profit-seeking internet pharmacies, shady physicians (such as my own), and a subset of patients willing to pay a premium to access drugs (most commonly weight loss drugs, erectile dysfunction drugs, and commonly-abused antidepressants and painkillers).

According to one analysis, one such website offering prescriptions from its own doctors listed prices for fluoxetine (brand name Prozac) and alprazolam (brand name Xanax) that were roughly 400% to 1800% higher than prices from a more traditional Internet pharmacy not offering prescriptions. The fact that such “remote prescription” websites remain in business despite the huge price differential suggests that they are attracting patients willing to pay that premium to avoid seeing their regular doctor. And as for where that money is going—well, my doctor was alleged to have received roughly $2.5 million over six years.

Similar Incentives Could Exist for Telehealth Writ Large

Given the clear business case driving abuse in this model of “remote prescribing”, I wondered about the risks of overuse and abuse in the rapidly burgeoning field of telehealth more broadly. After all, one of the promises of telehealth is its ability to make the delivery of services more convenient for both patients and providers. A physician could vastly expand the number of patients he/she sees without leaving the office—which has been identified as a potent way to alleviate the physician shortage problem.

But that would only hold true if the proliferation of telehealth does not generate additional, potentially unnecessary demand. And substantial evidence points to the presence of physician-induced demand under a fee-for-service system. Currently, Medicare pays for a limited set of telehealth services under the same fee-for-service payment model used for in-person visits. Within Medicaid, while select states are experimenting with bundled or capitated payments that include telehealth, others are retaining their fee-for-service model.

In a testimony before the House Energy and Commerce Committee last month, Dr. Ateev Mehrotra, an expert on telehealth, noted, “To reduce health care costs, telehealth options must replace in-person visits.” I’m not convinced this is the case—especially when there is a clear financial incentive to provide more care.

“The very advantage of telehealth, its ability to make care convenient, is also potentially its Achilles’ heel. Telehealth may be ‘too convenient.’” — Ateev Mehrotra

In some cases, fee-for-service payments for telehealth may result in outright fraud, as my physician may have done. In others, it may simply encourage providers to err on the side of providing more care given uncertainties in a practice environment. In fact, a study led by Dr. Mehrotra found that PCPs were more likely to prescribe antibiotics during e-visits than in-person visits.

As various constituencies continue to debate the best approach for paying for telehealth, it is imperative for us to better understand how the incentives and convenience of telehealth interact to affect overall utilization. Blindly carrying our existing fee-for-service system into the new world of telehealth options may produce some unintended consequences.

Tom Liu is a health services researcher based in Washington DC. He blogs at Project Millenial, where this post first appeared – and at his personal blog.

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15 replies »

  1. Jonathan Weremblewski
    Daniel Colleran
    English 105
    3/14/18

    “Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials? Analysis”

    In John PA Ioannidis journal he argues how there is no real benefit to antidepressants. He goes into great detail how it’s just a cash cow for pharmaceutical companies and there is no real evidence to support antidepressants effectiveness in cases of severe depression. His purpose for writing the essay is to argue how there is no real effectiveness of antidepressants. By analyzing his piece people will be able to better understand where his viewpoints came from.
    John PA Loannidis is strongly against the conclusion that antidepressants are effective and should be used as frequently and as much as they are today. He talks about how only the positive results found in the studies are published. Also, when studies that are conducted and produce negative results, they are still published but in a way that gives a positive outlook towards them. The studies aren’t really gaged to prove the effectiveness of the drug but to make sure there is enough data to pass the regulatory and legal processes. The FDA published 12 reports on studies conducted and didn’t find any real effects but still credited the antidepressants. He argues why 80 billion dollars goes to drugs that fight depression in the United States alone when there is evidence that a simple placebo pill can be just as effective in fighting depression for people with moderate to low depressive symptoms. In Isacsson, G., and M. Adler journal talks about how evidence of the effectiveness of antidepressants went down as depressive symptoms in participants went down they stated “38% of the combined sample at endpoint was measured with less than half the maximal reliability.” With the support of meta-analysis on all the studies conducted he was able to provide evidence that the effectiveness of the placebo only went down in cases with people who had severe depression and that there was no evidence that antidepressants became more effective in cases with people who had severe depression. The placebo effect of the drug actually increases the viewed effectiveness of the drug itself. He does add how antidepressants can be effective in clinical trials for people with extreme depression. John PA Loannidis says that the overuse and abuse of antidepressants comes from the misleading information published about the effectiveness of the drug. Using meta-analysis, you can tell that the “New England Journal of medicine” publishes selective and distorted findings to support antidepressants. Only about half of the drugs studies are published and the other half are either thrown away or further distorted until there is enough positive effects shown for it to be published.
    John PA Loannidis uses many different aspects to support his claim. He mainly talks about how the studies conducted on the drugs done by the pharmaceutical companies are designed to over represent positive outcomes of the drugs. The FDA published 12 reports on studies conducted and didn’t find any real effects but still credited the antidepressants. He analyzes many different types of researches on the drugs and came to the conclusion that there are very few published negative findings on the drugs. In his paper he focuses on how there is no proof that antidepressants have positive effects if any at all but still shows instances where they can effective for people suffering from severe depression. Some of his viewpoints that he used in his journal are biased because they are all examples of information that will help support his claim. His paper is directed to the general public and his colleagues so that they can be better informed about the issue in hopes that a change will be made to the process and orientation of the studies conducted on antidepressants.
    This journal makes you think twice about reliability of the studies conducted on antidepressants. But it is also focused on providing evidence on how the studies conducted aren’t reliable, so you have to take the information with a grain of salt. Overall there are many things to consider when reading argumentative reports and many other references are needed to cross examine the findings.

  2. The advantage of telemedicine, if the use is restricted to large organizations with real qa/qc and process management the results can be superior for many services such as Coumadin mgmt or diabetes mgmt.

  3. I think fraud is “a’ problem but it is not “the” problem with telehealth.

    I was looking at facebook today for reviews of a company called Doctor on Demand.

    It is a telemedicine service that charges $40 for a 15 minute consultation via iphone.

    I’m sure this company is legit and not committing fraud. However, what I see is the following:

    1. Numerous reviews praising Docs on Demand for giving antibiotics for a sinus infection.

    2 Numerous reviews praising DoD for giving antibiotics for an ear infection.

    3. Numerous reviews praising DoD for giving antibiotics for a “throat” infection (no strep testing done)

    Now, that might sound fine and dandy to you, but all 3 of those scenarios are blatantly bad medicine. We already know for a fact that the vast majority of sinus infections are viral, not bacterial, and wont respond to antibiotics. We know the same thing about ear infections (BTW how was the doctor able to look in the ear over the phone?)

    The bigger problem with telemedicine is poor medical care and rampant distribution of antibiotics for every viral upper respiratory infection under the sun.

  4. Y’all are missing the point. Free market is overutilization and regulated or planned economy is incompetence. There is a balance. We must be cognizant of not fraud but overutilization. Fraud is a criminal intent and overutilization is not. The author’s claim is that extrapolating from one idiot leads to across the board fraud by doctors. Your argument is faulty throughout.

  5. I am just now not particular wherever you happen to be getting the info, nevertheless good theme. We should take some time learning much more or working out much more. Many thanks for great facts I’m hunting for this data in my goal.

  6. Good point. Getting away from FFS only shifts the type of fraud that can be committed. The VA is a recent example. Making promises that you cannot keep is also fraud.

  7. Ergo Granpappy Yoakum, we should eliminate all healthcare all legal work, all car sales and banking and manufacturing and government because they have the potential for fraud. So basically, your argument is for subsistence living. OK sounds great. At best your position is ineffectual and weak.

  8. “fee-for-service payments for telehealth may result in outright fraud, as my physician may have done.”

    You need to look up the definition of “fraud.”

  9. Dr. Mike,
    Thank you for making this point. So many otherwise smart people accept on face value that fee for service is the root cause of overconsumption of health care services…..and don’t understand that whenever the consumer is financially insulated from the use of a service or product overconsumption ensues…..regardless of bureaucrats imposing rules, regulations and penalties to try and manage things from above.

  10. Also notice the misplaced blame on the fee for service system. It is not the fact that a fee is paid for the service that is the problem, it is that the fee is paid by someone other than the person receiving the service.

  11. Um, so I have to agree with “Not a provider” here.

    Not sure I’m buying this one. There are already many, many opportunities for this kind of abuse. Blaming telehealth isn’t the answer.

    The problem is unethical folks and their sneaky customers.

    The web sites that are involved in this kind of dirty business are another story. Something needs to be done about them. I say stomp ’em out!

  12. OK so your doctor was unethical and unqualified to practice medicine. Your post offers more insight into inability to choose a doctor than it does about the future of telemedicine. Your slippery slope argument is quite pedestrian . Much of Medicine is routine and banal and improved with telemedicine. Stop the chicken little talk. Fear not technology.

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