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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Billington1JuleeGel Beads Hot Cold Packplaton20click here Recent comment authors
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Billington1
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Billington1

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… Read more »

Julee
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Gel Beads Hot Cold Pack
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Very insightful opinions indeed! I may be of great help~

platon20
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platon20

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… Read more »

Not a provider
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Not a provider

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.

Not a provider
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Not a provider

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.

click here
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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.

Not a provider
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Not a provider

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.

Granpappy Yokum
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Granpappy Yokum

I don’t think you understood my post.

Granpappy Yokum
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Granpappy Yokum

“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.”

Dr. Mike
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Dr. Mike

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.

Paul Slobodian
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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.

LeoHolmMD
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LeoHolmMD

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.

Don't Go Back to Rockville
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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!

Not a provider
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Not a provider

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.