The Worrisome Rise of Direct-to-Consumer Medicine

Web-based health care could break down barriers to access. But it could also break down doctor-patient relationships.

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  • An increasing number of companies allow customers to get prescriptions approved online, without ever visiting a doctor in person.

    Visual: Undark; Base image via Getty


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If you’re on Instagram, or if you’ve taken the New York City Subway lately, chances are you’ve heard of Hims, the men’s health and wellness company with a penchant for advertisements featuring suggestive cacti and eggplants against pastel backgrounds. The web-based startup targets the young male demographic with skincare products, multivitamins, and erectile dysfunction medications. In January, just a few months after its first birthday, the company joined Silicon Valley’s vaunted “unicorn” club: It received a venture-capital investment that put its valuation at $1 billion.

The ambitious valuation is certainly a remarkable achievement for the young company. But it’s also yet another signal that a new e-commerce market that one might call “direct-to-consumer medicine” is on the rise. Although the companies in this sector have different styles and specialties, they all aim to link patients, pharmacies, and doctors through web apps and the cloud. Their core business models are remarkably similar. First, a self-diagnosing consumer selects a product they think they need. Then, the customer completes an online questionnaire, which is reviewed by a physician if a prescription is needed. A secure messaging platform is available if the customer has questions for the physician before the order is filled and mailed to their door.

These direct-to-consumer companies have historically occupied the periphery of American health care, offering services that often aren’t covered by traditional medical insurance. For instance, there’s Hubble for vision testing and contact lens prescriptions, SmileDirect for mail-order orthodontics, and Keeps for hair loss. But as younger consumers express a growing preference to shop for products and services online, the industry has started to encroach into the territory of traditional primary care. Consumers can turn to Hims and Roman for erectile dysfunction, to Nurx for oral contraception, to Cove for migraines, and to Zero to quit smoking. As more drugs have gone generic, the trend has accelerated, and investors have grown more eager to get in the game.

As a medical student who just finished a rotation in a primary care office, I can see the appeal. Hims in particular has potential to bring stigmatized men’s health topics out of the shadows and connect men to affordable treatments for conditions that they otherwise might not address. Direct-to-consumer medicine is certainly more convenient and discreet than a trip to a doctor’s office, where patients commonly endure long waits only to be rushed through a conversation with a physician who’s weighed down by too many obligations. If a doctor’s office is like Blockbuster, Hims feels more like Netflix.

But I also question whether direct-to-consumer medicine is truly safe for patients. Take erectile dysfunction, or ED. On paper, it seems like a simple diagnosis. In reality, however, it’s a textbook example of the complexity of human health. Sometimes ED occurs on its own, with no identifiable cause. But more often than not, it is a symptom or precursor of other conditions: anxiety, depression, clogged blood vessels, high blood pressure, diabetes, or hormone imbalances.

That’s why the American Urological Association advises physicians treating patients with ED to also screen for the condition’s potential physical, social, and behavioral causes, including relationship issues and drinking and smoking habits. The association recommends, at the very least, checking vitals, performing a genital exam, and — for patients presenting with ED issues for the first time — screening for high cholesterol, diabetes, and other diagnoses commonly associated with ED. For some direct-to-consumer health products, like oral contraception (now offered by Hers, a subsidiary of Hims, among other companies), an online evaluation may be sufficient. But Hims’ evaluation for ED appears to fall far short of the basic AUA guidelines.

The direct-to-consumer companies also present ethical dilemmas. The physicians who work for them may be hamstrung in terms of the scope of the advice they can offer and their ability to follow up with patients to track progress. And they surely must feel some pressure to push their employer’s products. The companies essentially operate on islands of care, where doctors can’t address secondary issues that surface during a consultation and can’t add information to a patient’s home medical record. There’s also the risk of muddying the critical distinction between health and wellness: Hims’ marketing and website design places FDA-approved drugs like propranolol — commonly used off-label to treat performance anxiety — alongside supplements like biotin gummies, conflating the two categories for unwitting consumers.

One could argue that direct-to-consumer medical startups and their venture capital investors are attempting to disrupt primary care by “unbundling” it. This goal contrasts with the vision of primary care enshrined in legislation like the Affordable Care Act, which championed a “patient-centered medical home” where a strong physician-patient relationship is supported by ancillary professionals. Instead, the e-commerce model takes the view that physicians are middlemen clinging to an industry ripe for change — much like taxi cabs, bookstores, and hotels in the days before Uber, Amazon, and Airbnb.

In this technocratic, patient-empowered dream, however, I can’t help but wonder what is lost. During my primary care rotation, I would always begin conversations with patients by asking what prompted their visit. Yet the conversation hardly ever ended there. Our agenda was dynamic, hinged to the information gathered in real time in the exam room. Frequently, we’d shift gears to discuss a patient’s previous diagnoses, to address new concerns such as high blood pressure readings, or to talk about plans for end of life care. We often discussed evidence-based preventive measures — like options for eating healthier, methods to quit smoking, or guidelines for colon cancer screening. In other words, we would act on the concerns of the present, but also anticipate the needs of the future.

In many ways, Hims and other startups are capitalizing on a cultural moment. Their products address a genuine frustration with the current state of American health care, and they are emblematic of what’s likely to be a lasting trend toward commodification in medicine. The companies’ early successes are arguably a smoke signal for traditional primary care — a warning that doctors’ offices must adapt to become less clunky and bureaucratic. The question of whether companies like Hims and Roman are heroes or villains of the health care ecosystem continues to be hotly debated. Christina Farr, a reporter for CNBC, recently tweeted that the rise of personal wellness startups was “the most divisive trend” she’s seen in her years covering health and technology.

I’d like to think there is room for both health care models to coexist. Considering how big the direct-to-consumer market has now become, today’s primary care physicians have a pragmatic obligation to ask patients if they use online wellness companies, to understand which products they offer, and to counsel patients on the potential risks and benefits of those products. If these companies are leveraged correctly, they very well could declutter primary care and break down barriers to access. But we should push for greater regulation to address potential ethical concerns, draw clear distinctions between health and wellness, and establish guidelines that protect our patients.

As more startups like Hims take root, the window of opportunity to set the rules of direct-to-consumer medicine will close. The time to act is now.


Vishal Khetpal is a freelance writer and third-year medical student at the Warren Alpert Medical School of Brown University.

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3 comments / Join the Discussion

    I’m an MD. There’s room for different healthcare delivery models for patients and doctors. The unintended consequences remain to be seen.

    Reply

    Physicians have only themselves to blame. I am a victim of one who ended my PhD studies by refusing to treat a serious case of myxedema which I had never heard of before, because I participated in the student health insurance program at Harvard. In a final outburst, he called health insurance “immoral”, adding “people who are unable to pay out of pocket for medical treatment do not deserve to have any”. By that time I had blown all my savings and knew I was gravely ill, so returned home to die. Mother panicked in another attack, called in a Polish Jew who survived WW2 in the underground, who discovered I was on the verge of myxedemic coma (which had few survivors in those days). Recovery required two years, during which I changed college major to health economics, lecturing frequently in various universities and medical societies – mostly to unreceptive physicians. For twelve years I established health systems in developing countries. including highly beneficial systems in Korea and Thailand. U.S. Department of Health & Human Services finally ended my very successful career by means of outright lies unlawful actions (from Surgeon General Koop an his deputy Faye Abdellah), to assignments that were undoable, and which he hoped would end my career. Since then I have been misdiagnosed on further occasions, leading to preventable stroke and very painful physical conditions. Indeed, misdiagnoses are the third leading cause of death in the U.S. Occasionally physicians are competent and helpful, but it comes at unnecessarily high cost owing to big pharma, consolidating hospital systems and bureaucracy – all assisted by payoffs and political contributions. I admit that physicians are dismayed by bureaucracy, but is the medical industry’s own doing. We could have a much more effective and medical system than we have, but must physician oppose what it requires and injures those who champion it. Doctors, cure thyselves!

    Reply

    Great read Vishal!

    I am an MD and I have been in telemedicine for many years. I have also been thinking about the value these services create. They target the younger “healthy” generation and there is an increasing uptake among men. It could be a trend or there is a “hidden” health problem in this generation that is not being addressed by traditional healthcare, or they are used to get what they want online. What I know from the teledermatology service that I started, is that the younger generation do not want to pay for a dermatologist (specialist doctor) giving a probable diagnosis and advice on what next steps to take: 8/10 stop at the payment wall: 1/10 complain (abuse/ threaten they will give a one star review) about our service; “the doctor is wrong”, “could have Googled the answer”, “did not get a prescription” etc … basically they act as if they are a specialist doctor after having spent time searching online. Interestingly our best and happiest customers are 37 years old married men, with young children.

    I foresee that Amazon will introduce AI on dermatology conditions in 2-5 years, and since AI will be more accurate than doctors, the “lighter” medical conditions will be served by Amazon prime. This is not bad, because dermatologists can spend more time on treating skin cancer, which is increasing with 5% every year.

    In regards to AI, it would be interesting if you could conduct a survey on what specialties are in demand at medical school these days. Does the future of AI have an influence on what people will choose?

    Have a good week-end
    Alexander

    Reply
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