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Tuesday May 14, 2019

Health Startups: Revolutionary or Threat to Primary Care?

"How to get Viagra without going to the doctor." Google returns hundreds of results for this search query.

[woman in blanket using smartphone]

Some are online pharmaceutical companies based in other countries. Others are discount coupons. But many are glossy questionnaire websites that promise a prescription at the end.

This latter gaggle of startups shares much in common. The companies' minimalist ads cater to the Snapchat generation. They spend a ton on marketing to appear effortlessly cool. They are, ultimately, an easy way for patients to get medications -- but not necessarily medical care -- for conditions ranging from erectile dysfunction to hair loss and from herpes to contraception.

It's algorithm medicine. Rather than doctors taking a history and diagnosing a condition, patients self-diagnose and then select the medications they want. They enter a payment. In the background, a doctor will review their history and flag any risk factors. These doctors often approve the medication.

That these virtual health companies are growing at a rapid clip comes as no surprise. They are consumer-driven and convenient. In fact, one of them, Ro, is now valued at $500 million(techcrunch.com) after having raised $173 million in its first two rounds of funding.

Of course, given unclear federal regulations coupled with inconsistent state regulations, some observers have raised concerns regarding the safety of these companies -- both for patients and doctors.

For example, although individual patient information is protected under HIPAA, the collective, anonymous patient information these startups hold is rich with data that third-party marketing services would happily pay for.

Already, problems have arisen.

In February, a doctor who prescribed medications for an online site had to surrender his medical license. This after an investigator from the Medical Board of California posed as a patient and was able to get Ella and Viagra on different occasions by writing dubious statements on a questionnaire.

The board wrote in its decision(4patientsafety.org) that "furnishing dangerous drugs … without an appropriate prior examination and a medical indication constitutes unprofessional conduct."

Another startup claimed to be promoting women's empowerment by easing access to birth control pills. However, the company was storing medications in a shoe organizer and reshipping returned drugs, according to an investigative report(www.nytimes.com) by The New York Times.

For companies like these, the pressure to grow often eclipses patient safety and the professional standards we adhere to in medicine.

And although these sorts of business practices are alarming, it's easy to see how -- and why -- they have proliferated: These startups are often run by Silicon Valley entrepreneurs, not doctors.

Yet, as primary care physicians, we are responsible for ensuring that the care we deliver is high quality and safe, as well as accessible and convenient. With health care becoming increasingly complex, patients sometimes want simplified care -- and they deserve it.

The rise of these startups actually results from systemic issues in health care. Why do these patients not have a primary care physician? Or why are they willing to pay a premium for anonymity and convenience rather than see their PCP?

The solution? Family physicians should embrace more convenient (including virtual) access points for patients, but they need to be wrapped into a larger primary care model.

For example, at my organization, patients are able to send questions to me, their PCP, via messaging, or they can reach a clinician through a video visit.

And although the online telemedicine industry is also growing, companies that provide this service usually offer telemedicine alone. For my practice, the virtual care is in addition to -- not instead of -- the in-person visits we provide.

This model of care is safe for patients while still being convenient. We have their full records with recent vitals, labs, medications, etc. Most importantly, I intimately know my patients. When we message back and forth, I am not just a name and medical license.

An algorithm can never replace the doctor-patient relationship. A website questionnaire can never capture the complexity of a patient's health or fears or behaviors.

But as family physicians, rather than scoffing at or ignoring these health-tech startups, we would be wise to recognize that they are filling a void. And we should consider how we can effectively fill this void instead.

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan.(twitter.com)

Read other Fresh Perspectives posts by this blogger.

Posted at 11:30AM May 14, 2019 by Natasha Bhuyan, M.D.

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