Direct-To-Consumer Prescription Services

Well, this was a long time coming, but I finally got around to making this list. Essentially, there has been so much hype on how ‘online pharmacies’ are disrupting how patients get their medications I just had to take the time to look into them and what they offer. First off, I hate the idea of calling these online pharmacies - as most of them are not and rather outsource the filling of medications to companies like Truepill or right to the customer’s pharmacy. However, this has caused some issues, like the CVS and Pillclub news last month, and recent news highlights that Hims is opening its own pharmacy. Nonetheless, I feel that it is better to call these direct-to-consumer prescription services as they allow a patient to use an app or online service to directly get a prescription (after following the companies protocols, such as online survey, and talking with a provider).

How Did I make this List?

I had a few inclusion and exclusion criteria when I set out to make this infographic:

• Inclusion Criteria: Companies that listed what therapeutic areas they covered, there were several teleservices but no emphasis on what they covered. Those that I could find online easily through searches.

• Exclusion Criteria: Large general teleservices which I think cross multiple areas and are not specifically aiming for DTC but rather a telemedicine platform overall. I did not look at companies outside of the US.

What did I find?

Its rather interesting looking into the trends some of these companies had and products they were prescribing/supplying. As follows are my general analysis.

Overall, most of these companies are fixated on several therapeutic areas. The rational (to me) is that they are what I would call “Low Stake Diseases” which I would quantify as therapeutic areas that can be:

• Diagnosed easily enough (no excessive tools/devices but can utilize patient-based surveys on subjective/objective experiences). Example: Birth Control - I desire an intervention that can reduce my risk of pregnancy.

• Limited disease monitoring processes (patient will or will not subjectively/objectively experience benefit). Example: Erectile Dysfunction - I take this drug and I do or do not have erections.

• Diseases lack multifactorial involvement (conditions being affected or impacting other diseases is limited for the patient). Example: Smoking Cessation - Bupropion can interact with other drugs, but impact on other conditions (outside of mental health) can be screened and not pose a large issue.

• Drug therapies are easy to prescribe, monitor, low drug interactions, stable (e.g., non-refrigerated and oral for easy use) and generally limited side effects. Example: Hair Loss - Minoxidil apply as directed, little to no monitoring or drug interactions.

Now, I am not exactly surprised about the numbers based on these assumptions. And I think the therapeutic areas targeted all have their pros/cons, and worth discussing some of them below.

• Infectious Diseases, I do not see much beyond GoodRx or Lemonaid targeting short term infections, because I think the ROI is limited. Most of these companies want continued use as it will maintain membership. So, genital herpes, Cold sores, PrEP make sense to me as they either make money from the drugs or the longterm use. UTIs, Flu, and Sinus Infections come and go. So I don’t expect that space to blow up any time soon, especially with time to make a diagnosis and get treatment to a patient taking more time, so why not just go to an urgent care/minute clinic?

• Mental Health, it’s interesting to see propranolol used so much for anxiety by some of these companies. I suppose with limited issues (though even I am a bit hesitant with beta-blockers), it is possible to screen out high-risk patients and focus on a younger crowd that may see the benefits from these products. Their ads list things like “speaking in public” and related areas that younger patients may struggle with and go after. Lemonaid and Maven (and others that I did not list) are looking for other areas of depression and anxiety. I am curious if they are using controlled substances (e.g., Benzos) or not, but with SSRIs/TCAs/SNRIs for these conditions, if they have the specialists they could do it.

• Birth Control, for all intents and purposes this is a no-brainer area. They are available OTC in other parts of the world or easy enough to get. Their risks are high in some demographics (e.g., blood clots) but if you screen well enough you should be able to prevent high-risk events. This area had the largest concentration, and to be honest I think it will reach a tipping point where only so many companies can survive. Its interesting to see companies like GoodRx get into this space, and likely others like BlinkHealth will as well. One issue will be where Pharmacies get involved, such as Walgreens and CVS that may push their own services, which could bring this to a head like PillClub.

• Hair Loss and Eyelash Growth, well these areas strike me as easy enough. Perhaps the one thing that threw me off though was the push for eyelash growth therapy. The use of Latisse (which is also used for glaucoma) is interesting.

• Sexual Health, again, most of these are easy enough. I suppose I really surprised with a lack of emphasis on menopausal syndromes (e.g., Hot flashes) but that could be to a demographic preference by some of these companies. Hers having Filbanserin was interesting to me, as I didn’t see anyone else with that product, and Ro considering going into the BPH field is interesting to me. In general, Ro seems to be the only company thinking longterm about tech-inclined older adults aging and gravitating towards these platforms. The issue with BPH is who they will select to treat (e.g., diagnosis or use of 5-alpha reductase inhibitors will be interesting).

• Dermatology, well, mostly acne but a lot of focus on ‘aging/fine lines’ prevention and rosacea I saw. I think this area will take off more as well, but one issue that struck me is that there were a lot of companies that were putting up their own in house ‘individually’ compounded products with the same active ingredients. I really had to pause on that, and then there are other companies I’ve seen (not listed) that purport to do genomic testing to ascertain what is the best skin products for you.

Things that struck me odd or interesting…

There were some things I found weird or thought-provoking during this review. One, how will controls be handled? There wasn’t a lot of language on that. Two, off-label use of some medications seemed interesting such as for premature ejaculation, which don’t get me wrong I have recommended this, but I wonder how far it can taken (within guidelines acceptance I suppose if I had to hazard a guess). Three, the use of antibiotics for some of these conditions worry me in regard to the risk of the general issue of bacterial resistance if over prescribed. Four, how are some of these medications monitored for adverse drug events or negative outcomes? I didn’t see a lot of that discussed in these services. Lastly, most companies are targeting a younger population based specifically on therapeutic areas and I do not see a lot on ‘older adults’ health problems.

What other therapeutic areas can be targeted?

Personally, I think there are several worth talking about. In general, I think the low-stake conditions are worth targeting, as long as the consultative cost is successful to prove a profit, and they are routine/long-term treatments that will have consumers revisiting the service (and continuing their membership). So self-limiting conditions are an issue (as mentioned above).

• Cardiology - I do not think we are ‘there’ yet to really start tackling items like hypertension, heart failure, atrial fibrillation, post-MI management with DTC at this point. I mean, hypertension is attractive, but look at the work current companies like Livongo and Omada are putting into management, and that’s not including drug management. You need more diagnostics and monitoring tools which I do not think DTC companies want to be involved with. Take for example even the first-line therapies for hypertension, ACEi/ARBs, CCB, and Thiazides. ACEi/ARBs and Thiazides need a basic metabolic test just to monitor electrolytes and renal function. The patient's subjective experience will be limited (most of us do not feel our blood pressure) so you need a blood pressure cuff to monitor. At that point, you have multiple visits, expectations by the consumer/patient, that I think really just reduce your ROI. These companies aren’t looking to be sponsored by payors or reduce health outcomes at this time, so why go down that path? That’s why I think maybe GoodRx and Lemonaid will do statins and related cardiometabolic because those are at least low-key and manageable at this time.

• Pulmonary - Now this I think might be interesting. Is it feasible for Asthma or COPD management? Possible, but same issues as above with cardiology.

• Endocrinology - No one is going to take on Diabetes right now with DTC. Same reasons.

• Mental Health - I think there is an expansion here that is possible. I think its more work but highly feasible with the right providers on-boarded and procedures/protocols well thought out. Also, there’s a shortage of mental health providers in the US so I think there is going to be a big approach to tie a DTC company with CBT company as well at some point. Lastly, someone is going to do ADHD based on the interest with a younger population, but the issue with controls really makes me concerned.

• Neurology - I do not expect this to take off as well. No one is going to touch seizures, dementia, parkinson’s or such. But, I think migraines will take off and others will get on board with that area.

• Oncology - NOPE.

• Nephrology - Again, to many issues with renal monitoring to make it feasible.

• Gastrointestinal - Now, I think Irritable Bowel Disease (IBS) could be a big target here. There are some concerns with diagnosis, but I wouldn’t be surprised if someone is looking into this. GERD is being taken on a bit, but with the movement of most drugs OTC I am not sure if highly profitable.

• Pain - This would be an issue with controlled substances, and given the current health climate I don’t see anyone really touching this.

• Sleep - I didn’t list this in my graphic, but some companies are targeting sleep, but just with melatonin (available OTC). I think there’s a possibility of using Z-drugs or others, but again the issue with controlled substances.

• Hormonal Therapy - I expect someone to start doing testosterone at some point. It just makes sense from a business perspective, though I see a lot of issues with preventing negative outcomes if not screened appropriately. Also, I think more emphasis on menopause will come up. I can see someone getting birth control from a company that also has menopause as a therapeutic category of treatment, and recommending the service to their mother who has menopause based on word-of-mouth.

• Immunizations - Ok, what if we start having patients give themselves their own vaccinations? Patients can already be educated to do insulin and other injectables. Now the big issue here is stability, as many vaccines need to be transferred at a certain temperature which could be cost-concerning for these companies. One area that would be interesting is Flu vaccines or those for travel medicine. Actually, a travel medicine medication box being delivered before you travel could be interesting as well.

• Life Extension - I am just gonna say it. Someone is going to start trying to do metformin as a life extension therapy DTC and I think it would take off in some spaces. Just the monitoring and other concerns they are going to have to address.

Final thoughts are that I think the ‘Golden Egg’ of DTC Prescription Services is to target diseases of low risk (and items mentioned in the beginning) that lead to returning chronic use to maintain membership. But, these conditions cannot turn the consumer into a full-fledged ‘patient’ that will need to return back for routine questions and concerns. As I mentioned with hypertension, it would be a lot of monitoring and management which I don’t think would be immediately profitable for how these companies are currently running.

BUT. If the day comes where high uptake of sensors (e.g., Apple Watch with blood glucose and blood pressure monitoring) that can measure vitals or similar take-off, and low cost home testing is easy to accomplish (see my list of startups), then I think DTC may look into the above-mentioned issues.

Why Am I Concerned About This?

Pharmacists really want to prescribe. A lot. Some see it as a means of opening the floodgates to a better business proposition. I am not really on that side. Maybe 10 years ago it would have been a more feasible time, but with the inroads of these companies, I think the pharmacy profession has lost ot much ground to gain back. If you want to really understand my logic, watch the following video:

What about Digital Therapeutics?

Now hear me out. I think Digital Therapeutics (DTx) will take off in 5-years, and that using DTC Prescription Services may be a huge means for getting their products to the market. I could see this working several ways, but I’ll leave that for another post.

So What’s Next for Pharmacists?

The bottom line is that pharmacists need to know that these services are real and here to stay. I don’t know who the winners of this space will be, but if you are considering going into a prescription model then you need to be cognizant of your competition. We should look for DTx as one solution, but also target mid-stakes diseases that DTC won’t touch, like hypertension and diabetes. That may be the niche that we can carve out, as the low-stakes diseases I think are a lost cause of a significant business opportunity down stream.