Telehealth startups get scary
Telehealth startups get scary
Are they selling "freedom," or just selling pills?
This week, Bloomberg published a chilling look at Cerebral, an online mental health service that markets itself heavily as a place to get fast ADHD treatment (and drugs). According to Bloomberg’s reporting, the company’s business model relies on overloading prescribers with patients; one prescriber who spoke to the site had 1000 patients, sometimes seeing 30 of them each day. “Dozens” of employees have left the company “amid concerns about the company’s prescribing practices,” according to Bloomberg. A patient profiled in the story was prescribed five medications in just three months, and ended up hospitalized with a mental health crisis after she began to hear voices. Patients’ access to your providers is gatekept by an imaginary person named Eileen Davis—a smokescreen avatar for hundreds of different ‘care coordinators’ who message with patients, like a cursed healthcare version of an online chat with Comcast customer service.
Telehealth itself isn’t intrinsically bad; it’s great to be able to see a therapist over video-chat, for example. The problem with Cerebral isn’t that it happens over the internet, but that it uses telehealth as a way of squeezing as many patients as possible through the most minimal possible practice of medicine, in the name of profit.
But it’s not surprising that thousands of people end up using Cerebral, or similar services. After all, what are you supposed to do if the healthcare system hasn’t been there for you before? Maybe you’re unable to afford insurance at all. Maybe the doctor you saw was too busy, or just too much of a berk, to really pay attention to your problems. Maybe the doctor was unwilling to prescribe medication you need because of the regulations around controlled substances, or it was difficult to get it from the pharmacy for the same reason. Maybe you’ve experienced prejudice or discrimination from the medical system, which afflicts all sorts of groups—people of color, women, heavier people, trans people—and compounds the other problems I just mentioned. Maybe you live in a rural area, and what medical facilities do exist nearby are closing rapidly.
There are tens of millions of people in America who are uninsured or underinsured, or who fit into those categories I outlined above. Millions and millions of people across this country are not getting things they need from the healthcare system. Many of them are young, online, and desperate. They’re the prime target for a slick ad on TikTok or Instagram, selling them everything they haven’t been getting from the healthcare system—except for the honest practice of medicine. It’s completely unsurprising that startup vultures have sniffed your blood in the air, and thought what a delicious meal that would make.
To have an easy time getting healthcare in America, you need to have two things: A lot of money, and good health. You don’t have to be poor to struggle to access care. If you make, say, $40,000 a year and live in an expensive city, you’re not necessarily in poverty, but you’re also probably not making ends meet with any sort of comfort. You’re likelier to have high-deductible health insurance that makes it hard to go see the doctor, let alone find one who has time to care about you. If you strike out at one doctor, it could be another few hundred to see the next one, and the next, and the next. When it comes to finding a psychiatrist in-network, forget about it. You’d have an easier time finding an old dine-in Pizza Hut with the good cups.
Enter the Instagram-aesthetic health startups, with beautifully designed websites and the promise of personalized, fast healthcare. A key characteristic of services like this is that they list the medications they prescribe on their site, like a menu; they’re aimed at people who know what drugs they need or want already, but haven’t been able to get a prescription from a regular doctor, or want an easier way to get them. You might have heard of Hims, which started out selling erectile dysfunction meds but has expanded into skincare and mental health treatment. I use another startup, Apostrophe, to get acne treatment. There’s Cove, for migraine drugs. There’s Nurx, for birth control, acne treatment and migraine treatment. (There are also many companies that focus exclusively on dietary supplements and openly flout regulations on the marketing of these products, like Uqora for UTIs, which I wrote about in 2019.) Both Cove and Nurx are operated by Thirty Madison, which describes itself as the “premier specialty healthcare company for people living with chronic conditions.” It’s telling that so many of these startups are aimed at conditions poorly treated by the current healthcare system, like migraines and mental health.
The selling point for these start-ups is flexibility, affordability, and control. On the Nurx website, a banner reads “HELLO FREEDOM.” Their service, they claim, allows “anyone, regardless of circumstance, to get medication quickly, discreetly, and affordably.” Cove’s website emphasizes how their treatment plans are more personalized to patients, but it’s also aimed at people who have previously found the right drugs with a real doctor: “Already know what works for you? Just let us know.” Bloomberg noted that Cerebral works best for patients “with existing diagnoses who are seeking quick and easy online care.” You can see why someone who has already been diagnosed with a condition would be interested in one of these services: Instead of having to physically go to a doctor and pay a co-pay to refill your prescriptions every so often, you can just order them online, like any other recurring subscription for cat litter or toilet paper. Never mind getting your blood pressure checked, of course.
So Cerebral is just one—though it sounds like a particularly poorly run example—of many startups that aim to replace seeing a doctor, and that exist to essentially sell certain prescriptions to people who already know they want them. All of these, I would argue, are poor replacements for seeing a doctor who is not marketed to you as a provider of specific drugs. (Cerebral literally calls their nurse practitioners “prescribers,” because they are mainly there to prescribe drugs.)
There are pretty obvious problems when the primary product and selling point of a company are that they will prescribe you specific drugs that they also sell. When you sign up for Nurx or Cove or Cerebral, even if you do ‘meet’ or converse with a doctor, they obviously have a massive incentive to prescribe you something that you’ll also pay them for; Bloomberg also noted that Cerebral prescribers who choose not to prescribe drugs when the patient wants them can “trigger bad reviews.” Either way, the companies exist to attract patients who specifically want those drugs; they’re not trying to say no. It’s a completely different way of providing healthcare—one that has the potential to help patients who have been ignored or mistreated by regular doctors, but also to damage those who are sucked in by marketing, or overloaded with prescriptions by overworked prescribers. It does nothing to fundamentally fix the problems that make it so hard to get adequate healthcare in the first place; healthcare is still a business, just with a different model.
In Cerebral’s case, the desire to sell prescriptions, rather than treat patients, was made very explicit, according to Bloomberg:
In meetings with managers, Chief Medical Officer David Mou has said 95% of people who see a Cerebral nurse should get a prescription, according to two people familiar with his remarks. He was equally emphatic, according to the former employees, that the rate cannot be 100%—saying the company would be a “pill mill” at that rate. Campbell said the 95% figure “refers only to the subset of patients who have received a clinical mental health diagnosis that warrants a prescription as first line treatment,” but the former employees say no such distinction was made.
Sure, wouldn’t want to be a pill mill by giving everyone a prescription—but 95% is fine. Regular old medicine.
Not everyone who signs up for Cerebral gets prescribed Adderall, but as Bloomberg laid out in their piece, the company does particularly push ADHD treatment. Its advertisements focus on easy access to Adderall: When I Googled Adderall in an incognito window, I got an ad for Cerebral that promised “ADHD Meds Prescribed Fast Online,” and another for a similar company, Done, advertising “Same-day ADHD Video Visits.”
This is not to say that people shouldn’t be able to get ADHD meds if they need them. I’m saying the opposite: The very fact that mental health treatment is so hard to access, for a variety of reasons, creates an opportunity for profiteering startups to provide shoddy treatment people suffering from ADHD—and, potentially, people without it. Do you trust that these ‘prescribers’ are being careful and thorough, in just 30 minute sessions, in diagnosing ADHD and prescribing Adderall? One former prescriber told Bloomberg that the model was “we’re going to prescribe the most medicine to the most patients so we get the most patients.” This is not healthcare; it’s sales.
And the sales pitch for Cerebral practically writes itself. There is plenty of social media content out there, often made by and aimed at young people, implying or claiming that a very wide range of symptoms are likely attributable to undiagnosed ADHD. Some of it is undoubtedly helpful and important visibility, and some of it is… not that. “What it’s like living with ADHD” is a meme, as well as a genuine expression of the difficulty of living with a medical condition. (It can be both!)
I have wondered about myself and landed, with the guidance of a psychiatrist, on the conclusion that I don’t have it; I think I just use the internet too much. Lucky me, for having a psychiatrist with no vested interest one way or the other in diagnosing me with ADHD!
I’m not especially worried about ADHD becoming a ‘trendy’ thing, or people thinking they have it if they don’t. The real problem begins if there’s no way for them to actually find out whether they do, outside of giving money to a company that also wants them to pay every month for prescriptions and follow-up ‘care’ with people who cannot possibly care for them properly. It is extremely dangerous if the only feasible or affordable path to getting mental health care is self-diagnosis based on TikTok videos, followed by paying money to a snazzy company that wants to sell you drugs, followed by a complete lack of adequate care once you’re on the drug. If this is the only way to get mental health treatment in this country, man, we are so fucked.
For people who have been able to make telehealth startups work for them, that’s great. But none of this is a substitute for a real healthcare system. None of this is a substitute for being able to go to a doctor whose job is to treat you as a patient, not sell you a product, and who has time and emotional space to care for you. If we had free healthcare and medicine, plentiful appointments with primary care providers, and easy access to mental health treatment, it would be much harder for a company like Cerebral to succeed. Instead, it’s valued at $4.8 billion. Man, we are so fucked.
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