The ads in the New York subway system drew my attention<\/a>, as I suppose they were meant to do \u2014 they were unmissable both online and when I was in the city earlier this summer. I saw a woman injecting herself alongside a panel promising \u201ca weekly shot to lose weight.\u201d This particular ad didn\u2019t feature the names of the popular weight loss injections Ozempic, Wegovy, or Mounjaro. It didn\u2019t warn about side effects, either. It looked like an ad for drop-shipped makeup or direct-to-consumer bras. The only name attached was \u201cRo.\u201d<\/p>\n<\/div>\n Other ads did include \u201cWegovy,\u201d along with a list of side effects. Ro\u2019s advertising campaigns aren\u2019t just subway stations, either. There are digital ads, TV ads, and influencer campaigns<\/a>. And though those campaigns might feature the drug, that\u2019s not the only thing they\u2019re advertising.<\/p>\n<\/div>\n The subway ad buys ended in May, and for other New York regional trains, the ads ran from June to July \u2014\u00a0though some ads remained up until another advertiser bought the space, according to Ro spokesperson Michelle Suconick. Ro paused its advertising efforts in June, due to the shortages of GLP-1 medications, she says in an email. She didn\u2019t respond to questions regarding how much the ad campaigns cost.<\/p>\n<\/div>\n Ro is one of a slew of telehealth providers:\u00a0a way to see a doctor without actually physically going to a doctor\u2019s office. These companies have been around for a while, but they\u2019ve boomed since the pandemic. And some of their practices have exposed regulatory loopholes \u2014 building up an Uber model for medicine, for instance. That\u2019s just one of several ways to side-step regulations meant to keep consumers informed.<\/p>\n<\/div>\n \u201cLegally, it\u2019s falling into a gap,\u201d says Tara Sklar, the faculty director of the Health Law & Policy Program at the University of Arizona\u2019s law school.\u00a0<\/p>\n<\/div>\n There are three relevant regulatory agencies here. One is the US Food and Drug Administration, which approves marketing for pharmaceutical manufacturers and oversees direct-to-consumer advertising. It\u2019s one of the reasons you often hear the long list of side effects on drug ads \u2014\u00a0something called \u201cfair balance<\/a>\u201d requires it.\u00a0Another is the Federal Trade Commission, which brings action against false or misleading advertising. The third is the\u00a0Federal Communications Commission, which is primarily concerned with expanding access to telehealth to rural communities.<\/p>\n<\/div>\n There are a few loopholes that explain the explosion of advertising. First, there\u2019s something called \u201chelp-seeking\u201d advertisements, where a specific condition is referenced but no drug is suggested. Those ads fall under the purview of the FTC and are basically fine just as long as they aren\u2019t false. But second, telehealth companies that are structured as technology platforms \u2014\u00a0just connecting patients with the doctors, ma\u2019am \u2014\u00a0aren\u2019t regulated by the FDA. Which means that if a telehealth platform posts an ad naming a drug, it does not have to abide by the FDA \u201cfair balance\u201d standard, and the FDA can\u2019t pursue it for not doing so. If you were wondering why Instagram was briefly clogged with ads for ketamine therapy, that may help explain it.<\/p>\n<\/div>\n As for the FCC, the main concern for telehealth appears to be making sure rural areas \u2014\u00a0places that are less likely to have doctors \u2014 have access to telemedicine. But the profit model for many telehealth companies isn\u2019t based on serving needy rural communities or primary care. Indeed, looking at Ro\u2019s \u201cTop Products\u201d tab is instructive: dick pills (Cialis, Viagra), a prescription for growing longer eyelashes, hair growth medication (both finasteride and minoxidil), and valacyclovir, an antiviral for treating herpes.\u00a0<\/p>\n<\/div>\n So when I got a prescription through Ro for Ozempic, I shouldn\u2019t have been surprised. After all, getting prescribed<\/em> Ozempic (or Wegovy) was kind of the idea when I pitched this story about telemedicine. And I did get exactly what I paid for.<\/p>\n<\/div>\n Ro, founded in 2017, was initially called Roman and originally sold drugs for treating erectile dysfunction. Its CEO, Zachariah Reitano, told The New York Times<\/em> that his own experience with erectile dysfunction<\/a> \u2014\u00a0the result of a heart condition \u2014 was what had inspired the startup.\u00a0<\/p>\n<\/div>\n Since then, it has expanded rapidly. In 2018, the company broadened its focus<\/a>, offering smoking cessation products and renaming itself Ro. In 2019, the company targeted menopausal women<\/a> with prescription offerings for hot flashes and vaginal dryness, among other symptoms, under the brand Rory. (Roman became Ro\u2019s male-oriented vertical as the company\u2019s services grew.) In 2020, the company began offering a weight loss product, Plenity,<\/a> and, a year later, at-home covid tests<\/a>.<\/p>\n<\/div>\n That\u2019s not all \u2014 the company also owns a pharmacy, a mental health clinic, and a reproductive health clinic.<\/p>\n<\/div>\n Ro has raised $1 billion in funding to date, according to Crunchbase<\/a>; its investors include Initialized Capital and General Catalyst. But in 2021, TechCrunch <\/em>wrote<\/a> that the company was unable to \u201cmonetize meaningfully outside of Roman, its erectile dysfunction vertical.\u201d Last February, sources, including Bloomberg<\/em>, valued the company at $7 billion<\/a> \u2014\u00a0but it sliced 18 percent of its staff that summer to, according to an email sent by the company to its employees, manage expenses<\/a>, among other reasons.<\/p>\n<\/div>\n When I got a prescription through Ro for Ozempic, I shouldn\u2019t have been surprised<\/p>\n<\/div>\n<\/div>\n Ro\u2019s terms of service suggest it may provide people with information on healthcare and wellness, pharmacy services, healthcare records, administrative support for scheduling and paying for healthcare, and a way to contact a healthcare provider through messages, phone chats, or video calls. But the healthcare providers themselves, per the terms of service<\/a>, aren\u2019t employed by Ro. They are instead an \u201caffiliated network of providers,\u201d which means \u201ca medical practice focused on providing care to patients through Ro\u2019s telehealth platform,\u201d says Ro spokesperson Suconick. Patients who participate in Ro Body are treated by those network providers.<\/p>\n<\/div>\n While the FDA controls how pharmaceutical companies market drugs, it doesn\u2019t control how medicine is prescribed. Doctors can prescribe as they see fit, and so-called off-label prescriptions are fairly normal in medicine.<\/p>\n<\/div>\n At a BMI of 27, I\u2019m overweight. The FDA approved Wegovy \u2014\u00a0semaglutide, the same medication as Ozempic \u2014 for marketing to people with a BMI of more than 30 or for people with a BMI of 27 with at least one weight-related condition. I don\u2019t have a weight-related condition. If I was going to get one of the hot new weight loss drugs, my prescription would be off-label.<\/p>\n<\/div>\n It\u2019s never been that<\/em> difficult to find pill mills. In her addiction memoir How to Murder Your Life<\/em>, Cat Marnell describes looking for the lowest-rated doctors on Yelp; more recently, in his addiction standup special Baby J<\/em>, John Mulaney says he used WebMD the same way. But thanks to Ro, my path was even easier.<\/p>\n<\/div>\n Let\u2019s start with the obvious: weight is not the same as health. If you are skinny but you smoke cigarettes to control your appetite, you might be in worse trouble than you would be if you were overweight. Weight loss is, nonetheless, a booming business in America \u2014 and one with a long and dangerous history.\u00a0<\/p>\n<\/div>\n For decades, pharmaceutical companies have introduced successive waves of weight loss treatments that all come with painful and sometimes deadly side effects. Amphetamines and methamphetamines became such popular appetite suppressants that they helped the US produce enough amphetamine salts by 1962 to give every American 43 standard 10mg doses that year<\/a>. (By 1971,\u00a0all amphetamine products were moved to Schedule II controlled substances, and prescription sales fell immediately by 60 percent.)\u00a0<\/p>\n<\/div>\n For decades, pharmaceutical companies have introduced waves of weight loss treatments with painful and sometimes deadly side effects<\/p>\n<\/div>\n<\/div>\n The next wave was a combo punch. Fenfluramine and dexfenfluramine, which had the serious side effect of creating high blood pressure in the lungs, were combined with the amphetamine derivative phentermine to create a drug widely known as fen-phen, which produced weight loss \u2014\u00a0and damage to heart valves. Fenfluramine and dexfenfluramine were pulled from the market in 1997 after the FDA raised concerns about the drugs\u2019 safety as diet drugs.<\/p>\n<\/div>\n More recently, sibutramine and rimonabant were approved in Europe, then removed from the market because of cardiovascular risk and psychiatric problems, respectively. Orlistat, approved for weight loss treatment in the US in 1999, tends to cause diarrhea, among other gastrointestinal complications.\u00a0<\/p>\n<\/div>\n Part of the reason for the weight loss drug boom is simple: an increase in the number of overweight and obese people, widely dubbed the \u201cobesity epidemic<\/a>.\u201d The epidemic\u2019s existence, however, is deeply intertwined with the diet industry. The definition of overweight and obesity is based on a measure called body mass index, or BMI, which has been understood to be \u201cnot fully satisfactory\u201d as a measure of health since 1972<\/a>. (That said, they also found it to be \u201cat least as good as any other relative weight index as an indicator of relative obesity.\u201d) However, BMI alone isn\u2019t enough to determine metabolic health<\/a> and can be a bad indicator of body fat overall<\/a>.<\/p>\n<\/div>\n For a while, the definition of \u201coverweight\u201d and \u201cobese\u201d varied. In 1985, a National Institutes of Health\u00a0conference set the standard for overweight<\/a> at a BMI of greater than 27.8 for men and 27.3 for women. The National Center for Health Statistics defined overweight as a BMI of more than 28 for men and more than 27 for women<\/a>. Meanwhile, the Department of Health and Human Services and the Department of Agriculture defined overweight men as having a BMI of 25\u201326 and women as a BMI of 24\u201325.\u00a0<\/p>\n<\/div>\n In 1998, the NIH lowered its standard \u2014 a move that, according to a CNN article from the period, worried critics<\/a>, as it stood to \u201cpersuade doctors to start prescribing diet drugs for people who don\u2019t need them.\u201d While the new guideline brought the NIH in line with the World Health Organization\u2019s standards, the Newark Star-Ledger <\/em>also <\/em>reported<\/a>,\u00a0\u201cEight of the nine members of the National Institutes of Health task force on prevention and treatment of obesity have ties to the weight loss industry.\u201d<\/p>\n<\/div>\n With a BMI of 27, I would have counted as \u201cnormal\u201d in the 1980s and 1990s by many standards, rather than overweight. I\u2019m also active: I usually <\/strong>hike somewhere between 45 and 50 miles a week, spend a fair amount of time in downward dog, and lift weights. My cholesterol is normal, and my primary care doctor has called my blood sugar \u201cenviable.\u201d\u00a0<\/p>\n<\/div>\n With a BMI of 27, I would have counted as \u201cnormal\u201d in the 1980s and 1990s by many standards<\/p>\n<\/div>\n<\/div>\n I\u2019m not going to tell you that weight has no<\/em> relationship to health \u2014 one of the first signs I was getting sick with what turned out to be a thyroid condition was weight gain, and it remains a reliable indicator I need to get my medication adjusted. But I don\u2019t meet the label criteria for an Ozempic prescription. The only real reason for me to lose weight, as far as I can tell, is aesthetic. I wondered if Ro would prescribe medicine to me anyway.<\/p>\n<\/div>\n The process of finding out was fairly easy, if a little unsettling. First, I filled out a form. Then, I uploaded two full-body photos of myself: from the front and from the side. Blood tests are required, and patients can either go to Quest Diagnostics and use their insurance for tests \u2014 Ro receives no money for this \u2014 or do an at-home test from Ro. If patients choose the at-home test, they pay Ro for it. I chose the at-home test.<\/p>\n<\/div>\n After a few days, I got a kit in the mail asking me to prick my own finger for a blood test. At every turn, Ro wanted me to use video \u2014 the test featured no written instructions, only a phone holder, an \u201capp,\u201d and the strong suggestion I should video chat with someone at Ro while I drew my own blood.<\/p>\n<\/div>\n I\u2019m an old hand at drawing my blood at home since I participated in a University of California, Berkeley covid study <\/strong>for a few years. I really do not need someone to talk me through the process of drawing a successful sample; I wanted written instructions, not a video. But I watched the video anyway. The best part of the entire process was the centrifuge the company sent me: I was to spin my own sample to prep it for the lab. I would happily do this for doctors\u2019 appointments for the rest of my life. Centrifuges are cool. Sadly, I had to pack it up and send it back with the sample.<\/p>\n<\/div>\n The blood test returned familiar results: normal blood sugar, normal cholesterol, and normal TSH. I was written a prescription for Ozempic. At no point during this process did I need to speak with a doctor.<\/p>\n<\/div>\n Asynchronous care, which is what I received, depends on the state and medical concern, says Ro spokesperson Suconick. \u201cIn terms of how clinical eligibility is determined in an asynchronous visit, Ro\u2019s Online Visit is dynamic, and enables the patient to detail their health history and goals,\u201d she says in an email. \u201cIn addition, the required blood test gives the Ro-affiliated provider a clear picture of each patient\u2019s metabolic health, beyond Body Mass Index, to determine if treatment is safe and appropriate.\u201d <\/p>\n<\/div>\n All patients have the opportunity to speak with a provider through a phone call or video chat if they have concerns. \u201cNot every patient chooses to do so,\u201d she says.<\/p>\n<\/div>\n GLP-1 agonists, the class of drug Ozempic belongs to, weren\u2019t initially meant for weight loss. They were first approved as type 2 diabetes drugs. Because of their intended use in a chronic disease, there wasn\u2019t really an end in sight for when people should stop taking them. One trial for the weight loss indication lasted 68 weeks and found that the group taking the drug lost significantly more weight than placebo<\/a>. Another, which lasted two years, similarly showed serious effectiveness<\/a>.\u00a0<\/p>\n<\/div>\n I had expected, at some point, for a human person affiliated with Ro to insist<\/em> I have a discussion with them<\/p>\n<\/div>\n<\/div>\n But these trials didn\u2019t demonstrate whether the weight stayed off when people quit taking the drugs. There is reason to believe, from other papers<\/a>, that patients will regain weight if they stop taking the drugs. A follow-up of the patients in the 68-week trial found that participants regained two-thirds of the weight they\u2019d lost within a year of quitting their medicine<\/a>. \u201cOngoing treatment is required to maintain improvements in weight and health,\u201d the authors wrote. That may mean that people in Ro\u2019s weight loss program will have to stay in it indefinitely.<\/p>\n<\/div>\n \u201cThe expectation that individuals should be able to maintain their weight loss without treatment again highlights the widespread, but mistaken social view of obesity more as a flaw of willpower and self-discipline, rather than a complex chronic disease,\u201d Suconick says. It\u2019s certainly true that other medications are also taken for indefinite periods; I will probably take levothyroxine for my thyroid condition every morning for the rest of my life. But I don\u2019t pay my doctor a monthly fee for my refills.<\/p>\n<\/div>\n Ro\u2019s weight loss services cost a discounted $99 for the first month and $145 a month after that.\u00a0This is called \u201cThe Body Program,\u201d which includes a \u201cpersonal health coach,\u201d a \u201cweekly curriculum email,\u201d an \u201cinsurance concierge service,\u201d \u201congoing provider care,\u201d and, of course, weight loss drugs. The curriculum seems to have such ground-breaking suggestions as physical activity is good for you and you should get enough sleep.<\/p>\n<\/div>\n Ro isn\u2019t just making money on its weight loss program, though. Ro also offers pharmacy services. And that fun centrifuge I used? It was part of Ro\u2019s lab testing \u2014 though patients can opt to test via Quest. <\/p>\n<\/div>\n Anyway, after Ro processed my blood sample, I got a message from a nurse practitioner I hadn\u2019t spoken to telling me I was approved for GLP-1 treatment and that she was writing a prescription for semaglutide, the active ingredient in Ozempic and Wegovy. (What kind of medication, she said, would depend on my insurance.) However, the message contained a bolded section that gave me pause:<\/p>\n<\/div>\n Please note that GLP-1 medication can potentially alter Synthroid (Levothyroxine) concentration, please ensure that if you do start this medication to closely follow up with your primary provider and\/or Endocrinologist. Feel free to reach out with any questions.<\/strong><\/p>\n<\/blockquote>\n<\/div>\n I take thyroid hormone to replace the stuff my body doesn\u2019t make. Anything that affects how much of it I absorb is going to affect how I feel \u2014\u00a0which means if I were to start Ozempic, I\u2019d probably need more regular monitoring of my TSH to make sure my hormones remained in range.<\/p>\n<\/div>\n I hadn\u2019t actually planned to take the medication; the exercise of getting a prescription was primarily to see how easy it was. I had expected, at some point, for a human person affiliated with Ro to insist<\/em> I have a discussion with them about my thyroid, particularly since possible side effects listed on Ozempic\u2019s prescription label include possible thyroid tumors and thyroid cancer. The message I got from Ro indicated that my risks were my responsibility.<\/p>\n<\/div>\n This highlights another problem with these telehealth providers: even if you are using them as intended, they can fragment the healthcare system, offloading the risks onto the patient. Some providers, such as AgelessRX, prescribe drugs like metformin following a free, 10-minute online consultation. If I were sufficiently motivated, I \u2014 a non-diabetic \u2014\u00a0could potentially get multiple prescriptions from multiple providers. These providers aren\u2019t communicating with each other. It\u2019s a pillhead\u2019s dream.<\/p>\n<\/div>\n Doctors who are ready with a prescription pad aren\u2019t anything new. (See also: \u201cDr. Feelgood\u201d by M\u00f6tley Cr\u00fce, \u201cCharlie\u2019s Medicine\u201d by Warren Zevon, and \u201cDoctor Robert\u201d by the Beatles.) Sensationally advertised diet solutions aren\u2019t new, either \u2014 once upon a time, even sugar was advertised that way<\/a>. But the internet has introduced a new level of scale, combined with a tremendous lack of accountability.<\/p>\n<\/div>\n The US is one of only two countries in the world where direct-to-consumer advertising of pharmaceuticals is allowed. (The other is New Zealand.) The phenomenon is fairly recent: it only began in 1997, when the FDA proposed new guidelines for DTC ads<\/a>. (Those guidelines were formalized in 1999<\/a>.) There is some research suggesting that all<\/em> DTC pharma ads<\/a> harm patients by increasing medical costs. Another concern is that these ads promote the use of new drugs with safety profiles that are not fully known. The most famous example is Vioxx, a painkiller that was among the most heavily advertised drugs in the US before it was pulled from the market by its manufacturer after a study found that it could cause\u00a0strokes and heart attacks.<\/p>\n<\/div>\n Ro can run subway ads with copy<\/a> like \u201cA weekly shot to lose weight\u201d without mentioning any of the side effects of the GLP-1 class drugs, alongside images of models injecting themselves. (The campaign ads that do mention GLP-1 drugs by name, such as Wegovy, list the side effects.) Some panels feature reassuring copy: \u201cMedication for weight loss is not cheating,\u201d it reads. \u201cIt\u2019s not a shortcut. And it\u2019s nothing to feel guilty about. It\u2019s a medication\u00a0for a condition. And if it\u2019s right for you, it could be life-changing.\u201d\u00a0<\/p>\n<\/div>\n \u201cThere\u2019s an implicit idea that advertising is a form of speech and it\u2019s protected by the First Amendment\u201d<\/p>\n<\/div>\n<\/div>\n The side effects of these drugs can be substantial: nausea, vomiting, abdominal pain, diarrhea, and constipation. Rarer adverse reactions\u00a0on the Ozempic FDA-approved label include<\/a> pancreatitis, kidney injury, and gallbladder disease, as well as a warning about the risk of thyroid tumors. The FDA requires that manufacturers have to disclose those risks in ads, but telehealth companies don\u2019t have to if they aren\u2019t affiliated with the drug manufacturers or distributors, Sklar says.\u00a0<\/p>\n<\/div>\n Part of the reason drug ads \u2014 telehealth or otherwise \u2014\u00a0are allowed in the first place has to do with the US Constitution. \u201cThere\u2019s an implicit idea that advertising is a form of speech and it\u2019s protected by the First Amendment,\u201d says Christopher Robertson, a professor at Boston University\u2019s School of Public Health. \u201cSo I think that\u2019s going to be a challenge for anyone cracking down on the telemedicine companies.\u201d<\/p>\n<\/div>\n The FTC can step in if the ads are misleading. But the agency is a little hamstrung: if there is evidence that a drug is useful for the purpose being advertised, even if the drug isn\u2019t FDA-approved for that purpose, the FTC won\u2019t act, Sklar says. \u201cWe\u2019ve gotten to this point where two large regulatory agencies don\u2019t really have authority over telehealth companies,\u201d she says. \u201cAnd if there\u2019s going to be no oversight, then it\u2019s going to continue to grow.\u201d<\/p>\n<\/div>\n The doctors who are on these apps are subject to medical board oversight, Robertson notes. A few doctors who promoted themselves as prescribing ivermectin to interested parties during the covid pandemic were disciplined by their state medical boards, but by and large, this is rare, he says. \u201cIt\u2019s hard to object to the mere advertising alone,\u201d Robertson says. \u201cYou need cases of bad healthcare, in particular.\u201d<\/p>\n<\/div>\n These ads can also be a little sneaky. Sure, a drug might be FDA-approved, but it might not be FDA-approved for the indication it\u2019s being advertised for by a telemedicine company. This isn\u2019t a distinction the average consumer is likely to make.\u00a0<\/p>\n<\/div>\n Though the FTC can take action on ads that are misleading, it doesn\u2019t generally require that advertisements disclose risks or potential side effects when discussing drugs\u2019 benefits. It also doesn\u2019t take action on companies that promote off-label use of prescription drugs if the companies can provide evidence supporting their claims. So between the lack of oversight from the FDA and FTC, advertising for weight loss medication has exploded, and not just on the New York subway system \u2014 but on TikTok, Facebook, and Instagram.<\/p>\n<\/div>\n And the advertising has been alarmingly effective. As real-world and online ads for GLP-1 drugs for weight loss purposes have proliferated, there is now a shortage of these drugs<\/a>. Ro is hardly the only telehealth provider that\u2019s seen the opportunity here; Teladoc and Everly Health have also expanded weight management programs that offer GLP-1s<\/a>.<\/p>\n<\/div>\n I asked Ro if the company was concerned that their advertisements of GLP-1s for weight loss might exacerbate the shortage for diabetes patients. \u201cWhen we talk about patients using GLP-1s for weight loss vs. diabetes, we are more often than not talking about the same patients,\u201d says Suconick in an email. \u201cWe at Ro believe everyone who is clinically-eligible and needs access to medication should have access to it. The idea that this is a competition between people with diabetes and people with obesity, as opposed to a need to supply medication to multiple groups that need it, shows the widespread bias against people with obesity and our society\u2019s failure to view obesity as a disease.\u201d<\/p>\n<\/div>\n Photo by Amelia Holowaty Krales \/ The Verge<\/cite><\/p>\n<\/div>\n<\/div>\n Telemedicine companies prescribing controlled substances \u2014 Adderall, Oxycontin, ketamine \u2014 have gotten a lot of interest from the Biden administration, which has proposed limiting online prescriptions for certain drugs in those classes. This, in some ways, misses an important point: telehealth companies provide a quick and easy way for people to get any prescription drug they want. The various regulatory loopholes meant a proliferation of advertising. An important one is the idea that telehealth companies are just tech.<\/p>\n<\/div>\n \u201cThey consistently have language around what they\u2019re doing that\u2019s like, \u2018We\u2019re a platform or a facilitator for providers and patients. We\u2019re unaffiliated with the drug manufacturer and distributor,\u2019\u201d says Sklar.\u00a0That means the FDA can\u2019t really regulate them. But that wasn\u2019t so much of an issue until the public health emergency around covid created an onslaught of ads, she says. In 2020, telehealth companies spent $10 million on digital ads. By 2021, that figure had ballooned to\u00a0$100 million, according to an analysis of 18 telehealth startups\u2019 ad spending by Pathmatics, a marketing research firm.<\/p>\n<\/div>\n Telehealth company Cerebral came under fire for how it handled Adderall prescriptions for ADHD<\/a> \u2014 resulting in the decision to halt prescriptions of controlled substances for new patients. The decision to offer Adderall in the first place happened because, according to The Wall Street Journal,<\/em> \u201cit was half as costly to advertise for ADHD patients than for those with depression and anxiety because each ad dollar yielded more customers.\u201d<\/p>\n<\/div>\n Cerebral\u2019s ads showcased how easy it was to get ADHD treatment for the platform. The Biden administration has proposed banning online prescriptions of certain drugs, but that in some ways misses the point. It\u2019s easy to get all kinds of treatment through telehealth. I\u2019m focusing on weight loss drugs because they\u2019re a hot market, but I can also easily find inhalable oxytocin, an immunosuppressant called rapamycin marketed for potential anti-aging properties, and an HGH-producing drug called sermorelin. This is to say nothing of the dick pills, eyelash lengtheners, acne medications, and hair loss treatments.\u00a0<\/p>\n<\/div>\n The financial incentives behind telehealth can be tricky. Cerebral required users to sign up for a monthly fee, for instance. Doctors pay Ro for its software. It also gets revenue from its test kits and online pharmacy. Sure, limiting controlled substances might help prevent too much Adderall, ketamine, or Oxycontin from hitting the street, but what about everything else?<\/p>\n<\/div>\n \u201cThat\u2019s pretty wild when you think about it, that someone can use your data and there\u2019s nothing you can do\u201d<\/p>\n<\/div>\n<\/div>\n There are other risks that come with telehealth, mainly in the form of data privacy. An investigation of 50 direct-to-consumer telehealth sites found that 49 examined companies had sent patient information to social media platforms<\/a>, such as Facebook, TikTok, and LinkedIn. Though the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) limits what information can be shared, it\u2019s not a proactive law. Something has to go wrong for it to be triggered, Sklar points out.<\/p>\n<\/div>\n It\u2019s actually even worse:\u00a0if a company violates HIPAA, consumers can\u2019t sue, says Christopher Robertson. \u201cAll you can do is go to the Department of Health and Human Services and file a complaint, and maybe HHS will investigate, and maybe HHS will impose sanctions,\u201d he says. \u201cThat\u2019s pretty wild when you think about it, that someone can use your data and there\u2019s nothing you can do.\u201d<\/p>\n<\/div>\n Robertson hopes states will pass laws to allow private litigation. \u201cRight now, we\u2019re just sort of sitting ducks, and our data is breached left and right, and there\u2019s very little we can do about it under the law, except like go beg some bureaucrats to help us out,\u201d he says. \u201cWe really need private causes of action, statutory damages, mostly in state tort.\u201d<\/p>\n<\/div>\n The FTC has seemingly been better at dealing with data privacy than the other issues raised by telehealth.\u00a0It has fined GoodRx and BetterHelp for sharing patient information<\/a>, for instance. This year, Cerebral disclosed a data breach to the US Department of Health and Human Services, and the company is now being investigated by the FTC for its business practices, including its advertisements. <\/p>\n<\/div>\n When I was uploading those full-body shots of myself, I did wonder who besides Ro employees might eventually see them. (When I emailed the company about this story, I was assured that Ro follows \u201cindustry-leading best practices to secure patient information\u201d and referred to the privacy policy.) As a patient, there\u2019s very little I can do to protect myself, and nothing I can do to punish a company that leaks my sensitive medical data. That seems like a risk for consumer safety, too.<\/p>\n<\/div>\n Then there\u2019s the shortage of the GLP-1 drugs. In some cases, compounding pharmacies have stepped into the breach, offering off-brand versions of Ozempic. The problem is that those formulations aren\u2019t the same as the FDA-approved drug and haven\u2019t been evaluated by the FDA, either. The FDA has received reports of adverse events from the compounding pharmacy<\/a> Ozempic knock-offs, which may contain different active ingredients than the approved drugs. \u201cPatients should know that you\u2019re not getting the full benefit of the FDA approval process,\u201d Robertson says.<\/p>\n<\/div>\n Some websites even skip doctors completely<\/a>, selling compounded versions of GLP-1s to consumers \u201cusually with disclaimers that it\u2019s not for human use,\u201d The Washington Post<\/em> reports.\u00a0<\/p>\n<\/div>\n Though pharmacists have to be licensed, like doctors, their day-to-day work is not heavily regulated, says Robertson. \u201cThe actual practice of pharmacy under the American model is distributed to those professionals,\u201d he says.<\/p>\n<\/div>\n And there are real questions about how this aggressive advertising push from telehealth companies is going to affect Medicare, Medicaid, and health insurance premiums, Sklar says. After all, Ro did successfully get my insurance to approve Ozempic, a drug I don\u2019t think I actually needed. And particularly with weight loss, it seems likely that public health interventions could also be effective if that\u2019s something we as a society really want.<\/p>\n<\/div>\n I find it hard to fault anyone who would see Ro\u2019s advertising\u00a0\u2014 whether digital ads, TV ads, or influencer campaigns<\/a> \u2014 and decide to try out the \u201clife-changing\u201d injection. The advertising industry has been pushing images of skinny women all my life, and our society prefers skinny people, especially skinny women<\/a>. Research suggests that the healthcare industry treats fat patients worse<\/a> than skinny ones and that fat people are also discriminated against at work and school<\/a>. Weight discrimination may even literally take years off people\u2019s lives<\/a>.<\/p>\n<\/div>\n To my mind, people shouldn\u2019t feel bad or guilty about their weight. While it\u2019s true that there are adverse effects that accrue from being obese<\/a>, it\u2019s also true that being perfectly healthy isn\u2019t really the point of life. (If it were, bars would be in trouble.) You don\u2019t need to be healthy to be deserving of dignity. You shouldn\u2019t have to be skinny, either.<\/p>\n<\/div>\n One thing that does worry me is the possibility that the GLP-1s set people up\u00a0for yo-yo dieting<\/a>. Some have raised concerns<\/a> that Ozempic causes lean mass loss<\/a> \u2014 such as muscle and bone, things you want to keep. Part of the reason muscle mass is important is because muscle is more metabolically active than fat; that matters for maintaining weight loss<\/a>. The approval of semaglutide for weight loss hinged on the changes in BMI<\/a>, not DEXA scans.<\/p>\n<\/div>\n To me, the problem here isn\u2019t any individual patient or even any individual medicine, though the GLP-1 weight loss drugs really do strike me as the poster children of the telehealth boom. It\u2019s the largely for-profit system, combined with regulatory loopholes. Telehealth probably isn\u2019t primarily a lifeline for rural patients in the way that many have been hoping.<\/p>\n<\/div>\n By the time I visited New York City and saw the Ro ads in real life, I\u2019d already canceled the weight loss program subscription I made for this story. But my options were only expanding. WeightWatchers, which has renamed itself to WW, has purchased its own telehealth platform<\/a>.\u00a0You\u2019re never going to guess what they primarily plan to sell.<\/p>\n<\/div>\n Sklar is, overall, an advocate for telehealth; after all, bad actors \u2014 pill mills, drug diversion, and so on \u2014 existed before telehealth companies did. What\u2019s lagging behind is oversight. There\u2019s a need for congressional catch-up, she says. \u201cIt\u2019s novel and emerging,\u201d she says. \u201cThe Wild West will be reined in over time, maybe initially at the state level rather than federally.\u201d<\/p>\n<\/div>\n The advertisements might not just be for telehealth, either. Telehealth companies are increasingly partnering with drug manufacturers<\/a>, which means they could begin to advertise inside<\/em> those platforms. \u201cWhile you\u2019re waiting to see your doctor, there might be an ad that comes for Ozempic,\u201d Robertson says. \u201cAnd even when your doctor is talking to you, your doctor may be seeing an ad for Ozempic on the side of her screen.\u201d<\/p>\n<\/div>\n Photo illustrations by Cath Virginia \/ The Verge<\/em><\/p>\n<\/div>\n<\/div>\n\n