Who wins when telehealth companies push weight loss drugs?

The ads in the New York subway system drew my attention, as I suppose they were meant to do — 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 “a weekly shot to lose weight.” This particular ad didn’t feature the names of the popular weight loss injections Ozempic, Wegovy, or Mounjaro. It didn’t warn about side effects, either. It looked like an ad for drop-shipped makeup or direct-to-consumer bras. The only name attached was “Ro.”

Other ads did include “Wegovy,” along with a list of side effects. Ro’s advertising campaigns aren’t just subway stations, either. There are digital ads, TV ads, and influencer campaigns. And though those campaigns might feature the drug, that’s not the only thing they’re advertising.

The subway ad buys ended in May, and for other New York regional trains, the ads ran from June to July — though 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’t respond to questions regarding how much the ad campaigns cost.

Ro is one of a slew of telehealth providers: a way to see a doctor without actually physically going to a doctor’s office. These companies have been around for a while, but they’ve boomed since the pandemic. And some of their practices have exposed regulatory loopholes — building up an Uber model for medicine, for instance. That’s just one of several ways to side-step regulations meant to keep consumers informed.

“Legally, it’s falling into a gap,” says Tara Sklar, the faculty director of the Health Law & Policy Program at the University of Arizona’s law school. 

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’s one of the reasons you often hear the long list of side effects on drug ads — something called “fair balance” requires it. Another is the Federal Trade Commission, which brings action against false or misleading advertising. The third is the Federal Communications Commission, which is primarily concerned with expanding access to telehealth to rural communities.

There are a few loopholes that explain the explosion of advertising. First, there’s something called “help-seeking” 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’t false. But second, telehealth companies that are structured as technology platforms — just connecting patients with the doctors, ma’am — aren’t 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 “fair balance” standard, and the FDA can’t 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.

As for the FCC, the main concern for telehealth appears to be making sure rural areas — places that are less likely to have doctors — have access to telemedicine. But the profit model for many telehealth companies isn’t based on serving needy rural communities or primary care. Indeed, looking at Ro’s “Top Products” 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. 

So when I got a prescription through Ro for Ozempic, I shouldn’t have been surprised. After all, getting prescribed Ozempic (or Wegovy) was kind of the idea when I pitched this story about telemedicine. And I did get exactly what I paid for.

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 that his own experience with erectile dysfunction — the result of a heart condition — was what had inspired the startup. 

Since then, it has expanded rapidly. In 2018, the company broadened its focus, offering smoking cessation products and renaming itself Ro. In 2019, the company targeted menopausal women with prescription offerings for hot flashes and vaginal dryness, among other symptoms, under the brand Rory. (Roman became Ro’s male-oriented vertical as the company’s services grew.) In 2020, the company began offering a weight loss product, Plenity, and, a year later, at-home covid tests.

That’s not all — the company also owns a pharmacy, a mental health clinic, and a reproductive health clinic.

Ro has raised $1 billion in funding to date, according to Crunchbase; its investors include Initialized Capital and General Catalyst. But in 2021, TechCrunch wrote that the company was unable to “monetize meaningfully outside of Roman, its erectile dysfunction vertical.” Last February, sources, including Bloomberg, valued the company at $7 billion — but it sliced 18 percent of its staff that summer to, according to an email sent by the company to its employees, manage expenses, among other reasons.

Ro’s 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, aren’t employed by Ro. They are instead an “affiliated network of providers,” which means “a medical practice focused on providing care to patients through Ro’s telehealth platform,” says Ro spokesperson Suconick. Patients who participate in Ro Body are treated by those network providers.

While the FDA controls how pharmaceutical companies market drugs, it doesn’t control how medicine is prescribed. Doctors can prescribe as they see fit, and so-called off-label prescriptions are fairly normal in medicine.

At a BMI of 27, I’m overweight. The FDA approved Wegovy — semaglutide, the same medication as Ozempic — 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’t 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.

It’s never been that difficult to find pill mills. In her addiction memoir How to Murder Your Life, Cat Marnell describes looking for the lowest-rated doctors on Yelp; more recently, in his addiction standup special Baby J, John Mulaney says he used WebMD the same way. But thanks to Ro, my path was even easier.

Let’s 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 — and one with a long and dangerous history. 

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. (By 1971, all amphetamine products were moved to Schedule II controlled substances, and prescription sales fell immediately by 60 percent.) 

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 — and damage to heart valves. Fenfluramine and dexfenfluramine were pulled from the market in 1997 after the FDA raised concerns about the drugs’ safety as diet drugs.

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. 

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 “obesity epidemic.” The epidemic’s 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 “not fully satisfactory” as a measure of health since 1972. (That said, they also found it to be “at least as good as any other relative weight index as an indicator of relative obesity.”) However, BMI alone isn’t enough to determine metabolic health and can be a bad indicator of body fat overall.

In 1998, the NIH lowered its standard — a move that, according to a CNN article from the period, worried critics, as it stood to “persuade doctors to start prescribing diet drugs for people who don’t need them.” While the new guideline brought the NIH in line with the World Health Organization’s standards, the Newark Star-Ledger also reported, “Eight 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.”

With a BMI of 27, I would have counted as “normal” in the 1980s and 1990s by many standards, rather than overweight. I’m also active: I usually 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 “enviable.” 

I’m not going to tell you that weight has no relationship to health — 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’t 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.

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 — Ro receives no money for this — 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.

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 — the test featured no written instructions, only a phone holder, an “app,” and the strong suggestion I should video chat with someone at Ro while I drew my own blood.

I’m an old hand at drawing my blood at home since I participated in a University of California, Berkeley covid study 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’ appointments for the rest of my life. Centrifuges are cool. Sadly, I had to pack it up and send it back with the sample.

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.

Asynchronous care, which is what I received, depends on the state and medical concern, says Ro spokesperson Suconick. “In terms of how clinical eligibility is determined in an asynchronous visit, Ro’s Online Visit is dynamic, and enables the patient to detail their health history and goals,” she says in an email. “In addition, the required blood test gives the Ro-affiliated provider a clear picture of each patient’s metabolic health, beyond Body Mass Index, to determine if treatment is safe and appropriate.”

All patients have the opportunity to speak with a provider through a phone call or video chat if they have concerns. “Not every patient chooses to do so,” she says.

GLP-1 agonists, the class of drug Ozempic belongs to, weren’t 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’t 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. Another, which lasted two years, similarly showed serious effectiveness. 

But these trials didn’t demonstrate whether the weight stayed off when people quit taking the drugs. There is reason to believe, from other papers, 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’d lost within a year of quitting their medicine. “Ongoing treatment is required to maintain improvements in weight and health,” the authors wrote. That may mean that people in Ro’s weight loss program will have to stay in it indefinitely.

“The 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,” Suconick says. It’s 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’t pay my doctor a monthly fee for my refills.

Ro’s weight loss services cost a discounted $99 for the first month and $145 a month after that. This is called “The Body Program,” which includes a “personal health coach,” a “weekly curriculum email,” an “insurance concierge service,” “ongoing provider care,” 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.

Ro isn’t 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’s lab testing — though patients can opt to test via Quest.

Anyway, after Ro processed my blood sample, I got a message from a nurse practitioner I hadn’t 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:

I take thyroid hormone to replace the stuff my body doesn’t make. Anything that affects how much of it I absorb is going to affect how I feel — which means if I were to start Ozempic, I’d probably need more regular monitoring of my TSH to make sure my hormones remained in range.

I hadn’t 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 I have a discussion with them about my thyroid, particularly since possible side effects listed on Ozempic’s prescription label include possible thyroid tumors and thyroid cancer. The message I got from Ro indicated that my risks were my responsibility.

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 — a non-diabetic — could potentially get multiple prescriptions from multiple providers. These providers aren’t communicating with each other. It’s a pillhead’s dream.

Doctors who are ready with a prescription pad aren’t anything new. (See also: “Dr. Feelgood” by Mötley Crüe, “Charlie’s Medicine” by Warren Zevon, and “Doctor Robert” by the Beatles.) Sensationally advertised diet solutions aren’t new, either — once upon a time, even sugar was advertised that way. But the internet has introduced a new level of scale, combined with a tremendous lack of accountability.

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. (Those guidelines were formalized in 1999.) There is some research suggesting that all DTC pharma ads 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 strokes and heart attacks.

Ro can run subway ads with copy like “A weekly shot to lose weight” 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: “Medication for weight loss is not cheating,” it reads. “It’s not a shortcut. And it’s nothing to feel guilty about. It’s a medication for a condition. And if it’s right for you, it could be life-changing.” 

The side effects of these drugs can be substantial: nausea, vomiting, abdominal pain, diarrhea, and constipation. Rarer adverse reactions on the Ozempic FDA-approved label include 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’t have to if they aren’t affiliated with the drug manufacturers or distributors, Sklar says. 

Part of the reason drug ads — telehealth or otherwise — are allowed in the first place has to do with the US Constitution. “There’s an implicit idea that advertising is a form of speech and it’s protected by the First Amendment,” says Christopher Robertson, a professor at Boston University’s School of Public Health. “So I think that’s going to be a challenge for anyone cracking down on the telemedicine companies.”

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’t FDA-approved for that purpose, the FTC won’t act, Sklar says. “We’ve gotten to this point where two large regulatory agencies don’t really have authority over telehealth companies,” she says. “And if there’s going to be no oversight, then it’s going to continue to grow.”

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. “It’s hard to object to the mere advertising alone,” Robertson says. “You need cases of bad healthcare, in particular.”

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’s being advertised for by a telemedicine company. This isn’t a distinction the average consumer is likely to make. 

Though the FTC can take action on ads that are misleading, it doesn’t generally require that advertisements disclose risks or potential side effects when discussing drugs’ benefits. It also doesn’t 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 — but on TikTok, Facebook, and Instagram.

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. Ro is hardly the only telehealth provider that’s seen the opportunity here; Teladoc and Everly Health have also expanded weight management programs that offer GLP-1s.

I asked Ro if the company was concerned that their advertisements of GLP-1s for weight loss might exacerbate the shortage for diabetes patients. “When we talk about patients using GLP-1s for weight loss vs. diabetes, we are more often than not talking about the same patients,” says Suconick in an email. “We 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’s failure to view obesity as a disease.”

Telemedicine companies prescribing controlled substances — Adderall, Oxycontin, ketamine — 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.

“They consistently have language around what they’re doing that’s like, ‘We’re a platform or a facilitator for providers and patients. We’re unaffiliated with the drug manufacturer and distributor,’” says Sklar. That means the FDA can’t really regulate them. But that wasn’t 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 $100 million, according to an analysis of 18 telehealth startups’ ad spending by Pathmatics, a marketing research firm.

Telehealth company Cerebral came under fire for how it handled Adderall prescriptions for ADHD — 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, “it was half as costly to advertise for ADHD patients than for those with depression and anxiety because each ad dollar yielded more customers.”

Cerebral’s 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’s easy to get all kinds of treatment through telehealth. I’m focusing on weight loss drugs because they’re 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. 

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?

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, such as Facebook, TikTok, and LinkedIn. Though the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) limits what information can be shared, it’s not a proactive law. Something has to go wrong for it to be triggered, Sklar points out.

It’s actually even worse: if a company violates HIPAA, consumers can’t sue, says Christopher Robertson. “All 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,” he says. “That’s pretty wild when you think about it, that someone can use your data and there’s nothing you can do.”

Robertson hopes states will pass laws to allow private litigation. “Right now, we’re just sort of sitting ducks, and our data is breached left and right, and there’s very little we can do about it under the law, except like go beg some bureaucrats to help us out,” he says. “We really need private causes of action, statutory damages, mostly in state tort.”

The FTC has seemingly been better at dealing with data privacy than the other issues raised by telehealth. It has fined GoodRx and BetterHelp for sharing patient information, 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.

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 “industry-leading best practices to secure patient information” and referred to the privacy policy.) As a patient, there’s 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.

Then there’s 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’t the same as the FDA-approved drug and haven’t been evaluated by the FDA, either. The FDA has received reports of adverse events from the compounding pharmacy Ozempic knock-offs, which may contain different active ingredients than the approved drugs. “Patients should know that you’re not getting the full benefit of the FDA approval process,” Robertson says.

Some websites even skip doctors completely, selling compounded versions of GLP-1s to consumers “usually with disclaimers that it’s not for human use,” The Washington Post reports. 

Though pharmacists have to be licensed, like doctors, their day-to-day work is not heavily regulated, says Robertson. “The actual practice of pharmacy under the American model is distributed to those professionals,” he says.

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’t think I actually needed. And particularly with weight loss, it seems likely that public health interventions could also be effective if that’s something we as a society really want.

To my mind, people shouldn’t feel bad or guilty about their weight. While it’s true that there are adverse effects that accrue from being obese, it’s also true that being perfectly healthy isn’t really the point of life. (If it were, bars would be in trouble.) You don’t need to be healthy to be deserving of dignity. You shouldn’t have to be skinny, either.

To me, the problem here isn’t 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’s the largely for-profit system, combined with regulatory loopholes. Telehealth probably isn’t primarily a lifeline for rural patients in the way that many have been hoping.

By the time I visited New York City and saw the Ro ads in real life, I’d 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. You’re never going to guess what they primarily plan to sell.

Sklar is, overall, an advocate for telehealth; after all, bad actors — pill mills, drug diversion, and so on — existed before telehealth companies did. What’s lagging behind is oversight. There’s a need for congressional catch-up, she says. “It’s novel and emerging,” she says. “The Wild West will be reined in over time, maybe initially at the state level rather than federally.”

The advertisements might not just be for telehealth, either. Telehealth companies are increasingly partnering with drug manufacturers, which means they could begin to advertise inside those platforms. “While you’re waiting to see your doctor, there might be an ad that comes for Ozempic,” Robertson says. “And even when your doctor is talking to you, your doctor may be seeing an ad for Ozempic on the side of her screen.”

Photo illustrations by Cath Virginia / The Verge