The Pill Mill Went Legit
A few months ago, I wrote about a telehealth company called Done that helped turn the pandemic-era demand for ADHD medication into an extremely lucrative business.
The model was fairly straightforward. Patients saw advertisements suggesting they might have ADHD, paid for a subscription and completed a brief online evaluation. On the other side of the screen, clinicians were expected to review an enormous number of cases and, in many instances, prescribe controlled substances to patients they had barely evaluated.
According to federal prosecutors, the founders of Done went well beyond merely providing questionable care. The Department of Justice accused them of conspiring to distribute Adderall and other stimulants to patients who did not have a legitimate medical need for them. The company’s founder and clinical president were arrested. Done denied the allegations.
It was easy to look at that scandal and blame a particularly reckless company, the relaxed telehealth rules of the pandemic, or the unusual regulatory problems surrounding controlled substances.
The drugs are different. The allegations are different. But the business model felt awfully familiar.
LifeMD is a publicly traded telehealth company that has become a major provider of GLP-1 weight-loss treatment. It connects patients with clinicians, helps them obtain prescriptions, and charges recurring fees for continued access to its platform.
Unlike Done, LifeMD is not operating on the disreputable edges of American healthcare. It has been presented to consumers as part of the legitimate infrastructure surrounding some of the most successful drugs in pharmaceutical history.
Novo Nordisk has promoted LifeMD as a telehealth provider offering legitimate medicine and patient support. LifeMD also integrates with the direct pharmacy programs established by Novo Nordisk and Eli Lilly. A patient interested in losing weight can encounter an advertisement for a GLP-1, visit a manufacturer-supported website, connect with a telehealth provider, and obtain medication without ever setting foot inside a traditional medical practice.
This is supposed to represent the future of healthcare.
According to several former employees and executives, however, the future looks quite a bit like the past.
Lawsuits and interviews with former LifeMD employees describe clinicians being pressured to move through cases at extraordinary speed, sometimes reviewing as many as 25 “tasks” per hour. Traditional video visits were reportedly shortened from 20 minutes to 15, while providers were encouraged to rely more heavily on asynchronous prescribing based on patient intake forms.
Clinicians said they were discouraged from asking questions that might “delay care.” Refill requests and dose escalations allegedly piled up by the hundreds or thousands. Providers were sometimes asked to make decisions about patients they had never treated, working from medical records that contained little meaningful information.
To be clear, LifeMD disputes these characterizations and says its clinicians retain independent medical judgment. The company has also defended its productivity standards by arguing that a “task” can include relatively simple administrative work, not merely a complete patient evaluation.
That may be true. Reviewing 25 tasks in an hour does not necessarily mean writing 25 new prescriptions.
It is still difficult to imagine a productivity target like that improving anyone’s medical judgment.
The most illuminating defense came from LifeMD CEO Justin Schreiber, who explained the financial consequences of patients not receiving the treatment they expected. Patients who are denied prescriptions, he said, generally do not remain customers. A high rejection rate therefore creates a “massive financial hit” for the company.
This is the central problem, beautifully confessed aloud.
LifeMD can insist that its clinicians are completely independent. But the company’s economics punish the exercise of that independence. Every patient who hears “no” is not merely a disappointed patient. That person is lost recurring revenue.
The clinician is therefore placed in an impossible position. The company attracts customers with the promise of convenient access to a highly desirable drug. The customer arrives expecting that drug. The company only retains the customer if the clinician delivers it. Yet everyone is asked to pretend that this arrangement has no effect on clinical decision-making.
That is roughly like paying a bouncer based on how many people get into the nightclub and then insisting he has complete independence to enforce the dress code.
LifeMD is not the first company to discover this problem.
When I wrote about Done, I described its prescribers as throughput constraints. They were the human beings standing between consumer demand and company revenue. Every clinical question slowed the system down. Every denial risked losing a subscription. Once the company began treating healthcare like a technology platform, the obvious solution was to optimize away that friction.
The federal government treated Done as an extraordinary case because the company was allegedly distributing controlled substances. But the underlying conflict was never unique to Adderall.
Done showed what happens when telehealth turns a controlled substance into a subscription product. The allegations against LifeMD suggest the real problem may have been the subscription product itself.
There is nothing inherently wrong with treating patients through telehealth. There is also nothing inherently wrong with prescribing GLP-1 drugs online. Many patients can be evaluated, treated and monitored safely without occupying an examination room.
The problem begins when the company selling access to the clinician only makes money if that clinician provides the treatment the patient arrived expecting.
Good medical care regularly involves disappointing people. Patients ask for antibiotics they do not need. They request controlled substances that are inappropriate for them. They want higher doses, faster titration schedules and medications they heard about from friends or saw advertised online.
Sometimes the correct answer is yes. Sometimes it is no. Often it is, “I need more information.”
The entire purpose of having a clinician involved is to determine which answer is appropriate. If the business collapses whenever that answer is not yes, the clinician is no longer functioning as an independent medical professional. He or she is functioning as an obstacle inside a sales funnel.
GLP-1s make this conflict particularly important because they are real medicine. These drugs are extraordinarily effective. They have changed the treatment of obesity and will likely improve or extend millions of lives.
But FDA approval does not mean every patient should receive them. It does not certify every intake questionnaire, telehealth platform, prescribing algorithm or dose-escalation schedule used to sell them.
A legitimate medication can still be delivered through an illegitimate clinical process.
In fact, the effectiveness of GLP-1s may make this model more dangerous. Consumers desperately want these drugs because they work. Drugmakers are spending heavily to make sure they know about them. Telehealth companies promise convenient access. Providers are then dropped into the middle and expected to preserve clinical independence inside a system in which every other participant benefits from the prescription being written.
The drugmakers deserve more scrutiny here than they have received.
Novo Nordisk and Eli Lilly are no longer simply manufacturing medications and shipping them to wholesalers. They are building consumer-facing distribution systems. They advertise directly to patients, operate their own pharmacy programs and establish relationships with telehealth companies that can convert consumer interest into prescriptions.
These arrangements allow manufacturers to present themselves as champions of access while leaving the most uncomfortable part of the transaction to someone else.
The drugmaker creates the demand. The telehealth company captures the customer. The clinician writes the prescription. The pharmacy dispenses the medication. If something goes wrong, every participant points toward the independent judgment of the person who spent a few minutes reviewing an intake form.
It is less a healthcare system than a carefully constructed liability-distribution system.
The allegations against LifeMD include one particularly disturbing example. A former company executive claims that LifeMD’s Chief Medical Officer prescribed him multiple GLP-1 drugs and escalated his treatment too aggressively, contributing to severe medical consequences. LifeMD has disputed his account and is fighting his claims in court.
I do not know what happened in that individual case. A lawsuit is an allegation, not a verdict. But even if every claim is ultimately rejected, the structural conflict remains.
Healthcare companies are designing systems in which speed, prescription conversion, and recurring revenue are measured constantly. Thorough evaluations, follow-up questions, and clinical hesitation are treated as inefficiencies. We can decorate that model with the language of access and patient empowerment, but the economics do not disappear.
The pharmaceutical industry wants to separate the medication from the inconvenient parts of medicine. The evaluation. The documentation. The follow-up. The dose adjustment. The conversation in which a qualified professional occasionally tells a patient that the drug being advertised to them is not appropriate.
Those things look inefficient on a growth dashboard.
Clinically, they are the job.
Done became a national scandal because its alleged conduct was extreme enough to attract federal prosecutors. But prosecuting one company did nothing to address the machinery that produced it.
That machinery is still here. It is selling different medications now, through better websites, with more respectable partners.
The telehealth pill mill did not disappear.
It went legit.
Alec Wade Ginsberg, PharmD, RPh
4th-Gen Pharmacist | Owner & COO, C.O. Bigelow
Founder, Drugstore Cowboy
