Internet Availability of Prescription Pharmaceuticals to the Public

Editor's Note: This article was first released on the Web site of the American College of Physicians-American Society of Internal Medicine (www.acponline.org). The Internet is increasingly used to provide information to and facilitate interaction among patient, practitioner, payer, and researcher. This includes Internet visits to physicians and nurses, specialist consultations and second opinions, and myriad Web sites that provide information on treatment alternatives. Investigators are exploring uses of the Internet in population-based health and medical care research. Such uses are assumed to be beneficial because they may improve access to care while moderating costs. Patients can also use the Internet to purchase health services directly. We sought to describe availability of prescription pharmaceuticals to the public through the Internet. Methods We catalogued World Wide Web sites that sell prescription pharmaceuticals directly to the lay public. Various search engines, including Excite, WebCrawler, Lycos, Yahoo!, Alta Vista, and HotBot, were used to identify Internet sites that sold medications available only by physician prescription in the United States. Multiple search engines were used because each one uses different parameters to catalogue information. All information was obtained during February and March 1999. The perspective was that of a person seeking prescription medications or comparison price shopping. Two criteria were used to enroll Web sites. First, sites had to be an anchor site (an actual provider of services) and not a portal site (independent Web pages that connect to the provider). Most portal sites are paid a commission by anchor sites for displaying an advertisement or taking the user to the service provider's site (also known as click through). Our original search produced many portal sites but only a few anchor sites. In addition, the site had to provide prescription pharmaceuticals. The site might require a prescription or dispense medication without a prescription; likewise, the site might require and offer a physician consultation to obtain the prescription, or it might not make this stipulation. Data were collected on requirements for obtaining a medication, prescription and shipping costs, availability and cost of Internet physician visits, the geographic location of the company providing the Web site and its consulting physicians, and list of medications available through the Web site. We compared the median cost of Internet physician consultations with payments for physician visits by Medicare and managed care organizations in the Philadelphia area. We compared per pill consumer prices of the two medications most commonly offered by Internet providers, sildenafil (Viagra, Pfizer, New York, New York) and finasteride (Propecia, Merck, West Point, Pennsylvania), with prices at five Philadelphia pharmacies. Results Forty-six Web sites met study entry criteria; of these, 37 required a physician consultation or prescription (or both) from the site's consulting physician or a personal physician. Of all sites surveyed, only 5 (10.7%) would reveal their geographic location (city and country) beyond any information offered on the Internet. No Web site would reveal the specific address of consulting physicians. All sites shipped the prescription directly to the purchaser. Site Classification We categorized Web sites into two groups based on willingness to dispense pharmaceuticals with or without a prescription, requirements for a physician consultation, and specified geographic location (based in the United States or based outside the United States). Sites That Required a Prescription or Consultation Thirty-three U.S. sites and 4 international sites (total, 80.4%) required a prescription from a personal physician or an online physician, with whom a consultation could be obtained for a separate fee. Prescriptions could be mailed or faxed, or the Internet site would contact the patient's personal physician directly if the patient agreed. The medication was dispensed only after receipt of a prescription and payment. The online consultation included a general and diagnosis-specific medical history (the latter was focused on the medication requested), concomitant medication use, and a waiver stating that the patient agreed not to hold the company liable for adverse outcomes. The patient was required to provide the number of a valid credit card. Consultation was purportedly with a physician; disclaimers noted that physicians may not reside in the same country as the patient or the firm selling the pharmaceuticals. All suppliers in this category notified the patient by e-mail of the results of the consultation and confirmed whether the specific prescription could be purchased. No information was available on physician name, specialty, location, or qualifications. Among the U.S.-based sites, prescriptions could be refilled twice, after which another physician consultation was required. Prescriptions could be used to purchase the desired medication from the Web site, from any other Web site, or from a personal pharmacy. Web sites that were based outside the United States did not provide prescriptions that could be used outside their site and did not permit prescription refills. No sites charged for the consultation if the person was denied a prescription for a requested medication. Among U.S. providers, all of which required a prescription or physician consultation, 22 sites sold sildenafil only; 2 sold finasteride only; 4 sold sildenafil and finasteride only; and 5 sites offered sildenafil, finasteride, loratadine (Claritin, Schering, Kenilworth, New Jersey), celecoxib (Celebrex, Searle, Skokie, Illinois), valacyclovir (Valtrex, Glaxo Wellcome, Research Triangle Park, North Carolina), bupropion (Zyban, Glaxo Wellcome), anabolic steroids, and birth control pills. All 4 international sites (3 in the United Kingdom and 1 in New Zealand) required physician consultation or medication prescriptions. However, their prescriptions were filled in the host country and could not be filled at a U.S. pharmacy or on another Web site. These four sites sold only sildenafil, finasteride, celecoxib, and orlistat (Xenical, Roche, Nutley, New Jersey). International Freelance Nine Web sites (19.6%), all outside the United States, were categorized as international freelance sites. None offered physician consultations, and none required a prescription from a personal physician. None would reveal their geographic location beyond that given on their Web site. One site was based in Hong Kong and sold fluoxetine (Prozac, Dista, Indianapolis, Indiana), valacyclovir, and orlistat; the latter agent was not approved by the U.S. Food and Drug Administration (FDA) for marketing in the United States during the study period. One site, whose location was unknown, shipped medications from Canada directly to U.S. customers. This site sold fluoxetine, valacyclovir, orlistat, amoxicillin, finasteride, sildenafil, loratadine, bupropion, sibutramine (Meridia, Knoll Pharmaceuticals, Mount Olive, New Jersey), simvastatin (Zocor, Merck), and anabolic steroids. One site based in Gibraltar and one site based in Switzerland sold only sildenafil. Two sites based in New Zealand sold sildenafil and orlistat; one also sold loratadine. Of three sites based in the United Kingdom, two sold only sildenafil and one sold only finasteride. Cost Comparisons All comparisons of per pill price were based on the same dose. Among the 37 sites selling sildenafil, the median per pill price was $5.49 (range, $4.50 to $28.40) plus shipping costs. Among Philadelphia-area pharmacies, the median per pill price was $4.50 (range, $4.30 to $6.45). Among the 16 Internet sites offering finasteride, the median per pill price was $1.94 (range, $1.55 to $5.20) plus shipping costs; among Philadelphia pharmacies, the median price was $1.83 (range, $1.55 to $1.95). On average, these two medications were about 10% more expensive when they were obtained from a Web site than from a local pharmacy. Shipping costs, which averaged $18 among U.S.-based Web sites and varied from $8 to $25 among Web sites based outside the United States, further increased the cost of medications obtained over the Internet. Internet physician consultation fees ranged from $20 to $90 (median price, $70). This fee was 16.7% higher than payment by Medicare or local managed care organizations for a primary care visit in the Philadelphia area ($60). Geographic location of the company that maintained the Web site, when known, had little effect on prescription prices, and the cost of physician consultations was slightly, but not consistently, lower for firms outside the United States. Discussion The Internet holds great promise for improving access to and quality of health care while reducing its cost. The popular press contains increasing discussion of use of the Internet to obtain medical services, but little empirical research about its effects has been published. As this study showed, access to the Internet can allow easy access to pharmaceuticals and physician consultations. Patients do not need to wait for an appointment with a physician or incur the expense of traveling to a physician's office. They can also minimize the social discomfort associated with use of certain medications, need not lose time from work or other normal activities, and do not have to spend time purchasing the medication from the pharmacy. Pharmaceuticals and physician consultations can be purchased 24 hours per day, 7 days per week. Furthermore, patients can obtain medications that are not available in the United States or are not approved by the FDA. Of note, U.S. consumers seem to be the primary target of international Internet pharmaceutical providersall prices were quoted in U.S. dollars. However, improved access to health care through the Internet comes at increased cost to the patient; this cost is almost never reimburse