Assessment of Sales and Marketing of Online Vouchers for Discounted Direct-to-Consumer Medical Imaging Services | Health Care Safety | JAMA Internal Medicine | JAMA Network
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Table 1.  Characteristics of Direct-to-Consumer Medical Imaging Services Marketed and Sold by 84 Companies via Groupon Vouchers, February 6, 2020
Characteristics of Direct-to-Consumer Medical Imaging Services Marketed and Sold by 84 Companies via Groupon Vouchers, February 6, 2020
Table 2.  Themes and Examples of Claims Made by Companies Marketing and Selling Discounted Imaging Services via Groupon Vouchers, and Related Customer-Patient Reviews
Themes and Examples of Claims Made by Companies Marketing and Selling Discounted Imaging Services via Groupon Vouchers, and Related Customer-Patient Reviews
1.
Illes  J, Kann  D, Karetsky  K,  et al.  Advertising, patient decision making, and self-referral for computed tomographic and magnetic resonance imaging.   Arch Intern Med. 2004;164(22):2415-2419. doi:10.1001/archinte.164.22.2415PubMedGoogle ScholarCrossref
2.
O’Malley  PG, Taylor  AJ.  Unregulated direct-to-consumer marketing and self-referral for screening imaging services: a call to action.   Arch Intern Med. 2004;164(22):2406-2408. doi:10.1001/archinte.164.22.2406PubMedGoogle ScholarCrossref
3.
Weber  L. Groupon for medical scans? discounted care can have hidden costs. National Public Radio. Published September 5, 2019. Accessed March 19, 2020. https://www.npr.org/sections/health-shots/2019/09/05/757708356/groupon-for-medical-scans-discounted-care-can-have-hidden-costs
4.
Groupon Inc. Frequently asked questions. Accessed May 5, 2020. https://www.groupon.com/faq
5.
McKee  MG.  Biofeedback: an overview in the context of heart-brain medicine.   Cleve Clin J Med. 2008;75(suppl 2):S31-S34. doi:10.3949/ccjm.75.Suppl_2.S31PubMedGoogle ScholarCrossref
6.
Spector-Bagdady  K.  Reconceptualizing consent for direct-to-consumer health services.   Am J Law Med. 2015;41(4):568-616. doi:10.1177/0098858815622191PubMedGoogle ScholarCrossref
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    Research Letter
    Less Is More
    November 2, 2020

    Assessment of Sales and Marketing of Online Vouchers for Discounted Direct-to-Consumer Medical Imaging Services

    Author Affiliations
    • 1Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Tufts University School of Medicine, Boston, Massachusetts
    • 3Boston University School of Medicine, Boston, Massachusetts
    • 4Vanderbilt University, Nashville, Tennessee
    • 5Harvard Medical School, Boston, Massachusetts
    JAMA Intern Med. 2021;181(2):267-269. doi:10.1001/jamainternmed.2020.3529

    The expansion of the direct-to-consumer (DTC) medical imaging market elicits several safety and ethical concerns.1 Discounted DTC imaging may lead to unnecessary testing and subsequent incidental findings, false-positive results, radiation exposure, and downstream interventions.2 Groupon, Inc, a global e-commerce marketplace, has garnered media attention for its vouchers for discounted DTC medical imaging services.3 In this study, we evaluated the scope, pricing, customer feedback, and claims of medical imaging services offered through Groupon vouchers.

    Methods

    We performed a cross-sectional analysis of Groupon offerings in the US on February 6, 2020. On the Groupon home page, in the Imaging and Scans section (a subcategory of Health and Fitness/Medical), we identified nonduplicate and active vouchers offered in each of the 50 states and in each state’s largest city. Then we used Google to search the internet for the keywords, Groupon medical scans and each of the 50 state names.

    For each imaging-service voucher identified, we collected core metrics: type of imaging, price of service, retail location, company rating, and number of vouchers purchased per customer. For group discount offers, we calculated the unit price per individual. Each offer was assessed to determine whether the company had outlined potential risks, required a preimaging consultation, offered physician or technician interpretation of results, made unsubstantiated medical claims, or included disease prevention and risk estimation assertions. For each company offering a Groupon voucher, the first 100 customer reviews were assessed for comments about preimaging consultations, motivation(s) for purchasing imaging services, upselling, and/or additional testing. The Partners Healthcare Institutional Review Board waived review of the study as all data were publicly available on the internet.

    Results

    We found 84 companies offering Groupon vouchers for 130 different types of medical imaging and scanning services in 27 states. California (n = 10, 11.9%), Illinois (n = 9, 10.7%), Nevada (n = 7, 8.3%), and Georgia (n = 6, 7.1%) had the most vouchers available. At least 28 380 vouchers for imaging had sold by February 6, 2020, with computed tomography accounting for 11 720 (41.3%) purchases (Table 14,5). The average price per imaging service ranged from $60 for a body or biofeedback scan to $687 for magnetic resonance imaging. The average customer rating was 4.8 out of 5.

    Unsubstantiated claims were made by 38 (45.2%) of the 84 companies offering vouchers (Table 2). Only 1 offer mentioned the potential risks of imaging (Table 2). While 57 (67.9%) companies stated that a consultation would be required to assess the purchaser’s eligibility for imaging services, none mentioned this requirement in their other advertisements.

    An analysis of 2044 customer reviews found 90 comments (4.4%) suggesting that upselling of added imaging had occurred at the visit (Table 2). Of reviews that included a motivation for purchasing imaging services, 100% (25 of 25) of patients noted that they were self-referred.

    Discussion

    Discounted DTC medical imaging services marketed on Groupon increase price transparency for customers.4 Although legal, advertisements for DTC imaging may not accurately or adequately inform customers of the potential risks.1,6 Promotions highlighting unsubstantiated medical claims may lead customers to purchase unnecessary, potentially unsafe examinations. Groupon-initiated medical consultations with physicians who are unfamiliar with these patients are unlikely to provide unbiased and thoughtful guidance. Some patients’ review comments suggested that the consultation may have been an extended sales pitch (Table 2).

    Although free-market solutions can increase patient flexibility and curtail health care costs, consumer independence must be balanced with the potential for harm. None of the customers in this study indicated that they had been referred for imaging by a physician. The combination of patient self-referral, uncorroborated marketing claims, and upselling leads to a challenging consumerization of medicine that can put patient safety and benefit at odds with financial goals.

    These findings had some limitations and should be interpreted in the context of the study design. We could not completely determine patient characteristics or motivations, assess the quality of the imaging, verify sales, or evaluate the authenticity of reviews.

    Future studies should examine the appropriateness, accuracy, safety, and follow-up of DTC imaging services to determine their true benefit. Improved regulation of medical advertising is needed to reduce false claims and improve patient safety, thereby maximizing the benefits of DTC imaging services while minimizing the potential for harm.

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    Article Information

    Accepted for Publication: June 13, 2020.

    Published Online: November 2, 2020. doi:10.1001/jamainternmed.2020.3529

    Correction: This Research Letter was corrected on December 14, 2020, to indicate in the Results section that the total number of vouchers were sold by February 6, 2020, not February 6, 1990.

    Corresponding Author: Arash Mostaghimi, MD, MPA, MPH, Department of Dermatology, Brigham and Women’s Hospital, 221 Longwood Ave, Boston, MA 02115 (amostaghimi@bwh.harvard.edu).

    Author Contributions: Ms Desai and Dr Mostaghimi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: P. Manjaly, Lee, Li, Mostaghimi.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Desai, P. Manjaly.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Desai, Lee.

    Administrative, technical, or material support: Lee, Li, Mostaghimi.

    Supervision: Mostaghimi.

    Conflict of Interest Disclosures: Dr Noe reported grants from Boehringer Ingelheim outside the submitted work. Dr Mostaghimi reported personal fees from Pfizer Inc, 3Derm Systems Inc, and Hims Inc outside the submitted work and equity in Hims Inc and Lucid Dermatology. No other disclosures were reported.

    References
    1.
    Illes  J, Kann  D, Karetsky  K,  et al.  Advertising, patient decision making, and self-referral for computed tomographic and magnetic resonance imaging.   Arch Intern Med. 2004;164(22):2415-2419. doi:10.1001/archinte.164.22.2415PubMedGoogle ScholarCrossref
    2.
    O’Malley  PG, Taylor  AJ.  Unregulated direct-to-consumer marketing and self-referral for screening imaging services: a call to action.   Arch Intern Med. 2004;164(22):2406-2408. doi:10.1001/archinte.164.22.2406PubMedGoogle ScholarCrossref
    3.
    Weber  L. Groupon for medical scans? discounted care can have hidden costs. National Public Radio. Published September 5, 2019. Accessed March 19, 2020. https://www.npr.org/sections/health-shots/2019/09/05/757708356/groupon-for-medical-scans-discounted-care-can-have-hidden-costs
    4.
    Groupon Inc. Frequently asked questions. Accessed May 5, 2020. https://www.groupon.com/faq
    5.
    McKee  MG.  Biofeedback: an overview in the context of heart-brain medicine.   Cleve Clin J Med. 2008;75(suppl 2):S31-S34. doi:10.3949/ccjm.75.Suppl_2.S31PubMedGoogle ScholarCrossref
    6.
    Spector-Bagdady  K.  Reconceptualizing consent for direct-to-consumer health services.   Am J Law Med. 2015;41(4):568-616. doi:10.1177/0098858815622191PubMedGoogle ScholarCrossref
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