The following story was written and reported by The Utah Investigative Journalism Project in partnership with The Park Record.
During the first year of Utah’s medical cannabis program, several clinics sprouted to help patients get the required card that allows them to purchase products from the state’s seven dispensaries.
But some worry that these businesses simply serve as “card mills” that overcharge patients but fail to deliver key services. They also blame state lawmakers for designing a program that drives up patient costs.
In 2020, patients could use letters of recommendation from their doctors to buy medical cannabis — a temporary bridge as Utah’s card system got fully implemented. But as of Jan. 1, 2021, these letters no longer work.
Dr. Andrew Talbott, a pain management specialist in Park City, wrote letters of recommendation for some of his patients last year so they could access Utah’s medical cannabis products. But he was taken aback when a Green Health Docs clinic contacted him asking for a patient’s specific diagnosis.
“They said they don’t make diagnoses, they certify patients with existing diagnoses for cannabis,” Talbott said.
His reply? “The patient’s paying $200, what is that money for?”
“We had a very tenuous back and forth about this, and they got upset and finally said that no one’s given us this hard of a time before,” Talbott said.
The Green Health Docs website lists a $200 fee for a patient’s initial 10-minute consultation, which includes help with the card application process. At 90 days, the patient pays another $50 for a 10-minute card renewal visit, and six months later another $150 for their third card renewal visit.
“A 10-minute visit is not enough to make an assessment, to counsel a patient appropriately on cannabis, and to also get them signed up,” Talbott said. “It’s really not doing any service for the patient.”
According to greenhealthdocs.com, the company operates clinics in 15 states, with two locations in Utah so far. Empathetix, a competitor, has clinics in Logan, Millcreek, Ogden, Payson, Provo, Salt Lake City and Spanish Fork. Empathetix charges $220 for the initial consultation, and $175 at the six-month visit.
Christine Stenquist, who founded TRUCE Utah (Together for Responsible Use and Cannabis Education) and pushed to get Utah’s Medical Cannabis initiative on the 2018 ballot, decried the changes state lawmakers made to the measure voters had approved.
“Legislators created this type of environment,” Stenquist said, noting her voter-approved bill had patients establishing relationships with their physicians. “You cannot do that in a 10-minute visit. And certainly not by asking another doctor for their homework to copy.”
Richard Oborn, director of the Utah Department of Health’s Center for Medical Cannabis, said that over 17,500 Utahns obtained medical cannabis cards last year.
In 2017, Dr. Anand Dugar — an anesthesiologist and pain management specialist — launched his first Green Health Docs clinic in Frederick, Maryland. He saw medical cannabis as a safer, more beneficial alternative to opioids.
“I knew that the way we were doing things with pain pills and pain injections wasn’t really sustainable and patients couldn’t tolerate this forever,” Dugar said. “And I began looking for different ways that were less harmful.”
Over the past four years, demand for medical cannabis fueled his company’s growth and expansion.
When asked about the 10-minute appointment slots, Dugar said he doesn’t charge a cancellation fee, and often only one in three appointments actually show up.
“So we do it so we can maximize the schedule. But in reality, the time is usually 30 to 45 minutes,” Dugar said. “For now, we just want to be accessible and make it easy for everyone to get in. But once they’re there, we want to make sure they get all their questions answered.”
But much of the cannabis education happens at the dispensary, he added.
“Truth be told, we’re not prescribing particular strains. For the most part, we’re approving them for cannabis and at the dispensary they’ll have to try different things to figure out what works best for them,” Dugar said.
For half a century, cannabis has been categorized as a Schedule 1 drug at the federal level, making it illegal to buy, sell and use. However, by November 2020 all but six states had legalized cannabis use in some form.
Therefore, insurance doesn’t cover the services Dugar’s clinics provide, nor the dispensary products.
“It’s not a reimbursable visit code. You can’t code for medical cannabis evaluation. That doesn’t exist,” Dugar said.
Shane Ericksen, founder of Empathetix, said that a patient will meet with their Qualified Medical Provider (QMP) for 10 to 15 minutes, and then it takes another half hour or so to help them navigate the Utah Department of Health’s online application process.
And because insurance doesn’t cover their services, Ericksen said they recommend that patients maintain care with their primary physician, but “just use us as their cannabis referral service, and use our QMPs for their cannabis renewals which are every six months.”
But he agreed that most cannabis education falls to the pharmacists “who are in the best position to recommend specific products for specific conditions.”
Utah’s medical cannabis law requires a medical professional take a four-hour online course and register with the state to become a QMP. Most QMPs are capped at 275 active cannabis patients, but for board-certified specialists, that cap can expand to 600.
Oborn, of the Utah Department of Health, said that QMPs are tasked with diagnosing patients with qualifying conditions during in-person visits, and then with logging on to the state’s electronic verification system and certifying a patient’s use of medical cannabis.
The health department began registering QMPs in March 2020 and by year’s end they totaled 570, the bulk of whom fall under the lower cap.
Rep. Ray Ward, R-Bountiful, periodically helps make the legislative sausage, but mostly he works as a family physician. In 2020, he went through the training to become a QMP.
For doctors such as himself who become QMPs and are willing to work with their patients on cannabis, he believes those office visits should be covered by insurance “the same as any other office visit,” Ward said.
“There are other clinics who all they want to do is recommend cannabis to people. They have no interest in going through insurance and therefore they run on a cash pay basis,” Ward said. “That’s their choice and the choice of patients who go to them.”
For those clinics that do spend only 10 minutes per patient, Ward said that runs at cross purposes with the Legislature’s intent.
“We tried to make the law so we wouldn’t get those clinics, but the private market is always a little bit more nimble than government at finding those loopholes,” Ward said.
But Ward believes there’s a better option than clamping down on these businesses.
“To me, the better solution would be to make it easier for physicians’ offices to do this, with the hope it would put these guys out of business, because the patient could get better service in their primary care office,” Ward said. “So that’s my hope for (this year’s legislative) session.”
Ward’s office staff shouldered the task of navigating the health department’s registration system for his patients who needed medical cannabis cards. And at first they encountered a steep learning curve.
“It’s a complicated process,” Ward said. “After having five bad experiences, we now have a couple of staff people who are very good at that. We’re happy enough that we’re doing it and it’s not a problem.”
But for an 80-year-old patient, even the initial log-in could be a roadblock, Ward added.
Since becoming a QMP, Ward said he’s learned a lot about medical cannabis.
“You do the little state CME course … and then most of your education comes from other providers, hearing their experiences, looking at studies on your own, working with patients and seeing how it did for them,” Ward said. “And that’s not that different from other medicines.”
Dr. Corey Anden, an Ogden-based board-certified doctor who specializes in sports medicine and non-surgical orthopedics, posted a “Respect the Plant” blog on her website coreyandenmd.com/blog/ that hints at her extensive knowledge of cannabis.
She’s also pursuing a master’s degree in medical cannabis science and therapeutics from the University of Maryland to learn more about the complex, plant-based medicine.
Over her 32 years of practicing medicine, Anden said she grew increasingly concerned about extensive use of opioids and other medications that have adverse side effects.
“It seemed like a more organic approach would be good,” Anden said, adding that “nobody dies from cannabis, but lots of people are dying from opioid abuse or overdosing.”
Anden became a QMP in 2020, but said she actually began discussing cannabis with patients shortly after the ballot initiative passed in 2018.
While she can diagnose patients for chronic pain, Anden said that other qualifying conditions (such as autism, cancer, Crohn’s disease and PTSD) would have to come from specialists in various fields.
“Patients would need to bring medical records that confirm those diagnoses. But anything musculoskeletal or pain related, I’m quite comfortable making those diagnoses,” Anden said.
As a QMP, Anden said she spends a lot of time educating patients about cannabis, so people can have success when they purchase the products.
“Insurance doesn’t cover this, so it can be expensive. I want people to purchase the correct product and not waste money buying things that aren’t right for their condition,” Anden said.
And her staff also spends significant time helping patients navigate the health department’s application process in order to obtain and renew their cards.
“That is not a simple thing, it’s not like ordering something on Amazon,” Anden said, noting it can take up to an hour per patient.
While insurance covers her other services, Anden’s initial cannabis evaluation sessions cost $300 out of pocket, which covers the examination, education, her recommendation, how to use cannabis and helping patients get their cards.
“Insurance doesn’t really want to hear anything about that because cannabis is still federally illegal and still categorized as a Schedule 1 drug under the Controlled Substances Act,” Anden said.
Because cannabis is plant based, Anden doubts insurance companies will change, because “they don’t cover vitamins and supplements … if it’s not a pill, it doesn’t really fit into the medical insurance paradigm as it is at present.”
But she believes the $300 charge is justified.
“I need an office and office staff. Nobody can do this without charging a fee,” Anden said.
In the upcoming legislative session, two Utah lawmakers expect to make some changes to the state’s medical cannabis program.
Sen. Evan Vickers, a pharmacist from Cedar City, played an instrumental role in shaping the current program. In November he told members of the Health & Human Services Interim Committee that several stakeholders came together to help resolve various issues.
While there is no current plan to increase QMP patient caps, they will recommend allowing other non-QMP physicians a cap of 15 medical cannabis patients.
“This would allow the patient to stay at home with their practitioner, and would allow that practitioner to at least get their toe wet and see how it works for their patient, and see if they have a desire to go beyond that and become a QMP,” Vickers said.
Another recommendation that could be implemented in the second half of 2021 would be to have the state health department transfer cannabis dispensing data to the controlled substance database when a software update becomes available.
But that recommendation got pushback from patients.
“There’s been some reluctance and sometimes emotional feeling about it. … They didn’t want that data available because of some fears,” Vickers said.
Outdoor signage cleanup is also planned, to make sure “signs are professional and pharmacy looking, and not recreational,” Vickers said.
Dosing guidelines could be clarified as well, so physicians and QMPs can utilize and delegate those tasks to the pharmacy.
“We’re finding that those pharmacists … are becoming the experts in the field,” Vickers said, noting that has always been the intent.
Sen. Luz Escamilla, D-Salt Lake City, also plans to sponsor legislation to add some consumer protections.
“We’re hearing of more patients that are seeing charges of between $300 and $600 to get a letter,” Escamilla told committee members in November.
As for Anden, she believes several things need to be fixed.
“I’m not sure why the state has this cap on the number of patients a physician can treat,” Anden said, referring to the 600 ceiling for a board-certified QMP. “I don’t see opioid prescribers having a limit, so I’m not sure why a practitioner who specializes in medical cannabis — a substance that never killed anyone — should be limited.”
She also has concerns about the Jan. 1, 2021, cutoff for Utah’s patients to legally purchase out-of-state products.
“In Utah the cultivators and pharmacies aren’t completely up to full speed so they don’t have a lot of product or the variety that’s available in our border states,” Anden said, noting that would mean patients would no longer have access to the product they’ve found works for them.
Anden said she knows of no other state that has that regulation.
She also believes that some of Utah’s legislatively approved medical cannabis products are actually more recreational than medical.
“Like the very potent, high THC percent vape cartridges and pens,” Anden said. “What I’d consider more medical use would be cannabis products that have more balance of other cannabinoids other than just high THC products.”
But her past efforts to inform lawmakers fell on deaf ears, Anden said.
“They’re not reaching out to the boots on the ground to know what’s actually going on,” Anden said. “They’re too busy making rules and regulations that don’t make any sense.”