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

Abstract

This qualitative study of online vouchers for discounted DTC imaging services reveals consumerization of medicine and calls for regulations to balance convenience and cost with patient safety and physician oversight.

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 1^4,5). 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.

Table 1. Characteristics of Direct-to-Consumer Medical Imaging Services Marketed and Sold by 84 Companies via Groupon Vouchers, February 6, 2020.

Groupon vouchers issued for imaging services	No. (%)	Average price, $		Discount (% off retail)	Vouchers sold, No. (%)
		Vouchera	Retailb
Total	130 (100)	107	286	63	>28 380 (100)
CTc	9 (6.9)	151	639	76	6390 (22.5)
Combination of CTsc	3 (2.3)	95	1569	94	5330 (18.8)
MRIc	2 (1.5)	687	2000	66	NA
Radiographyc	3 (2.3)	115	291	60	NA
Ultrasonography (other than fetal)c	8 (6.2)	107	222	52	20 (0.1)
Fetal ultrasonographyc,d	37 (28.5)	69	124	44	10 480 (36.9)
Mammographyc	2 (1.5)	199	449	56	110 (0.4)
DEXAc	21 (16.2)	99	279	65	5230 (18.4)
Body or biofeedbacke	22 (16.9)	60	126	52	430 (1.5)
Multiple body or biofeedback	11 (8.5)	65	130	50	240 (0.8)
Thermography	9 (6.9)	244	370	34	30 (0.1)
Other (hair, retina)c	3 (2.3)	131	368	64	120 (0.4)

Abbreviations: CT, computed tomography; DEXA, dual-energy x-ray absorptiometry; NA, not available; MRI, magnetic resonance imaging.

^aAverage price of the Groupon offer.⁴

^bAverage retail price for the imaging service, based on the vendor or manufacturer’s suggested retail price or price offered by another retailer.⁴

^cMay require an order from a licensed health care professional; regulations vary by state and type of imaging service.

^dFetal ultrasonography may be purchased for nonmedical reasons, eg, prenatal fetal portraits.

^eIncludes 3-dimensional full-body scanning services and biofeedback scanning modalities, which may include surface electromyography, respiration rate and depth, skin surface temperature, cardiovascular reactivity, and electrodermal response.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.

Table 2. Themes and Examples of Claims Made by Companies Marketing and Selling Discounted Imaging Services via Groupon Vouchers, and Related Customer-Patient Reviews.

Topic	Company advertisement (n = 84)	Consumer review (n = 2044)
Consultation	Consultation required, n = 57 (67.9%) “Consultation required, noncandidates will be refunded.” (MRI)	Consumer deemed a noncandidate after preimaging consultation, n = 2 (0.1%) “After I went there, they told me I had to go and see doctors which they would not cover.”
		Consumer noted helpfulness of consultation, n = 4 (0.2%) “The consultation was very thorough, but it took much longer than they had told me. I was in the office a total of one hour and 45 minutes. The scan took less than 10 minutes. I appreciate all the great information given to me, but I did not budget that much time.”
		Consumer noted unhelpfulness of consultation, n = 4 (0.2%) “The scan was awesome, but my husband didn't like the way they try to scare you into buying a full body scan and then as if that wasn't enough they try to get you to buy these huge packages. I would have gone for it, but he didn't like that. So, the hour consultation is nothing but trying to get you to buy more!”
Medical claims	Made unsubstantiated medical claims, n = 38 (45.2%) “Both safe and fast…the automated diagnostic equipment does not employ harmful radiation or uncomfortable breast compression. It can also see through dense breast tissue, resulting in a 90% cancer-detection sensitivity compared to 38% with mammography. And with no known side effects, the technology helps women of all ages walk out of the clinic free of pain and stress…” (breast thermography)	Consumer claimed imaging service was accurate, n = 9 (0.4%) “…[I]t turned out to be 100% accurate.”
	Claimed service can help prevent disease, n = 8 (9.5%) “[A] CT heart scan shows even the smallest coronary calcification in the heart, helping to prevent heart disease...[and] predict future heart attacks.” (CT)	Consumer claimed imaging service was inaccurate, n = 5 (0.2%) “We had a great experience with our son in 2017, but I bought the Groupon with this pregnancy and was told the wrong gender. We found out the correct one at my actual OB appt a month later. Really thankful we didn’t have a gender reveal party planned this time.”
	Claimed service can help estimate risk of developing disease, n = 8 (9.5%) “Noninvasive screening designed to determine a person's risk for developing breast cancer.” (breast thermography)
Risks	Risks of services outlined in Groupon voucher description, n = 1 (1.2%) “While it scans bodies, it exposes patients to the same minimal radiation as a mammogram.” (CT)	NA
Upselling	NA	The company tried to sell additional products/services to the consumer, n = 90 (4.4%) “Don't spend your time and money, after an hour talking about what you need to take care of your health, they want to sell you a scan of the whole body for almost 5000 dollars.”
		The seller did not try to sell consumer more products/services, n = 13 (0.6%) “Does not pressure you into buying other tests or services.”
Motivations	NA	Consumer was self-motivated to purchase imaging service, n = 25 (1.2%) “I got this for ‘maintenance’ for my husband and myself. My husband found he had a ’widow maker’ in his heart. He has now had triple bypass surgery and is doing terrific!! We are so blessed to have had this procedure done. It saved his life. Thank you.”
		Consumer pursued additional testing/scans/interventions or indicated willingness to return for additional visits, n = 341 (16.7%) “I have this Groupon to thank for not having a heart attack and maybe my life. I need 3 stents set for the end of this month. Best $$ I ever spent.”

Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; NA, not applicable.

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.