The Recurring-Revenue Incentive Problem
When the Business Model Rewards Prescribing
Evidence grade 3 of 5, Mixed. Read how the Atlas grades evidence.
The written rationale for this grade is still being prepared.
- FDA
- Testosterone is a controlled substance; the concern is the prescribing-incentive structure, not a regulatory status
Reference only. Not medical advice.
What can go wrong
The incentive can lead to prescribing for men without genuine hypogonadism or with contraindications (e.g., fertility goals), exposing them to fertility suppression, polycythemia, and cardiovascular monitoring needs. Continued prescribing without adequate monitoring is the downstream clinical risk.
This is something to take to a clinician. The Atlas can tell you what is known about the recurring-revenue incentive problem in general. It cannot tell you what is happening in your body, and the difference matters most for exactly the symptoms that bring people to this page.
The defining structural concern of TRT telehealth is that revenue recurs monthly, through subscription fees, marked-up medication, and monitoring charges, only as long as the patient stays on therapy. This creates a financial incentive to start and continue prescribing. The Dubin mystery-shopper study (data 2022; published JAMA Internal Medicine 2023), in which 6 of 7 clinics offered testosterone to a patient with normal testosterone who wanted future fertility, is the most-cited evidence that this incentive can override appropriate gatekeeping.
A subscription only earns while the prescription continues.
What people take it for
These are the reasons people give for taking it. They are not effects it has been shown to have.
How it is supposed to work
Subscription businesses maximize lifetime value by maximizing the number of paying months. In TRT, the paying months equal the months a patient is on therapy, so the model financially rewards initiating prescriptions and discourages discontinuation.
The conflict, stated plainly
A platform that earns only while a patient is prescribed has a financial reason to prescribe and to keep prescribing. Independent gatekeeping, declining inappropriate candidates, deprescribing when indicated, directly reduces revenue. The Dubin finding (a guideline-discordant prescribing offer in 6 of 7 clinics) shows this is not merely theoretical.
Safety in detail
TRT requires independent clinical judgment, appropriate candidate selection, and ongoing monitoring. A model that profits from prescribing should be evaluated for whether its gatekeeping is genuine.
What it does to fertility
Inappropriate prescribing under this incentive can expose fertility-seeking men to spermatogenesis-suppressing therapy, the exact failure mode the Dubin study probed (a normal-testosterone patient who stated he wanted children).
What has to be monitored
The bloodwork this needs, and the reason it belongs with a clinician rather than a website.
- Appropriate baseline workup
- Total/free testosterone
- Hematocrit
- PSA (age-appropriate)
- Estradiol
- Documented reassessment of continued need
What people get wrong
Often saidTelehealth doctors have no incentive to over-prescribe
ActuallyIn a subscription model, revenue continues only while the prescription does, creating a documented financial incentive to start and continue therapy.
Who profits, and who pushes back
Justin Dubin, MD
Six of seven online TRT clinics were willing to prescribe testosterone to a mystery shopper with normal testosterone who wanted to have children, a scenario in which guidelines advise against testosterone.
Every actor paid per active subscriber month, platform, pharmacy, monitoring service, and per-insertion provider, benefits from prescriptions continuing.
At a glance
- Revenue type
- Recurring subscription
- Incentive direction
- Toward starting and continuing prescriptions
- Key evidence
- Dubin (JAMA Intern Med 2023): 6 of 7 clinics offered to prescribe to a normal-testosterone patient seeking fertility
- Amplifiers
- ~50x medication markup; monitoring fees
What this entry does not yet cover
What follows is unfinished work on our side, not a finding about The Recurring-Revenue Incentive Problem. A short entry is not a safe entry.
- Timeline. We have not built the dated record of research and regulatory events.
- Cost and market. We have not documented what it sells for or who sells it.
- Supply chain. We have not mapped where it is made.
- Who uses it. We have not documented the user groups.
- What could change. No forward-looking summary yet.
- How it compares. We have not set it against the alternatives.
- Children and teenagers. We have not checked what is known about younger people.
Sources
No sources recorded for this entry yet. Nothing on this page can be checked against a citation until that changes, so treat it as a summary awaiting its evidence.