A few minutes of your time and about $100 gets you certified for Missouri’s medical marijuana program. A clinic near St. Louis even offered a “Pot of Gold Legalization” discount for St. Patrick’s Day. Don’t want to leave your house? Try an online appointment, no medical records needed.
Missouri’s fledgling program, approved by voters in 2018, is under an intense amount of scrutiny — and not just by lawmakers. Physicians themselves are concerned about loopholes like telemedicine and a lack of oversight when it comes to certifying patients for pot.
“If this is how we're going to prescreen folks and allow them to obtain their card, just skip the formality and let's just go to recreational, let everybody get it, because in essence, that's where really where we are at this point,” said Dr. George Edwards, who certifies patients in Independence.
In the 33 states that have legalized medical marijuana, there’s a wide variety of approaches to oversight. And while the head of Missouri’s medical marijuana program said he started hearing from doctors about all of this in the fall, the state waited until February to draft rules that would allow the department to investigate physicians and suspend the ability to certify.
‘That opens a door for fraud’
More than 41,000 Missourians have a medical marijuana card. Amendment 2, which legalized pot for medical use, spelled out the qualifying conditions but let the newly created agency, Section for Medical Marijuana Regulation, figure out the exact certification process.
In order to get a card, a patient must have a physician with a Missouri license that’s in good standing signoff on a certification form. The form asks physicians to identify the qualifying condition, which includes cancer, epilepsy and PTSD, or “any other chronic, debilitating or other medical condition” a doctor cites.
The state’s certification form also requires a physician to review a patient’s medical records or medical history.
Dr. Lisa Roark runs Roark Family Health and Medical Spa in Cassville, in the southwest corner of the state. She asks only for a patient’s medical history, because, in her experience, reviewing documents meant sorting through “thousands of pages” of records. And patients sometimes had difficulty getting them.
Even if a patient is a child, she said she doesn’t need to see the documentation.
“If a parent needs me to review their records, and I absolutely will, but I don't need them to prove it,” Roark said. “I just need to take a thorough medical history.”
A “thorough medical history,” according to Roark, entails asking patients what medication they’re on, medicine they’re allergic to, surgeries they’ve had, medical conditions they’ve been diagnosed with (and for how long), medication they’ve tried in the past and current symptoms.
Roark said she isn’t concerned her method of certifying patients opens the door to recreational use.
“I don't believe there's such a thing as recreational use,” Roark said. “I believe anyone who's using cannabis, they're using it for a medical reason. And that might be they have anxiety and they use it to calm down, or they have difficulty sleeping, so they use it to help them sleep.”
That worries Emily Branch, who at one time oversaw seven certifying clinics across Missouri. Less than a year after opening the first clinic in Kansas City’s River Market, Branch shut everything down, saying she couldn’t compete with doctors rubber-stamping certifications.
Branch also pointed the finger at state officials for allowing doctors to review either medical records or medical history.
“I believe that they should only have to review medical records because how can you tell if someone has glaucoma? They're going to tell you? They're going to be honest?” Branch said. “That opens a door for fraud.”
Lyndall Fraker, who’s in charge of the state’s program, said Missouri doesn’t want to get in the middle of a doctor-patient relationship.
“It is that doctor’s opinion. They could be a brand new patient and that doctor would have to diagnose that patient as a new patient,” Fraker said, noting that the state held a number of public forums for input on the rules. “As far as us having to demand that they look at any kind of a document, I don't believe that's part of the rules.”
One doctor gives the state the “benefit of the doubt” when it comes to certifications. But there are things he’d like to see changed, and sponsored a bill to do just that.
“If this is a medical marijuana program, we should do it in a way that's recognized by how we practice medicine,” GOP state Rep. Jon Patterson of Lee’s Summit said. “Seeing the patient history, physical examination, documentation and doing things in the right way. As opposed to talking with someone over the phone, taking a phone survey and then sending them a certificate after they pay the fee.”
Telemedicine’s next frontier
One of the central complaints from doctors is telemedicine, which according to the state’s website can be used as long as the “standard of care does not require an in-person encounter.”
The state decided telemedicine was OK after checking with the Missouri Board of Registration for the Healing Arts, which oversees the physician’s medical licenses. Fraker explains: “Our position is that — which we got clarification from the Board of Healing Arts early on — if telehealth was sufficient or adequate for an exam in other areas, then it should be adequate for an exam with medical marijuana,” Fraker said.
The certification form requires a physician to have “met with and examined the qualifying patient.” The state doesn’t track if a certification is done in-person or using telehealth.
Dr. Marc Taormina, who certifies medical marijuana patients in Lee’s Summit, interprets that language as an in-person examination.
“I think it should be fairly clear to physicians that the use of telemedicine should not be allowed for certification process,” Taormina said. “It's clear on the form that a physical examination needs to be performed and I can't imagine how that is able to be documented through a telemedicine platform.”
Patterson also is pushing for visits in person, partially because marijuana is still classified federally as a Schedule I drug (the U.S. Drug Enforcement Administration says it’s not “currently accepted medical use,” has a “high potential for abuse”).
“Things like Vicodin and narcotics are Schedule II drugs. You cannot call someone on the phone a physician on the phone and say, ‘I have this ailment, please send me a prescription for Vicodin,’” Patterson said. “So it does not make sense that you could call someone on the phone or be on a tele-exchange with a physician and they send you a Schedule I drug.”
An amendment made it into a bill in late February dealing with background checks in the medical marijuana program that would have required in-person examinations. But it was taken out by the House Administrative Oversight Committee over concerns it would hurt patient access, according to Patterson.
But with many major hospitals reluctant to have their doctors certify patients, some advocates say allowing telehealth helps make sure everyone can access medical marijuana. Roark noted that telemedicine is one of the only ways to reach people in rural areas like she’s in.
“I've had, for instance, a toddler who cannot be under fluorescent lights. So the mother had a lot of difficulty even bringing him into anyone's office,” Roark said. “... So when I told her that, we can do the evaluation via telehealth she literally cried because it was such a relief to her to not have to worry that her child was going to have seizures in order to just get his certification.”
No database for physician certifications
Missouri is a late adopter of medical marijuana in the U.S., and there is no one standard for how to handle oversight when it comes to certifications. A handful of states require doctors to go through a short training program about medical marijuana. Some states keep a list of physicians who are certifying people.
All Missouri does is check to make sure the physician’s license is in good standing. If a physician is under investigation or is certifying hundreds or thousands of people for the same condition, it does not raise a red flag with the department.
By contrast, Oregon requests additional records for any physician who recommends medical marijuana to more than 450 patients, according to Megan Lockwood with the state’s program.
“A physician who reaches this threshold must submit to the Oregon Health Authority, along with the required attending physician statement, proof that he or she has reviewed a patient's medical record,” Lockwood said. “They've conducted a thorough physical exam, and they provided a planned follow up care and that they've documented these activities within the patient's medical record.”
Taormina of Lee’s Summit said Missouri is falling short — “I don't think there's any oversight by the state.” — adding that he wants the state to make physicians take a two-hour course on medical marijuana and stop allowing telemedicine.
Missouri is looking to beef up its oversight: The department proposed new rules in February which would allow the department to investigate a physician and, if needed, suspend a physician’s ability to certify.
It comes after Fraker said he was made aware of concerns about “group examinations,” including an allegation that Dr. Zinia Thomas certified groups of patients during “cannabus” stops across the state and via teleconference. Thomas, who is based in Brentwood, did not respond to a KCUR interview request.
Fraker was interviewed about the allegation in October and was sent undercover video in December, according to an email obtained by KCUR.
“That's her license that’s on the line and she's gonna have to be responsible for that and in her practice and answer for that,” Fraker said.
There is no timeline for implementing the proposed rules, Fraker said. And, unlike some of their colleagues, not all physicians believe medical marijuana certifications need increased oversight.
“We’re 100% responsible for any decision we make,” Roark said. “And if we make the wrong decision, then we face losing our license.”
Aviva Okeson-Haberman is the Missouri government and politics reporter at KCUR 89.3. Follow her on Twitter: @avivaokeson.
