In an effort to help treat out-of-control and undiagnosed hypertension -- the second leading cause of death in the United States -- Las Vegas physician Kevin C. Petersen set up an Internet practice this past summer for uninsured patients around the country.
But his BPClinic.com could cost the doctor his license and result in a felony conviction that both lands him in the slammer and lightens his wallet.
"I don't look at myself as a criminal," he said. "This work is important. I believe I'm on the right side of things. Too many people can't afford to pay $100 or more for a doctor visit to get a prescription."
For what he calls blood pressure treatment on a limited budget, Petersen charges a $50 fee for a blood pressure prescription that includes online and phone consultations with patients.
"If he's prescribing medication to someone he has not examined (in person), it's illegal," said Douglas Cooper, executive director of the Nevada State Medical Board. "The state statutes are clear. They're there because it's dangerous to not physically examine someone before giving medication. You could be dealing with something other than high blood pressure, which is just a symptom of something more serious."
Yet when Petersen reads the state statute, NRS 453.3643, he thinks it applies only to controlled substances such as prescriptions for addictive drugs for pain and to doctors prescribing medications through illegal Internet pharmacies.
"I did a little research of my own, because I do not want to be in flagrant violation of the law even if what I am doing is good," Petersen said as he sat in his office near Summerlin Hospital. "Chapter 453 covers controlled drugs which bp (blood pressure) medications are not. Second, NRS 453.3643 applies to illegal Internet pharmacies."
That's not how Carolyn Cramer, general counsel of the Nevada State Board of Pharmacy, reads the statutes.
While she said it's true that controlled substances and illegal Internet pharmacies are referenced in the law, she also noted that one section of the statute reads:
"A practitioner who is located within this state shall not prescribe a prescription drug for another person located within or outside this state if: (a) The practitioner has not physically examined the other person within the 6 months preceding the date on which the prescription is issued."
Because he believes the law is open to interpretation, Petersen said he will continue BPClinic.com until authorities shut him down.
Petersen, whose medical practice is largely devoted to surgery for uninsured patients, said he currently has about 100 patients in the blood pressure program.
The prestigious Institute of Medicine, which is part of the National Academy of Sciences, calls hypertension a medical problem of epidemic proportions.
Health officials have long described hypertension, or high blood pressure, as sinister because it is silent. Individuals seldom notice symptoms until their organs already have been damaged.
High blood pressure triggers more than one-third of heart attacks, is a leading cause of kidney failure and strokes, and plays a role in blindness and dementia.
In February, the institute declared high blood pressure in the United States to be a neglected disease, a term that usually describes mysterious tropical illnesses, not a widely recognized plague of wealthy countries.
Nearly one-third of adults have high blood pressure, and it accounts for about one in six adult deaths annually, a 25 percent increase from 1995 to 2005. Yet the institute found that many individuals with high blood pressure have not been diagnosed and the majority of patients do not have it under control.
The institute also noted that multiple studies show that physicians are unlikely to start or intensify treatment for mild to moderate hypertension and that they are less aggressive about treating older patients, who are the most likely to have the condition and benefit from therapy. Many doctors complain they don't have the time to do proper examinations.
"We think health care providers can do better at helping patients control their blood pressure," said public health officer David Fleming, who chaired the Institute's committee that studied high blood pressure in the United States. "But what will make the biggest difference is creating environments that help people avoid the condition in the first place through healthy eating and active living."
Petersen said he really became aware of the extent of the hypertension problem in the United States when he began noinsurancesurgery.com two years ago, an Internet-fueled practice that caters to the uninsured across the country. He performs surgeries in Las Vegas that range from gallbladder removal to hernia repair on a cash-only basis.
The uninsured are largely enticed to come to Southern Nevada for treatment because he can perform, say, a hernia operation for a total charge of $5,000, about a third what patients have been quoted by other medical professionals or facilities.
Because of the cash nature of the practice, Petersen said he is able to negotiate lower fees for anesthesia and an operating facility just like plastic surgeons, who never receive insurance for cosmetic procedures.
What Petersen found when doing physicals on patients before their surgeries is that about one third had high blood pressure.
"They hadn't seen doctors for 10 or 20 years," he said.
Initially, he would just counsel patients about it, telling them to make sure to contact a doctor in their home states for blood pressure treatment. "But when I followed up with them later, I found that 100 percent failed to go back to a physician."
Then, Petersen said, he started prescribing blood pressure medication to his surgical patients for three months, with the admonition that they go and contact a physician at home when the prescription ran out.
Once again when he followed up on the phone with his patients, he found that "100 percent of them" weren't going see a physician for blood pressure treatment. The high cost of visits was the reason generally given, he said.
"I figured there must be many more people like them in the country, so I found a way to treat patients for high blood pressure over the Internet," Petersen said. "I'm definitely not getting rich off them by charging $50 every three months, but I am helping them stay healthy. Generic blood pressure medications I prescribe only cost the patient about $4 a month" at discount pharmacies such as Walmart.
Gloria Bell Martinez of Fresno, Calif., and Corey Parizo of Cedar Rapids, Iowa, said they are thankful for Petersen's Internet-based blood pressure treatment. They take blood pressure readings either at home or at a pharmacy and send them into BPClinic.com.
Both said in phone interviews that the doctor has plenty of questions to ask them about their medical history both online and on the phone.
"And it's so much cheaper," said the 29-year-old Parizo, who cleans restaurant kitchen exhausts. "I can't afford one-hundred some dollars every three months just to get a prescription rewritten. And I also can't afford to take time off my job to wait forever to see the doctor."
The BPClinic.com website encourages patients to get their blood pressure measured at a local pharmacy and then to send the results in. Petersen also encourages patients to buy their own blood pressure kits.
Dianna Hegeduis, executive director of the Nevada State Board of Osteopathic Medicine, isn't sure either suggested option will give an accurate reading.
"You know the ones at Walgreens probably aren't going to be accurate because kids are playing around with them all the time," she said. "And you don't know if people are calibrating the machines accurately at home."
Hegeduis said medical doctors and osteopathic doctors are governed by the law that says doctors must perform a physical exam before prescribing medication.
She said authorities have seen problems with prescriptions written without patients being seen by doctors.
A recent Food and Drug Administration report said, "It is impossible to accurately quantify adverse event rates because FDA's post-marketing surveillance system reports on only a relatively small percentage of all adverse events caused by drugs."
The report noted that a person was harmed recently by Viagra which was purchased from a website without an examination by a health care professional. "Unfortunately," the report said, "the man had a family history of heart disease and died after taking the drug."
Petersen said blood pressure medications are generally very safe. Any medication, he noted, can produce an allergic reaction in some people.
A person with multiple medical conditions could have kidney problems exacerbated with the wrong blood pressure medication, Petersen said, but he added that it is far more likely that people will develop kidney problems because they don't take medication. "I stay away from complicated cases," he said.
But the pharmacy board's Cramer pointed out that Petersen only knows what people tell him. "And that isn't always the truth," she said.
Under state law, if a patient suffers substantial bodily harm or dies as a result of a drug prescribed by a doctor who didn't examine him, the physician could face up to 15 years in prison and a $100,000 fine. Even without a patient suffering an adverse event, the doctor can lose his license to practice medicine for violating state statutes.
Authorities say it is far more likely that without a physical examination a doctor could miss an underlying cause of the hypertension. That could range from problems with oral contraceptives, alcohol- and cocaine-induced hypertension and sleep apnea to hyperthyroidism, atherosclerosis, metabolic syndrome and increased intracranial pressure.
Petersen said the vast majority of people simply have hypertension that comes with age, overeating and not eating a diet rich in fruits and vegetables. He said he counsels people on their diets.
The state medical board's Cooper said it could be possible for Petersen to get a telemedicine license, where doctor and patient can see each other through Internet video. But, he said, the doctor must have another medical practitioner at the other end with the patient. He acknowledged that would cost much more money and defeat Petersen's idea of giving low-cost blood pressure treatment.
"I have a certain amount of admiration for this doctor," Cooper said. "But there are definite risks in not examining a patient. It's definitely not the standard of care."
There is some good news for Petersen:Cooper said it will take a formal complaint against Petersen for the medical board to take action against him.
But there also is some bad news for the physician: "We read the newspaper," said the pharmacy board's Cramer.
Contact reporter Paul Harasim at firstname.lastname@example.org or 702-387-2908.