A proposal introduced this past legislative session, and backed by nine Republican lawmakers, would have given the Department of Health more authority to monitor physicians, including the power to limit the number of certifications that individual doctors can issue.
“I’m not sure how you have 9,000 or 10,000 or 15,000 patients, and try to keep track of how they’re doing,” state Rep. Tim Twardzik(R., Schuylkill), the bill’s prime sponsor, told Spotlight PA.
“There’s an awful lot of money to be made,” Twardzik later added. “… Physicians should be responsible for their patients and not just look at this as an easy revenue stream.”
Pennsylvania health department data show one doctor issued roughly 14,500 medical marijuana certifications in 2021 — which averages out to about 40 per day. That same doctor, Ahsan Iqbal, issued nearly 7,800 in Pennsylvania’s program the following year.
Iqbal also appeared to rank among the top certifiers in Florida during a similar period: the last half of 2021 and the first half of 2022. Multiple letters, emails, and calls to publicly listed contact information for Iqbal received no response from the doctor.
Twardzik’s concern about doctors’ responsibility to patients highlights a broader issue: the way medical marijuana certifications frequently happen outside the typical relationship between patients and primary care providers.
This Spotlight PA investigation is based on more than 1.5 million certifications, issued from 2017 through the first half of 2023, and interviews with more than 20 medical professionals, researchers, policymakers, industry experts, advocates, and patients.
While some doctors, researchers, and patients tout the benefits of medical marijuana and the relative safety of the drug, concerns persist about its potential risks and whether some high-volume practices undermine the credibility of medical programs and standards for patient care.
“There’s some cutoff at which it goes from a reasonable full year’s worth of work to being an unreasonable amount,” said Jordan Tishler, a Massachusetts physician and president of the Association of Cannabinoid Specialists. “And I think that the regulators should absolutely flag those prescribers.”
Gatekeepers
Since the medical marijuana program began in Pennsylvania, doctors have been the gatekeepers.
Instead of providing a traditional drug prescription, they issue a medical marijuana certification that allows patients to obtain a card and shop at dispensaries for the products they want. While the law enables doctors to limit the appropriate form of medical marijuana for each certification, they aren’t required to.
To issue a certification, physicians must determine that patients have a qualifying medical condition and are “likely to receive therapeutic or palliative benefit” from using the drug.
The price for a certification varies — a Spotlight PA review of more than a half dozen websites found a typical range of about $100 to $200 for a new patient. And “since medical marijuana consultations are not covered by medical insurance,” individual doctors can decide what to charge, a health department spokesperson told Spotlight PA.
Patients need to receive a certification at least once a year to continue with the medical marijuana program. The annual requirement and the cost burden it causes for patients have received some pushback.
Luke Shultz, a patient in the program and former Medical Marijuana Advisory Board member, in 2022 described the recertification as “almost a formality” for many patients, especially ones with chronic or terminal issues that aren’t going away.
But a proposal from Shultz to loosen the rules failed. A bipartisan bill with a similar goal stalled in the legislature this past session.
Some changes to oversight could be coming.
The Pennsylvania Department of Health told Spotlight PA that discussions with the Department of State — which enforces licensing standards for medical professionals — about “certification data and patient consultations escalated over the last year.” That time period follows a series of Spotlight PA investigations into the state’s medical marijuana program.
As of November, Pennsylvania’s medical marijuana program had more than 440,700 active patient certifications and over 1,900 approved practitioners. If those certifications were divided evenly, it would average out to about 228 for every certifying physician in the program.
Health department officials, along with some medical marijuana supporters and some medical professionals, said certification figures provide a limited view.
“There are health care providers that, by the nature of their work, would certify more patients than others,” Debra Bogen, secretary for the Department of Health, said in response to a lawmaker’s questioning last year. “And just looking at the numbers alone doesn’t really give us that information.”
Certifying doctors aren’t the only people patients can turn to for help. Pharmacists and other medical professionals who work for dispensaries are available to consult with patients, said Mark O’Neill, a health department spokesperson.
Spotlight PA recently spoke to or received statements from three of the state’s top certifying doctors or their representatives about the number of patients they approved and the benefits of their services.
One such doctor, Rebecca Maury, said she originally registered as a practitioner to make it easier for her hospice patients to access the program. She founded a medical marijuana practice in Philadelphia in 2018, around the same time dispensaries started opening.
Her practice grew and now has appointments six days a week, according to Maury. Health department records say she issued nearly 14,700 certifications in 2022, the highest number in the program that year. When asked if she approves patients for medical marijuana in other states, Maury said she only works in Pennsylvania.
Maury attributed the number of certifications she issued to her work effort.
“There are people out here like myself that are good, well-intended people that are trying to facilitate low-cost, efficient access to this medical program,” Maury told Spotlight PA.
She pushed back on the idea that certifications are a way for her to “grab money.” She said she’s following all the requirements for the process and is responding to the “need that is kind of coming in my direction because of having been doing this and doing a good job for seven years.”
To better understand the program, Spotlight PA sent a survey to publicly listed contact information for Maury and nine other doctors who each averaged more than 5,000 certifications a year from 2020 through 2022. Those 10 doctors also led the program for overall certifications from 2017 through the first six months of 2023. Maury was the only one who completed the survey, and Spotlight PA is making her full response available. She volunteered to answer additional questions and took part in an interview.
When Maury first started doing medical marijuana certifications, she said, she had hourlong patient visits. After the first year, she realized people who wanted their card renewed often didn’t have many questions, and changed her approach.
Now, her scheduling system doesn’t have a fixed amount of time for each appointment but generally operates with an open window of time. If she can’t reach patients, she’ll text and tell them to let her know when they are ready for a call.
She said she spends as much time as needed on the phone with each patient and asks open-ended questions, so they “are invited to tell me what they feel is relevant.” Her practice’s standard charge is $125 for a new certification and $75 for a recertification. She described their prices as among the lowest in the state.
In a doctor-patient visit, she said, most of the time is spent in two ways: diagnosing symptoms and discussing treatment options.
But patients come to certification appointments “with a clear articulation of the symptoms/diagnosis they have and their intention to treat those symptoms with cannabis,” she told Spotlight PA in a follow-up email. She said she also does not typically make specific recommendations for managing symptoms, saying the issue “is deferred to the dispensary pharmacist.”
That makes these appointments “inherently less complicated than a primary care visit, hospital admission intake, or ER visit,” she said.
Most of her cannabis patients already have a card and come to her for a recertification, she said. For patients who haven’t received a diagnosis elsewhere, she said she can make one based on symptoms and doesn’t charge extra to do so.
After an appointment, patients can email or call the support line or text or call Maury directly if they have questions. She highlighted the positive reviews the practice receives.
She said she hopes other doctors who “are busy doing this like I am … have an actual love and respect for the people that they’re working with — and are doing a good job.”
The issue of doctors approving large numbers of medical cannabis patients has drawn attention elsewhere.
In Michigan, the Office of the Auditor General wrote in 2023 that “it is likely some of these physicians did not have a bona fide physician-patient relationship with the applicants.” That audit highlighted 18 unnamed physicians responsible for about 83,000 cardholder certifications over a year and a half.
Neither Pennsylvania’s auditor general nor the health department has conducted a similar review, according to records and responses from both agencies.
In a 2011 article in the Journal of General Internal Medicine, three clinicians expressed concerns about Colorado’s medical marijuana system, the large share of approvals by 15 unnamed physicians, and the relationship between doctors and patients.
Florida’s medical marijuana law requires reporting certification data by individual physicians, as well as county and statewide totals. Reports are posted publicly.
Pennsylvania provided certification data by individual physicians only after a legal fight with Spotlight PA. Paula Knudsen Burke, an attorney with the Reporters Committee for Freedom of the Press, represented the newsroom at no cost in the case, which was resolved following mediation.
Tishler, president of the Association of Cannabinoid Specialists, told Spotlight PA he thinks states should be more active and aggressive when it comes to oversight of medical marijuana doctors — so that scrutiny is in line with other types of medicine. He thinks regulators could use certification data to identify doctors based on the volume they approve, and then the issue could be referred to state medical boards for further investigation.
“If we really want doctors to take this seriously, like all other fields of medicine, then we need to hold them to a high standard — like in all other fields of medicine,” he said.
The amount of time doctors spend with cannabis patients is relevant to whether they are living up to their responsibilities, he said. For a doctor, if the volume of certification appointments means “you’re spending five minutes with each patient then I think you know you have a problem,” he said.
In his medical cannabis practice, he said he books one-hour appointments for new patients and 30 minutes for returning visits and sees all of his patients at least twice a year. He said that a returning patient might not need the full time, but that’s not something he can predict in advance. They might be having problems — cannabis might not be working adequately, they could be doing something unsafe or unhealthy, or they might just be using too much. Situations vary.
“There needs to be enough time allocated … to give them the guidance that they need so that we can get the train back on the track,” he said.
Pennsylvania’s medical marijuana law doesn’t have any specific requirements or guidance for how long patient certification visits should last.
Karen O’Keefe, director of state policies at the Marijuana Policy Project, cautioned against suspicion based on certification numbers alone. She said the time for certification appointments “could actually be a lot longer than a lot of doctors are consulting with patients about far more serious drugs.”
She cited a study of primary care physician visits with older patients that found a median visit length of 15.7 minutes, with about five minutes spent on the longest topic and each remaining one receiving 1.1 minutes.
“When you think of medical cannabis, that is just one treatment option, generally for one medical condition,” said O’Keefe, whose group supports cannabis legalization for adults and patients.
For some companies that offer to connect patients with doctors, a quick and easy process is a selling point. These third-party companies often describe the benefits of their services for people dealing with a variety of medical conditions.
In Pennsylvania, the state’s medical marijuana law gives such companies a significant advantage over individual doctors. They are free to advertise, while individual physicians risk getting kicked out of the program and even receiving discipline on their medical license if they do the same.
Some medical marijuana doctors, including Maury, have criticized these types of companies. These businesses often operate in multiple states, aren’t mentioned in Pennsylvania’s medical marijuana law, and Department of Health officials have said they “don’t have any regulatory authority over” them.
Maury said big certification companies “are clearly plundering and don’t have any care whatsoever for the well-being of the folks that are using those services” and raised the idea of limiting their role.
If patients want to connect with their doctor after an appointment with one of these large companies, she said they can face barriers and a “Byzantine-like system.” That lack of direct access can create problems, such as if they need a doctor’s letter to continue as a cannabis patient while under court supervision, Maury said.
“I’ve talked to so many people that have gotten screwed over,” she said.
The doctor certification records released to Spotlight PA by the Department of Health do not include information about what companies, if any, doctors worked with when they approved the patients.
Debates over oversight
Multiple Spotlight PA investigations have led to calls for greater scrutiny of the medical marijuana program.
Following a November 2022 Spotlight PA investigation, some members of the state’s Medical Marijuana Advisory Board publicly questioned how thorough some doctors are when they issue certifications and requested more information from the health department about its oversight . Shortly afterward, the health department said it investigates all complaints and expects doctors “to practice ethically and responsibly.”
Ed Mahon / Spotlight PA
Department of Health officials in November 2022 faced questions about advertising by medical marijuana businesses and the rigor of telemedicine appointments for certifications.
During a budget hearing a few months later, state Sen. Greg Rothman (R., Cumberland) referenced the open records dispute over releasing doctor certification data. He wanted to know if the agency reviews the information. “And does the department protect against doctors from providing blanket approvals for medical marijuana use?” he added.
At that hearing, Bogen, the state’s health secretary, described the limits of looking at certification numbers alone. Shortly afterward, a health department spokesperson said the agency “has only used the information as part of enforcement actions that resulted from a patient complaint or compliance investigation.”
More recently, the Department of Health has described ongoing talks with the Pennsylvania Department of State related to certifications.
“Meetings were first held internally to review the data and identify potential areas of concern,” O’Neill, the health department spokesperson, told Spotlight PA in November.
O’Neill said the agency’s Bureau of Medical Marijuana “is working to establish consistent criteria or guidelines that outline what information will be shared with” the Department of State, as well as when and how.
Still, O’Neill stressed the limits on aggregate certification totals, saying they “do not reveal the context of a practitioner’s professional activities, the quality of care patients receive, and what aligns with industry best practices and” Department of State expectations.
Medical professionals and researchers hold a range of views on the type of blanket approvals Rothman asked about.
The Pennsylvania Psychiatric Society has warned of the potential risks of marijuana use, particularly for more vulnerable groups such as adolescents, pregnant women and their fetuses, and those with mental health conditions.
Some doctors also noted the drug’s relative safety. Unlike opioids, there are no reported deaths from an overdose of marijuana, according to the Drug Enforcement Administration.
“The harms are more … in perpetuating this stigma that medicinal marijuana is for legal stoners, when I have so many patients who truly benefit and whose lives have been changed by it,” said medical marijuana physician MaryFrances Koester.
Charles Harris, another Pennsylvania medical marijuana physician, said if patients don’t receive much direction from their certifying doctor, they probably won’t experience much harm. But he added, “where you really miss out is … that you’re not getting the benefit” of the doctor’s guidance. That information could help patients get better results when managing conditions such as migraines, he said.
Harris issued more than 1,300 certifications in 2021, which equals under four a day for the year. Koester issued fewer — about 1,100 certifications that year. Their certification totals each declined the following year.
Both doctors said they would welcome more state oversight of the program. So would Pennsylvania physician Bryan Negrini, who suggested regulators “should do random — not targeted — audits.”
Records obtained by Spotlight PA through a court victory have sparked debate over state oversight and the quality of medical care
