Female-Focused, Video-Free Telehealth – Varsha Rao, CEO of Nurx

Dr. Rishi Desai: Hi I'm Dr. Rishi Desai and today on Raise the Line, I'm happy to be joined by Varsha Rao, CEO of Nurx, a telemedicine provider that offers a hassle-free way to access healthcare and medication. Prior to Nurx, Varsha served as COO of Clover Health, where she brought operational leadership to the health insurance startup. She also served as Airbnb's head of global operations, managing the company's market expansion and host growth around the world as revenue grew from two hundred million to two billion dollars. Also, I'd like to thank our recent Raise the Line guest Chelsea Clinton for the introduction to Varsha Rao. Thanks so much for being with us today.

Varsha Rao: It's great to be here. Thank you. 

Dr. Rishi Desai: So, I'd love to just kind of understand your backstory. I mean, you've been involved in so many important businesses and well-known businesses. What got you interested in healthcare specifically?

Varsha Rao: Well, first of all, can I call you Rishi or should I call you Dr. Desai? 

Dr. Rishi Desai: Definitely call me Rishi.

Varsha Rao: Okay, Rishi. First of all, it is a pleasure to be here and I think for me, I spent most of my career in consumer tech over twenty years and I always really enjoyed the ability to work with and impact people directly. All of it was direct to the consumer, but I think after spending several years at Airbnb and really being in a very mission-driven company that was all around connecting the world and connecting cultures through travel...after I took a break from Airbnb, I really wanted to do something as meaningful if not more and to me, that is exactly what healthcare is. There are so many challenges that still exist so much around access that have not been solved. So that's where I felt that that would be really passionate for me. 

That's kind of what led me to first to Clover but then ultimately to Nurx where we have a direct-to-consumer focus today which allows us to have a tremendous impact in a relatively short amount of time. The company's been around for about five years. We now serve over 325,000 patients monthly. We've had over a million consultations with our patients over the last eighteen months or so. We've had tremendous scale and growth and at the foundation of that is we're helping people get access to health care that we think that they otherwise might not have gotten access to. So, that's what's been very meaningful and also helped us become quite large from a scale and size perspective. 

Dr. Rishi Desai: It's a remarkable story and you're right this is obviously a very large market and there's a lot of meaningful work to be had here. I'm curious, how do you explain how Nurx differs from other telehealth companies?

Varsha Rao: The way we look at it is a couple of things. First, we offer end-to-end care. There are telehealth platforms that are just around the consultation. Our view is to provide a really good experience and actually make sure people are getting the care they need, we want to allow for access to a consultation and a high-quality provider as well as access to labs if needed, getting a prescription, and then even getting that medication delivered to your door. So that end-to-end has been really important and a big unlock for us. 

The second thing is we are one of the only, if not the only, at-scale telehealth player end-to-end that accepts insurance. So, we do take insurance for your medication. Our view is a lot of people don't have insurance so of course, we have a strong cash offering but we also want to enable people, if they do have insurance, to use it because that's important. Taking insurance is hard as a company. You have to build a lot of things in place to be able to enable that, but we've invested in that so that people could actually use their insurance. 

And then the third way that we really set ourselves apart is probably in our female-focus. We are the largest, by far, female-focused telehealth player with the size and scale and going across so many issues. I think that's the other thing that sets us apart, which we really lean into.

Dr. Rishi Desai: That's amazing. I was looking at your list of offerings -- everything from infectious diseases to migraines -- and recently, you've gotten into kind of a new field. I'd love to hear you talk about how you chose that field and what that means for your audience.

Varsha Rao: We are not exclusively female, but our roots have certainly been around contraception which is where we got started. Our approach has been to really go deep with our patients, understand what their needs are and then as they tell us what more they need, let's make sure we're there to help serve them. We actually have gone out to our patients and they're the ones who have told us that about thirty-six percent of our patients experience migraines. We felt like, “Okay, that's an issue that we really wanted to help address.” 

About fifty percent of our patients told us they experienced acne and we thought, “Okay, that may seem like it's cosmetic but acne is super stigmatizing.” It can have really important and negative impacts on wellness, mental health, well-being, and we wanted to help address that, and there are some strong links between a lot of hormonal issues and acne and sometimes migraines as well. So they're all actually quite related and we have deep clinical expertise in a lot of these hormonal-related issues already. 

In March, we launched our dermatology service, it's gone incredibly well. We're really excited about that and then today actually, as an extension of our acne service -- which was the first part of dermatology -- we launched anti-aging and that is something we're really excited about. It builds on the same expertise that we've already developed for acne. It allows us to start to grow with our patients as they become a little bit older and you'll see more coming from us in the dermatology space as well, as we build out that whole area but we're really excited about it.

Dr. Rishi Desai: I'm excited too. I mean, I think that's an incredibly exciting thing to get into and one thing I'll say is that when it comes to hormonal conditions -- and you mentioned that women are the demographic where your roots are -- that's an area that I think medicine doesn't have a great track record around. There's the phrase "medical misogyny," where people can chalk up symptoms to a person's mental health without really doing a deep exploration of it. Famously, doctors don't have a lot of time to ask questions to really get into a person's life. I'm just curious how much of that was an impetus for Nurx to be a company and how is that going? What is the woman's experience on Nurx, and how is it different from kind of what we would classically think of as a path through medicine?

Varsha Rao: The roots of the company are all around areas where there's stigma and so, for example, about twenty million women live in contraception deserts, and that was part of the reason why we felt that focusing on contraception was a good starting point. It's also highly stigmatized, and there's a lot of people who still don't feel that comfortable talking about contraception and methods with their provider, with their families with their friends even, so we wanted to provide a safe space for that. That's actually the reason why we are an asynchronous platform today. We actually facilitate care through an asynchronous platform where people fill out an online questionnaire and exam basically - - it's an online exam -- and then we validate all that information and our providers take that information and do a consultation and evaluation based on that. If they have questions, they can message you back and forth. 

So there is interaction, but that asynchronous method actually also reduces barriers because sometimes people don't even want to be on a video consultation. Sometimes it's stigma, sometimes it's logistics, actually. Anything where you have to set up an appointment, there's invariably friction there. I would say that's one thing we've tried to do is create modalities that reduce friction, whether it's logistics or stigma, because those can be barriers to care. 

You mentioned sort of some of the other broader challenges. We have a culture of trying to really listen to our patients. We get thousands and thousands of comments about how we provide more information, they learned more from our providers than they ever got from their in-person doctors. The technology might facilitate that, but I think it's also the culture that we've fostered. We are really proud of that, and it's something we'll continue to bring. 

I think part of it also could be our deep specialization. When you treat hundreds of thousands of patients for any condition, you get really, really good at it and so we can provide more information than maybe your average primary care doctor can because we have deep expertise. We see a migration where people are choosing to get care -- women in particular, but not exclusively -- in areas where they can get specialization and more information and where their symptoms aren't going to get dismissed because they are talking to people that have seen these symptoms over and over again. That's another thing we get a lot of feedback on...that people feel really heard with us after having a lot of their symptom dismissed. Maybe that dismissal is happening because maybe providers aren't as experienced with some of these conditions. 

Dr. Rishi Desai: Yeah. I completely agree with that and I think a lot of clinicians aren't trained to think about it. There's a lot of information coming out now about the role of nutrition, the role of meditation, the role of exercise, and these sorts of things are not taught, frankly, to clinicians. So I think that sometimes people react in a way that, like you said, dismisses it or essentially they say, "Well, I don't know about it so I don't know what to tell you." I think that leaves a vacuum open where patients are like, "Well if you don't know about it but it's affecting my life, I need to be my own advocate. I'm curious if you think that this is the general trend? Are you seeing more and more people kind of resonate with asynchronous communications with their clinician...looking online, kind of searching it out themselves? In the "olden days", the doctor was the driver and the patient was kind of there for the ride, and it feels like now, the driver is really the patient and I'm just curious if you're seeing anecdotes or stories that resonate with that.

Varsha Rao: Well, I think there are a couple of things. I think people are becoming a lot more comfortable with telemedicine, partly driven by COVID-19. Unfortunately, a lot of people weren't able to see their provider in person and so they had to find different ways. Some of them were forced to use telemedicine, some of them sought services like ours. We saw dramatic, 100% year-on-year growth in so many of our different services based on the fact that people were really seeking new avenues of care. But I think one of the benefits of all that is people learn to trust that you can actually get good high-quality care through telehealth and not everything needs to have an in-person visit. 

I think there's more trust there and so that's why people are potentially seeking out new services than they may have sought out before. I think there's also more information out there and I think that's really a good thing. I see everything from services like Healthline and there's a lot of content services now increasingly vetting that content to make sure that it's an expert-vetted or provider-vetted. I think that's really a good thing because to the extent that people are becoming their own Google doctor, you want to make sure that they're not reading things that are going to potentially mislead them. 

We take a lot of effort at Nurx to make sure that the content that we put out is all provider-vetted and really has clinical expertise that's at the foundation because again, people might be relying on it and we want to make sure that it is sound. So, I do think people are being more self-directed. It could be for a first opinion, but it could also be for a second opinion and I think all of that is good. 

Dr. Rishi Desai: How do you guys manage keeping the clinicians themselves up to date? There's so much information out there. For a single person to be able to kind of triage all that is a lot and that's part of why I think a lot of clinicians feel inundated and overwhelmed. You mentioned specialization, and that helps a lot I would imagine. I'm just curious how do you keep the morale high, the focus on talking to patients and trusting what they're saying, but also keeping up to date with the science? How do you accomplish that?

Varsha Rao: It starts with leadership. We have an incredible clinical leadership team. We just hired a woman named Dr. Jennifer Peña. She came most recently from Oscar Health but before that, she was part of the White House physician corps. An impeccable clinician with a depth of expertise and really strong leadership. Then we also have a woman named Dr. Nancy Shannon who is the leader of our clinician team and again, she's been a clinician I think for thirty-five to forty years. She's worked in this setting since the beginning of Nurx, and she really understands the powers of telehealth and what we can do and what we can't do and all of that. So, I think it starts with leadership. 

The second thing I would say is it does help that we have had specialization or areas of focus. We don't do everything, and that's by design. We don't do allergies. We don't treat people with hypertension today. We don't do chronic care management in areas like cholesterol and some of those later in life issues. We've really focused in a number of areas and gone deep in them. I think by the very nature of what we do, if patients came to us for hypertension, we'd say sorry we're not the right folks. We can't treat you for that. I think that's a little bit different than a PCP. 

In all due respect of the PCP, they take in everything and that's a challenge. We need to be grateful for what they do. We have the luxury of not having to do that, but we also have created micro teams within our larger team. For example, migraine. Migraine is really complex and I think we have found that some of our providers don't want to focus there as much and we've said okay, it's your choice. We've created a sub-team, we have CME training in that area, we do consistent updates and we have tools to help share cases and we also have an expert. In each of these areas that we've launched, we have a clinical expert who serves as an advisor to bring the latest information. So, for example, in migraine, we have a woman named Charisse Litchman. She's a Yale-trained neurologist, and she is always bringing the team some of the latest and greatest, and that also helps to keep the team current.

Dr. Rishi Desai: That's awesome. I mean, this whole model is so refreshing because it brings in a lot of the stuff that I've always thought is obvious and make sense. The piece it sounds like you've kind of done is when people go to the doctor's office, classically, they feel like there's a laptop between them and their clinician and here you're ironically using laptops but in a way that feels much more human. I think that's kind of an interesting irony in a way. Do you get that sense? Like, when you're talking to patients and they say, 'I learned more from you than from my clinician', how much of that is because your team is talking directly using the laptop, versus the other way around?

Varsha Rao: I think it's the culture. Because we're not in person, through the messaging and through some of the communication, we really try to emphasize that's how you build a connection with your patients. I think our clinician team has really taken that to heart and so they probably go out of their way, relative to a doctor or provider that's in-person where that is the relationship. So maybe in the traditional setting, there's a feeling that you don't need to do anything extra. But it could also be that, again, we have such depth of expertise and we create modules of information that we can easily share and it's actually easy to send out information and links through technology. We've created easy ways to share information that is hard to do in a traditional setting. Like, what are you going to do? You don't go handing out pamphlets anymore. It all has to be verbalized and that takes time.

Dr. Rishi Desai: You say that Varsha, and yet where I've worked, they hand-out pamphlets. It's one of those things where I think you're clearly on the bleeding edge of things as they're moving. I'm a pediatrician. The number one story I hear from parents is, "My kids will be in the same room or same house with their friends and they'll be texting each other." You mentioned the asynchronous piece. It seems to me that for better or for worse, this is the modality that people are using. 

This asynchronous, multi-touch, lots of small communications approach over weeks or months versus "I'll see you for fifteen minutes and I may not see you again for six months or a year." That used to be the model and this is the new model. Whereas every other part of our lives is run, essentially, by phones, medicine still seems to be this kind of antiquated beast that keeps going and doing things and plodding along the way it always has. Nurx, I think, is doing it quite differently. Are you seeing that generational divide? Do you see that even within the demographics you're managing...like maybe the twenty-year-olds versus the thirty-year-olds versus the forty-year-olds? Do they respond differently to the platform and maybe even need less support because they just get it versus maybe others don't. Have you noticed that at all?

Varsha Rao: Well, for the areas they were in, it's all relatively young so I think I don't feel like we have any real technology challenges. I mean, even if you're a forty-year-old today, you're using your phone all the time. I think in our age group, we're working with people who are very facile with the phone and technology. One of the things I do think that people appreciate with our services is after you pay a consultation fee the first time, you actually get a year of unlimited messaging back and forth. A lot of people don't use it because if you don't have an issue most people don't use it. But if you have questions, you're welcome to message us whenever you want and we have a triage system to manage that effectively. I think people appreciate that because it can be really hard, as I'm sure everybody recognizes, to get back in touch with your doctor if you have a question. You call them, they're not available. They don't use text very well. So, the traditional environment is not set up for that, and we've sort of tried to bridge that gap. 

I empathize a lot though with our in-person clinicians because I think their model is not set up so that they have time or they're even compensated for all these other interactions. I don't envy them now that there's this need and people want to have more communications but they're not really set up for that. I think it's a challenge. I think they'll have to evolve and we'll have to figure it out as a society how to compensate physicians for valuable information and advice that they're giving along the way, instead of only when someone comes in for a visit. Sometimes patients don't even want to come in for a visit but now they're being forced to come in because that is how the provider is being compensated. It just doesn't work. Insurance is not evolving enough. I feel like the physicians and the primary care team is actually getting hurt the most.

Dr. Rishi Desai: I couldn't agree with you more. You mentioned at the outset that you've invested in integration with insurance companies to make that a differentiator. That might be good learning for the insurance companies, in general, to figure out how to compensate these sorts of interactions. I would like to ask you for your parting advice. 
We have lots and lots of folks that are early-stage clinicians or maybe interested in that career path for themselves as they hear about your own path and what you're trying to do. What advice do you have for folks that are just starting out? I'd love to hear you speak on that.

Varsha Rao: I'm not a clinician, so I think I can only advise from where I come from. I think if someone is interested in healthcare in particular and building something that's really innovative these days, a clinician partnership is critical. I have the honor to work with an amazing team of clinicians and that's the only reason we can do what we do at Nurx. So one, I would say if you're a clinician and are in the early stages of your career, I think there's a huge need for folks like yourselves in order for technologists to come up with something innovative. 

I guess the second thing I would say is learn all the technologies that are out there. The way we end up coming up with our innovations is to say, "What's the essence of what we're trying to get at and how did it used to be done?" What are you trying to understand? And then ask if there a new way to understand it that reduces the friction that couldn't have been done ten years or fifteen years ago because that technology didn't exist? Now it exists, and you can reduce the friction, increase access, reduce the cost, all of the above. Where the intention gets preserved, the quality can get preserved, but you can do it in a more seamless way. I think clinicians truthfully are at the heart of this because they really understand those intentions. We never innovate without our clinician partners side-by-side. That's when we get the best innovation...when we all come together. 

Dr. Rishi Desai: That makes a lot of sense and I love that preservation of intention. That makes a lot of sense. Listen, thank you so much for being with us today. That was fantastic. 

Varsha Rao: Thanks, Rishi. This is so much fun.

Dr. Rishi Desai: I'm Dr. Rishi Desai. Thank you for checking out today's show. Remember to do your part to flatten the curve and Raise the Line. We're all in this together.