SALT LAKE CITY — High-tech innovators are working to expand their roles in the effort to address skyrocketing health care costs — now in excess of $10,000 annually for the average American — including a new online pharmacist that just launched in Utah.
Nurx (pronounced nur-ex) is among a new crop of telepharmacy services that are aiming to disrupt old models by eliminating a trip to the corner pharmacist as well as the need to physically visit a physician ahead of that errand for medications.
But in its attempt to forge a new path, the company has also had some missteps.
Nurx is mostly focused on the birth control market, offering 50 generic and name-brand options available in pill, patch, ring and injection form, but also offers the HIV prevention medication PrEP, emergency contraception and an in-home HPV screening test kit. The company launched in Utah earlier this spring and, according to a Nurx spokeswoman, is currently available in 24 states and has drawn some 200,000 customers.
Dr. Nancy Shannon, a Minnesota-based physician that is one of Nurx's medical providers who is also licensed to practice in Utah, said the process for obtaining birth control from the company was simple. Patients, via the Nurx website or the company's smartphone app, respond to a brief medical history questionnaire, provide results from a recent blood pressure test and submit the info. A Nurx medical provider then reviews the information to make sure the product is appropriate for the patient and, if so, completes a prescription, which is then shipped directly to the customer.
Shannon said the physician review process is typically completed in three to five days and patients usually have their medications within a week via mail, but they can also opt to pick it up at a local pharmacy. Shannon said she worked for years in outpatient clinical settings before going to work for Nurx and had some initial qualms about how the high-tech approach — one that did not involve an in-person relationship with her patients — might negatively impact communication with patients. But she said the reality of the new model was a revelation.
"When I first started with Nurx, I was concerned that the doctor-patient relationship would be hurt," Shannon said. "But, boy was I surprised. It’s been exactly the opposite ... people are much more open about asking questions, telling their complete stories."
We’re available at a wide range of hours so we can meet the patients pretty much when it works for them. – Dr. Nancy Shannon, one of Nurx's medical providers
Shannon said while patients can connect with the Nurx medical providers via phone or video chat, about 99 percent of the patient-doctor communications happen via text messaging. She said one of the advantages of this asynchronous model is patients can circle back any time with questions or, for instance, add something to their medical history that they may have forgotten initially, without the hassle of waiting for another in-person appointment. And it alleviates the pressure common to clinical settings where there is always another patient next in line.
"We’re available at a wide range of hours so we can meet the patients pretty much when it works for them," Shannon said. "And I feel I can take as much time as I need with patients without worrying about a line building in my waiting room."
Shannon noted in instances where she needs to conduct further research or consult with a colleague about a particular patient, she has more latitude to do so in the telemedicine setting resulting in a system that she said "works out great for patients and providers."
Data in a 2018 report from the U.S. Department of Health and Human Services showed of the $10,739 the average American spent on health expenditures in 2017, some 10 percent went to retail prescription drugs. Shannon said Nurx doesn't charge for birth control prescription consultations, accepts most insurance plans and, for those who are paying out of pocket, there are plans available that limit costs to as little as $15 per month.
Nurx marketing vice president Katelyn Watson said the Bay Area company was launched in 2014 by two Norwegian-born entrepreneurs, Dr. Edvard Engesæth and Hans Gangeskar, who were aiming to create a new way to obtain medications that may come with some attached stigma. Watson said even in Norway, where health care is heavily subsidized by the national government and easily accessed, Engesæth was frequently contacted by friends who wanted a birth control prescription from someone they knew, rather than visiting a random physician. Now, the company has raised over $41 million in venture funding, including a $36 million round led last summer by Silicon Valley venture giant Kleiner Perkins. It's also attracted some marquee names to its board, including Chelsea Clinton and former U.S. Surgeon General Dr. Regina Benjamin.
All that firepower, however, hasn't kept the company from making some blunders, a few of which were highlighted in a New York Times story published late last month.
One former Nurx employee told the Times he was assigned to re-ship medications that had been returned to the company as undeliverable, a practice banned by federal and state regulators. Also, Nurx's former medical director said she was asked by company executives "to revise a Nurx policy that advised its doctors not to prescribe birth control with estrogen to women 35 and older who smoked."
The U.S. Food and Drug Administration has long warned against the use of birth control products containing estrogen by women over 35 who smoke, noting "cigarette smoking increases the risk of serious cardiovascular events from combination hormonal contraceptive use."
In response to a Deseret News request for comment on issues raised in the Times piece, Nurx referred to a Medium posting that included this statement about the re-shipping of returned prescriptions:
"The past business practices featured in the story were in place for a very limited time, impacted a very limited number of patients, and ended nearly a year ago. The story’s depiction of Nurx does not reflect our policies now, but just as importantly, they do not accurately reflect the full picture of how we operated then."
Regarding communications between the company's former medical director Dr. Jessica Knox and executives about prescription polices for patients over 35 who smoke, a Nurx spokeswoman clarified that while the topic was discussed, the decision was ultimately left to Knox.
"The discussion between our former CEO and former medical director regarding prescribing policies for women 35 and older who smoke was regarding whether we should inform these women about the risks of estrogen containing birth control so they can share decision-making with their medical provider and make an informed decision, also known as an informed consent model," the spokeswoman said in a statement. "This implied debate between Dr. Knox and our previous CEO was simply a discussion of whether our clinical guidelines would encourage our providers to employ such clinical judgment.
"And in the end, Dr. Knox’s clinical judgement - that the clinical protocols should reflect a more conservative approach which does not offer combination birth control for women who are 35 and older who smoke under any circumstances was upheld and is still upheld to this day. Our former medical director made the final decision regarding this matter, and our clinical organization always has the final say on clinical decision-making."
In the Medium posting, Nurx also noted recent changes in its leadership team, including the recent hiring of health tech veteran Varsha Rao to replace co-founder Gangeskar as CEO and, over the past year, a slate of other executive positions.
About half of pregnancies are unplanned and one in five are really unwanted pregnancies and a lot of it might have to do with poor availability of contraceptives. – Dr. Joseph Miner, a physician and executive director at the Utah Department of Health
Nurx entrance into the Utah market coincided with another new option for state residents, thanks to changes adopted by the Legislature in 2018, for obtaining birth control prescriptions directly from pharmacists. Proponents of the change, which implemented via a standing order issued in March of this year, say easier access to birth control medication has a direct and positive impact on reducing unplanned pregnancies.
Dr. Joseph Miner, a physician and executive director at the Utah Department of Health, told the Deseret News in March that the standing order will help people who either don't have the time or money to regularly see a doctor for birth control.
"About half of pregnancies are unplanned and one in five are really unwanted pregnancies and a lot of it might have to do with poor availability of contraceptives," Miner said.
Contributing: Wendy Leonard