Chasing Growth, a Women’s Health Start-Up Cut Corners

When Matt Cronin worked in customer service at Nurx, a San Francisco start-up that sells prescription drugs online, one of his jobs was to manage the office’s inventory of birth control pills.

The pills were kept in the pockets of a shoe organizer hanging inside a closet, Mr. Cronin said. They had been shipped to Nurx customers from its partner pharmacies, but ended up at the office when they bounced back in the mail. His supervisors regularly assigned him to mail those same medications to different Nurx customers who had not received their pills, he said.

The practice was unusual. For safety reasons, federal and state laws generally require prescription medications to be dispensed through a licensed pharmacy and prohibit pharmacies from shipping returned medicines.

“Just like there would be an inventory for medication at a pharmacy, there was an inventory of medication at the office,” said Mr. Cronin, who had no pharmacy training and who worked at Nurx (pronounced NUR-ex) for seven months until last May. “There was a closet full of birth control.”

The closet of pills was an example of Nurx’s unusual methods as it made growth a priority, according to interviews with Mr. Cronin and eight other former employees, five of whom spoke on the condition they not be named because they signed nondisclosure agreements or feared retaliation. The company is part of a new wave of start-ups seeking to upend traditional medicine by marketing prescription drugs and connecting people to physicians online who may prescribe them. Many of these sites’ practices, which merge commerce with medical care in new ways, have raised questions because the companies operate in a regulatory vacuum that could increase public health risks.

At Nurx, in addition to the unorthodox reshipment of returned drugs, executives tried to revise a policy on birth control for women over 35, even though state medical laws typically bar people without medical licenses from influencing medical policy. One Nurx customer also suffered a life-threatening blood clot after taking birth control pills she ordered through the app.

“It was this mentality of ‘Don’t ask for permission — ask for forgiveness later,’” said Dr. Jessica Knox, Nurx’s former medical director, who worked there from 2015 until this January.

Nurx, which has more than 200,000 customers, became known as the “Uber for birth control” and spread a message of female empowerment. It landed prominent board members like Chelsea Clinton and has raised more than $41 million, largely from Kleiner Perkins.

In a statement, Nurx said that it stood by its safety record and that blood clots were a known side effect of taking birth control. With regard to shipping pills from its office, the company said it took the issue seriously and was investigating. It said the practice had ended nearly a year ago and affected a tiny fraction of the million orders it had processed since opening in 2015.

Hans Gangeskar, who stepped down this month as Nurx’s chief executive, said in an email that he “did not authorize or endorse this practice.”

Nurx also said it had recently hired a slate of seasoned leaders, including a new chief executive. “There are no excuses for mistakes made by our former leadership team,” the company said, adding that practices described by former employees did not “reflect the current state of our team and how we currently operate.”

“We pride ourselves on being a trusted, safe health care destination,” said Jonathan Czaja, Nurx’s chief operating officer. “That’s how we’re trying to position ourselves.”

Kleiner Perkins declined to comment, as did a spokeswoman for Ms. Clinton.

Nurx was founded by two Norwegian entrepreneurs: Mr. Gangeskar and Edvard Engesaeth, now the chief innovation officer. In his email, Mr. Gangeskar said he had started Nurx to empower patients.

Together, they built an app that enables people as young as 13 to request medications like birth control pills by uploading a photo ID and answering questions about their health. One of about two dozen Nurx prescribers, including physicians and nurse practitioners, then reviews the answers and may approve drugs, which are shipped by a pharmacy. Prescribers may also deny a prescription request or ask users for other health information. Nurx said prescribers were compensated for their time, not by the number of prescriptions they write.

Many women’s health experts said birth control pills were safe enough to be available without a prescription. A recent study of Nurx and similar sites found they reduced barriers — like inconvenient clinic hours — to the pills.

“I think this is a perfect use for telemedicine,” said Dr. Daniel Grossman, a professor at the University of California, San Francisco, School of Medicine and a co-author of the study.

Yet in an effort to offer women more choices, Nurx executives were also trying to loosen prescribing standards, said Dr. Knox. Last year, she said, Mr. Czaja and Mr. Gangeskar asked her to revise a Nurx policy that advised its doctors not to prescribe birth control with estrogen to women 35 and older who smoked. Mr. Czaja said he and other executives wanted to leave the decision to women after informing them of the heightened risks.

Birth control pills with estrogen carry a federally mandated warning cautioning against their use in women 35 and older who smoke. Guidelines from the Centers for Disease Control and Prevention also say the risks of prescribing to these women, which include stroke and heart attack, “usually outweigh the advantages.”

Dr. Knox said that she had objected and that the company had backed off. But the disagreement lasted months, she said, and contributed to her departure. She added that medical and business decisions should be separate. “I felt like that was eroding as time went on,” she said.

Nurx said that its executives did not control its prescribers’ treatment decisions, but that they had weighed in on prescribing policies as part of the company’s health-empowerment mission.

“I believe that an important part of that is to have a culture that permits everyone to evaluate and provide input to established practices,” Mr. Gangeskar said in his email. “Equally important is that we leave the final medical decisions to the clinical decision makers.”

Some tension between the business and medical sides is good, Mr. Czaja said. “We have lots of healthy debates around the right way to serve our patients,” he said.

In California and many other states, executives and others without medical licenses are prohibited from influencing or interfering in doctors’ judgments, lest business motives skew patient care. Many states also prohibit businesses from directly employing doctors, but allow them to work with separate doctor-owned companies.

Dr. Knox said the company had directly paid her until 2016, the year after the site opened, before asking her to set up a separate corporation so she could be indirectly compensated.

Nurx did not address how it structured payments to Dr. Knox and other doctors. But Lina Brenner, senior vice president for legal affairs, said: “I believe that we are not engaged in the unlawful corporate practice of medicine.”

Some who work with Nurx said the start-up helped make health care more accessible. Courtney Puff Sherman, a nurse practitioner who reviews customer requests and prescribes for Nurx, said in a LinkedIn message that “I can answer questions at night, on weekends, and even on holidays.”

Former customer service representatives said they had a different experience. Kathy Hall-Ramer, a Nurx manager who left last August, said her boss had once asked her to fire a customer service representative who spent too long on individual customers. The ethos, she said, was: “Hurry, hurry, hurry, and we’ll deal with the consequences later.”

Stefanie Kovaleski, a teacher in a Detroit suburb, said she believed she was one of those consequences.

In June, she began taking Tri-Sprintec, an estrogen-progesterone pill she got through Nurx. In August, she rushed to a hospital with a blood clot, called deep vein thrombosis, that broke off and formed dozens of clots in her lungs. The New York Times confirmed Ms. Kovaleski’s experience after reviewing her medical records. She said doctors had said it was most likely caused by the Tri-Sprintec.

Dr. Carolyn Westhoff, the medical director of Columbia University’s Family Planning Clinic and an expert in deep vein thrombosis, said she would not have prescribed the pill to Ms. Kovaleski because of her high weight, which put her at a heightened risk for clots, and a gallbladder condition, which can cause abdominal pain. Dr. Westhoff reviewed Ms. Kovaleski’s medical records with her permission.

Nurx said that blood clots were a known side effect of such medications and that Ms. Kovaleski had been informed about the general risks of Tri-Sprintec. In a message, her Nurx doctor warned of a “small risk” of exacerbating her gallbladder symptoms.

Ms. Kovaleski, who said she would be on blood thinners for the rest of her life, said too much responsibility had been placed in her hands.

“I guess it’s scary to think that something that has such a strong potential of hurting somebody and causing death is so easily attainable,” she said.

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