The Second Opinion Market

ONE OF THE patients of Dr Sagar Makode, a 31-year-old cardiologist from Chandigarh, regularly wears a cardiac monitor. When it shows any abnormalities, he gets in touch with the doctor, who looks at the ECG tracings and suggests if there is anything to be addressed. Nothing out of the ordinary, except that the patient is in the United States and has never met Makode. There are reasons why the patient should consult someone in India like this. “It is difficult for him to visit doctors all the time, at odd hours, whenever the machine informs something,” says Makode. Online consultation solves that issue. Also, the price of a doctor’s consultation in the US can be prohibitively high and insurance plans are limited in their coverage. An Indian doctor comes at a cost people can afford whenever they want.

Makode is listed on online medical consultation platforms that act as middlemen between patients and doctors. He got on the bandwagon after having run a traditional practice for five to six years. In the medical fraternity, this trend was becoming apparent and some of his regular patients were also requesting it. He now spends about two to three hours of his work day doing online consultations. “In the era of internet and technology, relying on conventional healthcare setups is not enough,” he says.

The business of online consultation in India seems to be at an inflection point in taking off. Major healthcare startups like Practo and Lybrate have added online consultations to their apps. Hospital groups like Apollo are in it. Telecom providers like Jio and Airtel are offering it under their umbrella of services. From psychiatrists to IVF specialists; individual doctors and nursing homes are signing up for it. A platform that Dr Makode is listed on is iCliniq, founded by Dhruv Suyamprakasam, one of the earliest to venture into this space in 2012. It was then doing less than 50 consultations per week. “Right now, we do 900 to 1,000 per day, with over 2,500 doctors on our platform,” says Suyamprakasam.

In 2009, Suyamprakasam had been fresh out of engineering college when he travelled to Dubai and had a knee injury. He had no insurance. He consulted a doctor over the phone and was told that it was not a fracture, as he had feared, but an MCL Grade 1 injury, nothing to be alarmed about. The germ of a business idea was born. He came to India and formed the company in 2010. It would take another two years to launch as a simple video consulting platform. And then it would take two more years to get any traction. From 2014, the business focused on expats—Gujarati, Telugu and Malayali, in that order—and that is when it began to pick up. “We have patients from 100-plus countries and most of our revenue is from the international market, especially from North America,” he says.

It was hard to get doctors on board initially, but the proposition sold to them was that it would expand their horizon to other cities. Patients were given free consultations so they could trust the process. “The first use of the platform will be out of curiosity and our marketing language is aimed at triggering that curiosity. It took me one-and-a-half years to get to 1,000 patients,” he says.

Since he was an engineer, Suyamprakasam was clueless about the consultation process, and he decided to intern with doctors. One consultation he observed was particularly useful. He saw the doctor being attentive in the beginning, then switching off and then becoming alert again. He asked the doctor later whether there was anything about the patient that he disliked. “He said, ‘No no, everything went well. Check out the medical outcome after four days.’ The outcome was good,” he says. Suyamprakasam realised that there was a reason for it. The patient begins by telling his chief complaint and then, as he gets into a comfort zone psychologically with the doctor, he starts providing irrelevant details, making the doctor lose interest, until the latter once again starts probing for particulars on the ailment. This subconscious process gave Suyamprakasam a clue about how he should formalise the consultation process in iCliniq: doctors are encouraged to ask as many questions as possible and patients are nudged to be articulate themselves. Consultations (the starting price for which is Rs 199 per query, with additional charges for other services) can happen via chat, audio or video.

Suyamprakasam remembers one father posting a question about a rare disorder, Storage Pool Disease, that his son had inherited. “Not many doctors would have encountered it. The father was not finding any information, so he consulted a haematologist in iCliniq who advised him about some precautions before taking any surgical procedure. These were not known to the doctor who was treating the boy. It probably saved the boy’s life. A patient from Yemen, who had no access to a cardiologist, had an emergency heart issue and an iCliniq doctor could suggest some temporary measures till she could get access to a specialist there,” he says.

Among specialisations, he says there is a global trend for people seeking gynaecological consultations online. “From Indian cities, psychiatry is in high demand. Smaller towns ask for cardiac opinions because they would not be able to go to bigger cities,” he says. About 40 per cent of iCliniq’s patients are from smaller cities and towns, but that number is swiftly changing. He expects it to be 60 per cent by next year. “There is increasing internet penetration there and also a lack of specialists. For instance, India has just 28,000 gynaecologists and less than 5,000 dermatologists. Most of them seem to be in bigger cities. People from smaller cities have no option but to come online,” he says.

SOME ONLINE CONSULTATION platforms focus on niche medical specialisations. Like Onco.com for cancer specialists. Founded by Rashie Jain, an engineer, and Dr Amit Jotwani, an oncologist, they both arrived at the idea separately. Jain had done her biotech engineering from IIT Kanpur and worked in healthcare for nine years where she was exposed to the cancer treatment landscape. She had also had a personal experience with cancer care—when her father-in-law was diagnosed with esophageal carcinoma in 2009, the family had floundered. “We struggled to get information on what treatment and outcomes should be expected, who is the best doctor for his cancer. The information gap was massive and we were clueless. That was the inception of this idea in my mind. How do you get information on what is right for you?” she says.

Her co-founder, Dr Amit Jotwani, was also thinking of ways in which a technology-enabled business could be created in this specialised domain. Jain was doing her MBA from Wharton University and a professor, who also taught at Indian School of Business where Jotwani was studying, saw that both were working on similar ideas and introduced them to each other. “We had complementary skills. We got together and said let’s do it. That is how this company started,” says Jain.

Every month, Onco gets around 3,500 patients from 15 countries. They have 840 doctors on their network. Patients who come to Onco are asked a few fundamental questions on the type of cancer, stage, if they have undergone any treatment, how they are doing physically, etcetera. An initial free assessment then tells the patient what tests to undergo and which specialists to consult (for example, whether to go to a surgeon or a medical oncologist). Patients can then upload reports and choose paid services. An opinion from a multi-disciplinary panel of two or three oncologists is one such service. “We form that panel for the patient based on their condition. They give a collaborative multi-disciplinary opinion. That is how cancer cases are reviewed in the US, by the way. We tell them everything they need to know about the disease: follow-up plans, treatment recommendations, what to expect, what tests to undergo. If they want to connect with doctors for that specific procedure, we book appointments too,” says Jain.

Patients are also given information on clinical trials that are happening if they want to participate. There is also an option to get an opinion from a panel of oncologists based in the United States (Prices range from Rs 7,000 for a report by an Indian panel to $850 for a US panel). For every opinion that oncologists provide, the revenue is shared.

Onco’s patients are predominantly from South Asia with 80 per cent from India. Their second biggest market is the African continent, mostly countries like Nigeria and Kenya. Jain recounts a patient who had come from Kenya to India for an ovarian cancer surgery. “She was in recovery mode and about to fly back to Kenya when the local oncologist advised another surgery. Her husband got onto Onco.com and we assigned a panel of a surgical oncologist and a medical oncologist. They ruled that surgery need not be an option for her. She actually needed chemotherapy as per surgical guidelines and patient data. And chemotherapy could be done in Kenya itself. There was no need to stay in Delhi and spend so much.”

The main cases Onco sees are lung and oral cancer for men, and breast cancer for women. In India, half the patients are from big cities and the rest from Tier 2 and 3. “We were surprised that 50 per cent come from smaller cities. They are getting treated, but local infrastructure is bad,” says Jain. Jain quotes an Ernst & Young report that said 70 per cent of Indian oncologists reside in around eight cities. “A lot of patients would never have access to these doctors, but technology can now connect them.”

IN 2009, WHEN Shipra Dawar went to Australia to study management, she was 21 years old. It was the first time she was away from her family in a new environment. Unable to cope, she began to exhibit classic symptoms of depression— gloominess, fatigue, loss of concentration. One of her professors suggested she see the student counsellor. “I said, ‘I am sane, why would I see a counsellor?’ The words he said left a great impact on me: ‘Only sane people recognise there is an issue and they fix it’,” she says. Dawar went, and in about five sessions began a recovery process that eventually led her to be a gold medallist in academics there.

She returned to India and was working with Boston Consulting Group when one of her colleagues, who was going through a divorce, showed similar symptoms of depression. He was reluctant to take help despite Dawar’s exhortation because he didn’t know how to go about it and wouldn’t get time off from work either. These experiences led Dawar to the possibility of a business around online counselling.

“I found that in India we have only 900 registered clinical psychologists. Trained ones. And less than 10,000 counsellors for a population of 1.3 billion. And these are concentrated in metros. And then they are in hospitals and accessing them without a psychiatrist’s prescription is difficult. There was a lot of supply side chaos and a need also,” she says.

It led her to founding ePsyclinic. She put together a team of psychologists, and in 2015, launched online consultations through audio, video and chat. The business model has now evolved to be app-driven over mobile phones. Called iWill, a person who needs counselling logs on for an automated algorithm- based assessment. The app asks questions about mood, behaviour, emotions, age, gender, work, soft personality questions, and pairs the person with a therapist. Dawar says after launching ePsyclinic, it got just two consultations in the first month. Now, in the past five months, it has sold about 7,000 therapy programmes (prices range from Rs 3,600 to Rs 9,900 ) on iWill.

Dawar believes it is inevitable that online counselling will soon trump offline for three reasons. “One, talk therapy can be administered completely online. Second, convenience of online sessions cannot be matched by offline sessions. Therapy programmes are typically long. Commitment to a physical offline set-up is difficult. Third, psychologists are concentrated in metros. You cannot create more supply. Matching the existing supply to the larger population in non-metros can only be done online,” she says.

Government regulation of online consultations in India is hazy. In August, the Indian Medical Association (IMA) released a statement asking doctors to avoid phone consultations. This followed the Bombay High Court making adverse observations about the practice while hearing the case of a doctor who had prescribed medicines over the phone for a patient in a nursing home without an examination. She died and her husband filed a case of negligence. IMA’s statement was in the nature of advice. Online consultations that stick to the role of a second opinion do not seem to be in conflict with prevalent laws or ethics.

Dr Makode, for example, is clear that online cannot be an alternative to direct consultation, only an addition. Many of his patients too view it as that. “I notice them using an online consultation after they have visited a doctor. When they visit the doctor the next time, they discuss those possibilities. A direct visit becomes more fruitful then,” he says.

Giving prescriptions online remains a tricky issue and there is really no regulatory clarity on it. At present, not doing it is a choice many doctors and platforms make voluntarily. However, as competition increases with more businesses entering this space, this dynamic could change. Suyamprakasam anticipates government rules that would cover platforms like his and welcomes them. “It has to be regulated because only then can quality be maintained in patient care,” he says.

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