A Pristyn Care sales executive first contacted her on 11 May with details of the procedure she would eventually undergo—insertion of an intragastric balloon made by US-based Allurion Technologies. The next day, the same sales executive sent her a doctor’s prescription on WhatsApp, which contained a recommendation by Dr Nelson V Junghare, a young general surgeon, proctologist and laparoscopic surgeon, that she go for bariatric therapy. The Body Mass Index of the patient, as noted in the prescription, was the minimum mandated by India’s insurance regulator for such a procedure to be covered by insurance. The treatment, which costs a little less than ₹4 lakh, involves the patient swallowing a pill, which inflates into a balloon once inside the stomach. This limits the amount of food a person can eat and forces a calorie deficit, resulting in weight loss.
On 20 May, Panchal was admitted to a hospital in Mumbai’s Goregaon suburb to undergo this procedure. Just about half an hour later, however, she felt pain and unease, started vomiting, and began asking the doctors to remove the capsule from her stomach, according to a family member who asked not to be named.
Initially, her doctor counselled her that the uneasiness and nausea is a normal reaction to the procedure. But Panchal’s situation continued to deteriorate over the next few days.
What transpired next is now the subject of an investigation but raises unsettling questions about this emerging model of healthcare delivery. Pristyn Care, founded in 2018 by former Urban Company executive Harsimarbir Singh and doctor couple Vaibhav Kapoor and Garima Sawhney, partners with hospitals to lease infrastructure such as operation theatres and leverages digital marketing and a large sales team to convert online search queries into consultation and surgeries across a host of specialties such as gynaecology, ENT, urology, orthopaedics, dentistry and others. Elective surgeries differ from emergency surgeries in that they are planned in advance and patients tend to consult multiple doctors and also shop for the best offers.
Pristyn Care advertises competitive prices and discounts for surgeries across the board. It’s a venture capital-funded startup, with attendant growth expectations. The company has so far raised $177 million across five rounds. The latest was in December 2021, at the height of the start-up funding frenzy, when it was valued at $1.4 billion. Its investors include Peak XV (previously Sequoia Capital), Tiger Global, Winter Capital, Epiq Capital, Hummingbird Ventures and Trifecta Capital.
While it leases hospital infrastructure, the start-up brings in its own doctors, medical equipment and medical consumables. This also means the patient can be somewhat isolated from the broader ecosystem of the host hospital.
Panchal underwent the procedure at Lifeline Hospital, a Pristyn Care partner hospital in Mumbai’s Goregaon suburb. As the pain and discomfort did not subside even after two days, relatives begged the doctor to remove the balloon, according to text messages seen by Mint. On 22 May, the doctor messaged a relative saying he had already asked the hospital for the balloon to be removed even though he is supposed to wait for five days but wasn’t sure why that had not been done. “I don’t know why it has not got removed today, even after requesting for getting one today itself,” the doctor wrote in one text message.
At Pristyn Care’s offices in Delhi, this case raised hackles as the relatives were threatening legal action if the patient wasn’t immediately relieved of her pain. At least one senior executive involved with monitoring of this case later told another in exasperation that the delays were unacceptable for a startup. “We are concerned about insurance and money more than the patient,” the senior executive confided, according to the latter, suggesting the removal was being held up partly due to confusion and concerns over whether insurance coverage might be denied due to premature removal of the balloon.
Ultimately, two more days would pass before the surgery to remove the balloon was done on the evening of 24 May, after securing the presence of a gastroenterologist to perform an endoscopy. On the morning of 25 May, Panchal, a single mother of a four-year-old boy, died.
The grief stricken family has filed a police complaint alleging medical negligence. A spokesperson for Goregaon police said it was awaiting a chemical analysis report from the Directorate of Forensic Science Laboratories Ltd in Kalina, Mumbai.
Pristyn Care contested insurance money was a concern. “We wish to emphatically address and dismiss any allegations suggesting that the level of care provided to the patient was influenced by insurance considerations. We want to make it unequivocally clear that the pre-authorization process was firmly established well before the procedure and we don’t see how and why this conjecture can be constituted.”
It’s unclear what caused the fatal two-day delay between 22 May, when the doctor told a relative he has already told the hospital to remove the balloon, and 24 May, when the procedure to remove it finally took place. Also unclear was who was responsible once unforeseen complications developed. The Pristyn Care doctor who did the surgery was initially unavailable to relatives and later said the hospital was to do the removal. Dr Junghare, who ultimately performed the procedure to remove the balloon as well, declined comment saying the matter was already under investigation and he had given his explanation in writing to authorities.
Pristyn Care, while offering condolences, said that it is cooperating with the relevant authorities and noted that this was a rare instance of mortality among its patients.
“The overall mortality rate for elective surgery in India stood at 2.4%. Notably, at Pristyn Care, this rate is less than 0.0015% in the past 5 years, underlining our commitment to maintaining the highest standards of patient safety. Surgical procedures are undoubtedly intricate and come with inherent risks. While our approach is centred around patient safety, there are rare instances where unforeseen complications can occur, resulting in mortality,” the company said in a statement to Mint.
Surgery after surgery
How the incentives of various stakeholders work within the ecosystem Pristyn Care has built can be troubling when compared with the conventional approach of healthcare professionals, bound by the Hippocratic credo of ‘First, do no harm’.
It’s healthcare delivery layered with digital marketing, pushy sales executives, discount offers on surgeries and doctors judged by their ability to convert consulting outpatients into surgery customers. It’s what healthcare might look like on venture capital steroids.
Two people familiar with the company’s inner workings said that growth has been flat over the last two years, causing consternation among founders and senior management trying to meet targets.
The company said in a statement that “it is projecting to reach a revenue exceeding ₹1,200 crore in FY2023-24″. It last reported an operating revenue of ₹96 crore in FY21, according to MCA filings.
In its bid to boost growth, the company is pushing its sales executives to limits, the two executives cited above said.
Two patients who independently spoke with Mint on the condition of anonymity said sales executives and the doctors they were in touch with initially asked them to opt for surgery, and only later offered non-surgical options. Typically, surgical options are more expensive and offered only after the options for medical management of a condition are exhausted. An elective surgery, which Pristyn specializes in, can fetch the startup upwards of ₹30,000 and could run into several lakhs, as in the case of Amita Panchal.
One Indore-based couple, seeking a medical termination of pregnancy, went to a Pristyn Care doctor because she was offering a free initial consultation. The Pristyn sales executive and later the doctor spent a lot of time pitching surgery, despite the couple’s stated preference for a non-surgical option as the pregnancy was at an early stage, one of them told Mint in an interview. The couple thereafter opted to go to a larger hospital chain which prescribed drugs for the abortion, while also offering post-abortion care. The final bill also worked out to be much cheaper than what Pristyn Care was pushing for, they added.
In another instance, Mumbai-based Sohil Gurung went to a Pristyn Care doctor to treat haemorrhoids in early July. One week after his surgery concluded, he was in extreme discomfort and found new growth (of piles) at the site of the surgery. In the post-surgical consultation within a week, the Pristyn Care doctor recommended a second surgery, which would cost the patient extra money, Mohil, the patient’s brother, told Mint.
Seeking second opinions, the brothers went to two different doctors. Both doctors said the first operation had been botched up, Mohil said. After failing to register their complaint with Pristyn executives through the call centre, the brothers took to social media with their complaint. Pristyn executives thereafter offered a follow-up consultation with one of their own senior doctors.
“The senior doctor then told us immediate surgery was not required. They have prescribed creams and ointments as part of the treatment for now,” Mohil said.
Pristyn Care denied that its executives and doctors pushed patients to opt for surgeries. The company said over 12,000 new patients reach out to the platform daily, of which it performs around 1,300 consultations at Pristyn Care clinics. Of this, only around 200 surgeries per day take place at Pristyn Care partner hospitals, the company said. “This figure is much lower compared to similar renowned hospitals in the country,” the company spokesperson said.
“We recognize that surgery isn’t always the initial course, and some patients can find relief with appropriate medical management. Similarly, our approach emphasizes conservative strategies, exploring non-surgical options first,” the company said in a statement. It said each surgery is evaluated by Pristyn’s Medical Directorate team.
However, two company executives, with a high level of knowledge of company operations, who spoke to Mint on the condition of anonymity, said Pristyn Care maintains a registry which monitors each doctor’s specific conversion rates from out-patient department to in-patient department (OPD to IPD ratio).
Documents seen by Mint showed that most Pristyn doctors report a conversion anywhere from 60%-70% to well over 90%. There are also doctors with 98- 99% OPD to IPD conversion rate. “Sales executives also mostly send patients to doctors who have a higher conversion rate, as it helps them score conversions and meet targets. Doctors with a poor conversion ratio are slowly weeded out of the system that way,” one of the people cited above said.
Pristyn Care said it rejected “allegations of coerced surgeries”. “When patients reach out to us, they generally come after already consulting with doctors multiple times, only then they decide to undergo a surgical intervention,” the spokesperson said.
“Our current conversion rate of between 2% and 2.5% indicates that only 2 or 3 surgeries occur out of 100 patient interactions. We demonstrate our commitment to suggesting surgery judiciously,” the spokesperson said. Patient interactions include all conversations, including with sales executives and others, and are not limited to doctors.
“We adopt a model where our doctors receive a blend of fixed salary and a variable component, which is below the current industry benchmarks. Also, in contrast to conventional hospitals, we alleviate our doctors from the responsibilities associated with patient acquisition,” the company said.
Not everyone is convinced. Aniruddha Malpani, a doctor who runs an IVF clinic and is an angel investor through Malpani Ventures, said that the Pristyn Care model is skewed in favour of over-medication and its set-up is ripe for errors to occur.
“The Pristyn model encourages a behaviour where there are too many transitions of care with no one taking responsibility for what happens to the patient,” said Malpani, a vocal critic of Pristyn Care.
After having raised venture capital funding, its focus has been on growing revenue.
“Your bottom line is how do we increase revenue and people do not think of second order consequences. This is what leads to unnecessary surgeries. This is what leads to over- medicalization of treatments that can be managed conservatively,” he said.
One could argue that conventional hospitals also have instances where doctors push patients towards unnecessary surgeries, but the problem with Pristyn Care is “that they are institutionalizing this sort of bad practice,” Malpani said.
Pervasive churn
Pristyn Care’s fervent pursuit of growth is also causing its employees to work in toxic environments, sometimes leading to absurd situations.
Take the case of Jyoti Sharma, who joined Pristyn Care as a sales executive straight out of college in April and was assigned to the proctology department, a branch of medicine related to the colon, rectum and the anus.
Her job was to telephone patients who could potentially undergo a surgery at Pristyn Care. “We would get leads from our manager and our targets were to secure 18-20 surgeries a month,” she said.
The problem was that like many of her colleagues, Sharma was falling short of her targets. In the months of May and June, she had been able to convert or convince only around 8-10 patients to undergo a surgery through Pristyn Care.
Sharma said this was because the incoming funnel of leads was poor.
When Sharma joined the company in April, she was promised 300-400 such leads each month. But she ended up with only around 150 such leads in May, June and July. There were days and weeks when there would be no incoming leads as well.
One day in July, her manager cracked the whip, telling team members that they could not go home till they had achieved targets, even if it meant staying back at the office till midnight.
After 8 pm, when Sharma didn’t reach home, some 10 minutes away, her worried parents called the office a couple of times and were told employees were not available. Then her father showed up with the police to the company’s office to collect her.
Two days later, Sharma quit, and posted her ordeal on social media.
Many of Sharma’s colleagues also quit that month.
It should be little surprise therefore that attrition at the company is off the charts.
The entire category department—which is essentially sales executives who reach out to patients under different categories such as proctology or ophthalmology—reported a 140% attrition in FY23. The medical directorate department reported a 126% attrition, while the finance department reported an 80% attrition for FY23, internal documents seen by Mint showed.
Overall, company attrition stood at 97%—which means the company virtually saw the entire company churn within a year. Over 100% attrition indicates that in those departments even the replacement hires did not last a year.
Pristyn defended the attrition, noting that it divided its employees into two buckets.
It said the first segment included on-ground professionals dealing with care-co-ordinators, insurance and hospital operations, city operations, logistics, etc. “It’s worth mentioning that these roles mostly involve basic positions that tend to experience higher employee turnover,” the company said in a statement, but did not provide an attrition rate.
However, it said its second workforce comprised of corporate team members. “Our leadership team maintains steadfast continuity, and we take pride in the minimal attrition witnessed in pivotal departments like HR, technology and medical directorate. In fact, for positions starting from senior manager and above, the attrition rate stands around 30% to 35%,” the company said in a statement.
Delayed financials
Despite a high staff turnover in the finance, the company has been racing to file its financial statements for FY22 and FY23.
Two people with knowledge of the financial statements told Mint that BSR & Co, the auditing affiliate arm of KPMG International had told the company to get an external agency to “provide comfort” by conducting an internal audit.
These two people, who asked to remain anonymous, said that Grant Thornton was securing, verifying and filling information on behalf of Pristyn Care, which would then be sent to BSR. Some of this information included details of the company’s inventory, doctor agreements and expense trail. The audit is likely to be signed after the information is secured by Grant Thornton, the second person cited above said.
KPMG declined to comment.
“The delay in filing the FY22 financials can be attributed to the exceptional circumstances faced by the healthcare industry in the 2021-2022 period. As a young and rapidly expanding company, Pristyn Care encountered numerous challenges and resource limitations due to the unprecedented events affecting the healthcare sector. Despite these obstacles, we have diligently worked to ensure accurate revenue assessments and financial compliance. Regarding the FY22-23 financial statements, we are on track to file them before the September 30th 2023 deadline. Both statements will be filed before Sept 30, 2023,” the company said.