‘Consumerisation' Of Health Compromised Accuracy: MD Metropolis Healthcare Ameera Shah

The Covid-19 pandemic and its aftermath made Indians more conscious about health and wellness. The diagnostics sector did good business during the pandemic, as tests became rampant. Several players entered the segment as the overall healthcare segment came under immense pressure. In fact, in the first half of the ongoing financial year, health and wellness stocks recorded a 25-30% rally in the markets.

To understand how the landscape changed after the pandemic, The Core spoke to Ameera Shah, promoter and managing director of Metropolis Healthcare, who said that the wellness segment recorded significant growth. “Pre-Covid, the wellness market was less than 5%. I would say post-Covid it has grown probably between 5-10%, closer to 10%, but certainly not more than that. And we have seen the growth and demand for wellness actually expand post Covid,” Shah said. 

For the company, the business-to-consumer segment currently accounts for 53% of its income. It is now focusing on aggressive network expansion, and simultaneously, it has been growing its B2C segment. This includes both the prescription-led business and direct customer bookings for tests.

“Our B2C is growing at double the pace (at which) our B2B (business-to-business) is growing. B2B… the first six months, if I look at last year, was growing at about 10% per year. B2C (is) growing closer to 20%,” Shah said. 

In this week’s The Core: Weekend Report, Shah told financial journalist Govindraj Ethiraj that the company is strategically focusing on expanding the B2B business to make it the primary growth driver. “Just a few years ago, we were at 35% contribution. B2C, we're at 53% now as an organisation, and we want to get closer to 60-65%. We will keep pushing B2C as we keep growing B2B as well,” she said.

Edited excerpts:

You know more about me perhaps than I know about you. So tell me, what is it that you know about me right now? Apart from the fact that I might be dying soon!

Thank you for having me. But I don't know that about you. I'm not an astrologer. But look, when I think at Metropolis, obviously what we do is try to figure out the inner health trends, right? The things that all of us can't see in the mirror when we just look in the mirror. Therefore we land up having very important data on people and on their health. 

I think the trends that we are seeing, especially post-Covid — one we're certainly seeing is that the heart is certainly under more pressure, more stress. And we are definitely seeing, as we've seen sometimes in the news as well, that with the heart having weakened due to Covid, any additional too much pressure on that heart — sometimes people don't even realise what's happening — could be running on a treadmill, it could be running a marathon, it could be just something not even doing physical exercise. But usually, it is with some extreme physical exercise, that the heart is giving way. So that's definitely something we've all got to continue to monitor. And I think the known fact is that especially for men who are under more stress for cardiac disease above the age of 40-45, it's very important to do a CT scan as well as a cardiac risk profile on a regular basis — every couple of years just to see that things are okay. 

The second thing we're seeing is with pollution gone incredibly, very high in India, especially in metros like Delhi, Bombay, Calcutta, other places, I think we are seeing lungs really suffering from a perspective of just not being as healthy as they used to be. And the polluted air that we're all ingesting is actually, I saw one statistic somewhere, it's equivalent to smoking 25 cigarettes a day. And so I think we've just got to keep watching what's happening inside our bodies very carefully. 

The third thing I just want to point out is allergies. Allergies are something we've all got very used to living with. We all keep sneezing all day. We cough all day. We get on with our lives. We don't do anything about it. And we think it could be pollution, or we think it could be viral, which it certainly could be, but many times it's actually just an allergy. And that is something we have control over our bodies…to figure out what's actually irritating our systems and what's causing us to react in some way or the other. 

Let me start with the heart or the cardiac part first. What is the diagnostic call that comes to you? What are people looking for? Or what are the early signs that they are seeing that tells you that people have a heart problem?

There's something called a calcium score, which basically tells you sort of the amount of plaque that gets built up in your arteries, in your heart. It's like the kind of plaque that you have in your teeth. And with your calcium score, you can actually determine whether that's something really risky or not. Now, that can be determined through a CT scan. It can also be determined through a plaque test. We also have a profile called the cardiac risk markers. So include things like that. By doing a combination of these tests, you actually get a sense on are you at risk of a stroke. Are you at risk of a heart attack? Where does your heart stand in the current state? 

The good news is we have lots of diagnostics that help us to figure out what's happening. But this recent trend of people feeling like: Oh, I did a Rs 500 health checkup and I'm now all, okay, and I've ticked my box is total hogwash. And I mean, honestly, it's very important, and we'll maybe get to it later, but super important that you do the right number of tests. You don't need to do 100 tests. You need to do the right test for you. An important thing is you do it at a good quality lab that gives you accurate results.

The right test is something that would be obviously recommended by the right doctor. In this case, let's say, just to stick to the cardiac part, would be a cardiologist who would refer a patient. Is that how your flow of patients or their diagnostic needs is happening?

There's a wellness side and there's an illness side. On the illness side, you're right. Usually people fall sick, then they go to a doc and they get a prescription and they come, and the doctor is actually determining what test they need. 

What's happened in the wellness category is people are now assuming that actually I know better and I want to take health into my own hands and I want to be empowered to make a decision. Now, unfortunately, they don't have the knowledge to know how to make those decisions. One is the want to make it, and the second is how to make it. 

What people usually end up doing is they just go and they find a cheap package or something that says 100 tests, and they feel like: Oh, it's covered every part of my body, and I'm fine. And actually, that's the wrong way to go about selecting it. The right way to do it is to actually look at your family history. So some things are common, which you do for everybody, like a sugar and a thyroid, etc. But you got to also look at your family history and say that, look, if I've seen my father or my grandfather or somebody in my family pass away because of a heart attack or somebody's had a neurological disorder, or somebody's had diabetes in my family, or somebody's had autoimmune, like thyroid, then I need to include those to watch out and see whether I can find something in my body that reflects the same thing that I've inherited genetically. Curating your package is a very critical part of it. And like I said, if you land up going to a good quality lab, which is a brand, we will actually help you curate packages that make sense. 

You've taken a couple of potshots at the Rs 500, but I'll come back to that in a moment. But tell me today, in a day, how many tests do you do on a good day or a normal day? 

Hundreds of thousands. We land up getting tens of thousands of samples, and each of those samples require multiple tests. You'll end up doing hundreds of thousands of tests. 

And how many would be triggered by, let's say, doctors who have asked for something versus the wellness that you just spoke about.

About 90% of the market is still illness driven. It is people falling sick, going to the doctor, the doctor taking a call, what needs to be done. Pre-Covid, the wellness market was less than 5%. I would say post-Covid it has grown probably between 5-10%, closer to 10%, but certainly not more than that. And we have seen the growth and demand for wellness actually expand post Covid. But not as crazy as it was during Covid. Because during Covid people were just paranoid, and people really just wanted to make sure they were okay. And unfortunately, like any epidemic, once it's over, that awareness sort of dips, and then people sort of get a little bit more relaxed, and then the focus moves to more consumption of other things. 

But your revenues are growing in a secular way. You were, about 700-750 in 2018-19, and you are double that today, including the spike that we have seen during Covid. What stayed on? I mean, in terms of tests now, what are people doing more and how is it different from, pre-Covid? 

Like I said, the biggest difference is the wellness category has so more individuals and consumers are wanting to check their box and saying, I did a wellness package. That's certainly one trend which we've seen post Covid. 

The second trend is that even people who are coming for illness and who, let's say, came for three tests are now saying: look, if you're taking my blood, please do more and let me just cover more parts of my body. So that, again, sort of falls into the bundling or the wellness category. Just people wanting to seek more proactive information. 

I think the third thing we are seeing is people wanting to be more involved in the health decision. So there's definitely a lot more Google searches and other kinds of searches on YouTube,  trying to understand what's happening. 
Pre-Covid, there was a mindset, I'll go to my doctor, my doctor will guide me, and I don't need to do any research. And that's certainly a trend, which I would say in the last 5-7 years has really changed where consumers really want to understand. The problem with this only is there's so much misinformation out there that on any site, everything leads to cancer. So that only lands up actually creating a lot of anxiety for people because you don't know what's real and what's not, and everything scares you. And I know doctors, specialists get quite annoyed by the fact that patients will come and challenge their opinions and say: Oh, but Google said this and you are saying something else, so why would I believe you? 

And I think there has to be some balance between people understanding that the information out there is just information. It's not always accurate, it's not always factual. And when you're putting information out there, you're going to put every disclaimer possible. I mean, you take a Crocin tablet today and if you actually read the disclaimers on it, you probably never take a Crocin again. 

You said cardiac lung and then allergies. Would it be fair to say that the majority of tests that come to you relate to these three conditions one way or the other? 

No, I would not say that. I would say that a lot of the illness that comes to us, actually, we are very differentiated from most other labs in the fact that we work mostly with specialists. So oncologists, nephrologists, neurologists, gastroenterologists, people treating more significant issues, brain transplants, kidney transplants, heart issues, cancers, very significant cancers—those are the kind of doctors that actually refer a lot of patients to us. A lot of our business is actually very specialised health along with these three as well. It's a fair mix, I would say. But it's not majority based.

There are three things that you mentioned, and you said part of it is somewhat post Covid, but are there any newer things that you're seeing which are more on the horizon, which perhaps we don't know about as yet? 

Certainly. I mean, the most advanced, fast-moving area is genetics and genomics. That's an area. Today, when we take any tablet, it goes into our stomach first, then it goes into our bloodstream. It lands up, impacting other organs as it goes into our total body. In the future, we will see microbots delivering drugs to the specific organ it needs to be so that you don't have side effects on other things. Now, how do you determine all of this? 

A lot of it is going to be determined by your genetic makeup and what's actually happening in your body genetically. What are the traits you've inherited? What are the mutations which are in your body? And it's always a combination of genetic potential mutations, disorders, plus your lifestyle that leads to a problem. It's not just one or the other. You do sometimes see people who've had very healthy lifestyles will still have significant issues because of genetics or sometimes because of reasons unknown. But, for example, there used to be a time when women used to have miscarriages consistently, and they didn't know why. Today, we can genetically tell you whether you have a mutation that causes the miscarriage. 

Now, how much you can change it, you can't change it is still up for grabs. But you can understand why what's happening to you is happening. In cancers, we can actually, let's say somebody in the family has cancer and passes away. If you figured out which genetic mutation they passed away because of, and they got the cancer, you can then trace the family tree to see are there any other members of the family who have the same genetic disorder or mutation that may cause them a predictive possibility of cancer. There are some really interesting, amazing things happening. 

And this is available right now or is it? 

It's available right now. Again, because of a lack of regulation, there's a lot of noise out there. You'll see a lot of people talking about full genetic makeup and all of that. It's not necessary and frankly, not even fully accurate. What we are focusing more on is illness based stuff where actually you get good accuracy. If you come for a specific reason and say that, look, I'm looking for this thing, actually, the genetics today is pretty accurate and great to tell you where things stand?

Like, if you are a pregnant woman, you can actually figure out all the prenatal genetic potential diseases that an embryo or a foetus could have and therefore decide whether you want to terminate before the legal period or not. I think when you're looking for something specific, because of the entire genomic structure, we are still a needle in a haystack. We haven't mapped the entire human genome yet. When you're doing this entire thing, I'm just going to map everything. Actually, the accuracy is quite low, but when you're looking for something specific, the accuracy is high. 

Is this something that you are seeing at scale or is it more experimental in some laboratories?

I mean, it's available in more specific labs because they require a lot of specialisation in it, or at least good quality stuff. But now it's being prescribed more on mass because doctors are realising that how important—you take neurological diseases the next ten years is going to be all about neurological diseases and cancer globally. Things like Alzheimer's, dementia, Parkinson's and strokes, many other neurological diseases, you're only going to see it increasing. And genetics plays a very, very important role in all of these things. So I think we are going to see prescriptions only increase for genetics. 

Let me come back to your daily bread and butter work. Give us a sense of the number of samples. I mean, you said tens of thousands, but the samples that arrive at your collection centres, where are those collection centres typically? How many belong to you, how many are outsourced? And what's the journey like of a typical sample collected, let's say, in a city like Mumbai or maybe even a smaller town? 

Broadly we have two channels. One channel is B2C (business-to-consumer) where we have about 3,700 centres across approximately 500 cities and towns of India. By the end of this year, we'll be closer to 600. So what happens is patients can walk into these centres directly, or patients can go to a hospital, or another lab and give the sample and say, I want a Metropolis report. And that can also come to us through the B2B (business-to-business) channel. And then they would still get a Metropolis report. There are two different ways to access us. Obviously, the centres also include home visits and other things like that. 

Out of the 3,700 centres, about 450 centres are owned and operated by us. And approximately the balance are franchise collection centres. But they look and they feel and operate under our quality protocol. So they only collect the sample. And then that sample comes to our lab and we do all the testing and give them. Including the containers in which you collect the blood go from Metropolis. Because those containers have chemicals which are very important to mix with the blood to give an accurate report. And you don't want people taking shortcuts on those kinds of things.

What's very interesting is that there's a perception that a routine sugar test toh koi bhi kar sakta hai, anybody can do cholesterol (test). And while there are many labs who do it, what's important about pathology is precision. Somebody may say: ‘Oh, unnis bees meh kya hai’. But there's a big difference. Because let's say 200 is the cut-off for abnormal cholesterol. Like a normal is less than 200, abnormal is above 200. And if a lab just let's say, puts a sample which is not using the perfect container, not shaking it the right number of times, not transporting it in the right cold chain, not drawing the blood in the right way, not centrifuging it at the right speed, all of these steps are not taken care of, that sample comes to your lab and let's say you get 199. 

Now what a lot of labs do is they put the sample in the machine. And whatever report comes from the machine, they give it to the patient. Let's say you get 199. Now what does your doctor do with this result? Are you normal or are you abnormal? And if you were doing unnees bees, then you could have said that 199 could have been 180 also because it would have been within 10% variance. But actually, what if that 199 was retested, which is what we do, we retest. 

If we find anything on the borderline, we retest it again on a different technology, sometimes a different sample. And we will only give a report that we are sure of. 
Suppose it came 205, so that we know now that actually it's abnormal. Now, a 10% variance there could be critical for a person. It could be 180, it could be 220. 

You're doing this because you're seeing variations in the first run?

We use the best quality machines in the world. But I can tell you, the best quality machines in the world don't give you 100% accurate reports every time. Because every machine has technical loopholes and every machine has issues with it. So we have figured out, through 40 years of experience, which machine gives you the right test for the right kind of sample. And we still don't trust it 100%. And we'll repeat it when necessary, when it's on the borderline, to make sure the result that's being given is fully accurate.  

Then it's not only about giving the result, it's about the interpretation of the result. Right. What does the doctor make of that number and how do you apply it to treatment? So that interpretation, we do a lot of work on. We do global research and we put down, we make Indian reference ranges. See, most of these machines have been done R&D (research and development) in the Western world. 

Yeah. I've seen doctors ignore some of these findings because they feel but this is okay, this cholesterol is fine for India, right?

What we've done is we've Indianised the reference ranges based on our experience. A normal anaemia, for example, a haemoglobin below twelve globally would be considered anaemic. But in India, we know that Indian women generally have less haemoglobin. You will be actually wrong by putting twelve as the cut off, we've, based on data and patterns, we've created the cutoff to be lower. Right. So that doctors are able to make more sensible decisions based on our physiology and not a Western world's philosophy. lots of things like that make the report very differentiated versus just it being something commoditised. 

But if I was the user of your service, what are the, let's say, the diagnostics, which I should be careful of and maybe even retest, because they could be errors. 

I mean, honestly, it can be anything from a basic sugar to a complex test. If there's no test, which it feels like, oh, these are the specific ones where it could be an error. We have seen cases where consumers have gone to three different labs and given samples the same day, and the results in three different labs are highly variable, and the consumer will say, look, how do I know what to trust? And I would say, look, go with a good quality branded lab, which is NABL, CAP-credited because at least somebody is coming from global institutions and checking our processes. 99.9% labs in India don't follow, have any regulation or any approval system, and therefore, you don't know what is happening behind the scenes. 

But 85% of the market is unorganised… So therefore. 

Eighty-five is unorganised. But whether the market is unorganised or organised, I would have hoped, and still hoped that the government would put some minimum standards for 100% because you're dealing with life and death. If your diagnosis is wrong, your treatment is going to be wrong. A patient has a fever. Now, does that fever mean, is it dengue, leptospira? Viral, bacterial, what is it? And when the symptoms are the same. 

Now, when there is no minimum standard, you are giving a leeway to labs to say, I can take shortcuts on not putting good vacutainers. I can take shortcuts on not running controls. I don't have to use automated machines. I may have manpower, which is not qualified. You can do anything you want, which is what's happening today. And which is the scary part. 

But this sounds like you're saying that there are almost no guidelines for functioning or process control in diagnostic labs in India? 

I'm telling you there are no guidelines and there is no regulatory body. Nobody has any oversight. 

So anyone could just set up a diagnostic lab? 

Anybody today can set up a diagnostic lab. 

You don't even have to be a pathologist? 

No. 

To open a pharmacy, you have to be a pharmacist. 

That's right. But 90% of labs today are owned by non-pathologists. 

Because it's a lucrative business. 

Because it's a lucrative business. It has created a mushrooming of labs, which is fine as long as it provides great access to people. But there has to be a minimum quality standard, which is what is globally followed. But we don't have that in India yet, which leads to all kinds of malpractices and opportunities for people to take shortcuts. And who suffers? It's the patient, because that same patient gets a wrong diagnosis, or they have to go and get multiple diagnostics, which means it costs them money and anguish before they get the right result. 

Let me come back to the journey of the sample. I'm assuming a large part, not a large part or a good part of your effort, and your bandwidth is about the logistics of it, the time it takes to reach the laboratory, and if it's a complicated sample or it's going into multiple tests, the time it takes to turn around. Because finally, patients, the speed of the response is as important as the response in many cases.

This is a slight misnomer. I know consumers are always anxious to have their report as fast as possible, but the reality is not every result is critical. A thyroid test is not a critical result. It's not going to determine whether you're going into surgery right now or not. So there are some which are more critical, some which are not. 
Having said that, there are some tests which just take time. You take tuberculosis, you take microbiology, any microbiology sample, you're waiting for the culture to grow. Now, if you hurry that up and you don't wait for the culture to grow, you'll give a wrong report. 

Let's take genetics and genomics. There are lots of processes you have to follow, if you want a quality report. Actually, what I keep telling consumers is, I know you're anxious, but don't make your choices based on who gives you the fastest report, because often the people giving you the fastest report are the ones who are taking the shortcuts to actually hasten it and not following quality processes.

Actually, what is important in logistics is not the time taken from one place to another, it's the quality of your logistics. For example, every sample requires a different temperature. It has to be carried at. There are some which should be at refrigeration, some which should be frozen, some which should be at ambient temperature. So each has a different cold chain that you have to work with. And if you sometimes put the wrong sample in the wrong cold chain, it destroys the blood. 
Then, for example, did you separate the sample, the plasma and the serum before you transported it or after? Did it get shaken badly? That will create clots in the sample. Have you transported it on a bullet cart or on a bus with a lot of speed bumps versus on a smoother ride? There are many aspects of the logistics which are actually more critical for the quality of the report than the time it took from one location to the other. 

The time taken is also important. I'll tell you why. For the cold chain, for example, we've tested cold packs and we figured out that, look, you can transport it and it stays cold till that temperature for a certain number of hours. Now, if that transit takes longer than that, then you have to stop in the middle. Like you refuel an aeroplane, you need to change the cold pack and again transport it. Now, who's checking all this? See, we do all of this out of our own conscience or moral compass or because you're doing global accreditation, but that is, like I said, less than 0.1% of it. 

What's the global accreditation and what does that look for in a very broad sense? 

The global accreditation is College of American Pathologists, which is considered the gold standard in our industry. We've been doing this since 2005, where these American auditors not only come in once a year to check all the processes in the lab, they check your logistics, they check your inventory, they check for expired kits. Are you using proper kits? Good quality? Are you running three levels of control, etc. But along with that, every month they send us blind samples, and we do the tests of those blind samples, which means we don't know the data of the patient, we don't know what the result should be. We just know what test should be done, and we do everything, and we submit our results, and they grade us globally, comparing us to labs in Europe, Australia, America, all over the world. 

And we are currently in the top 1% of labs in the world based on their gradation. This kind of keeps you in check on a monthly basis:  hey, are you following everything that needs to be followed, or is anything out of control? And then you have your own QA systems.  You collect customer feedback, you collect complaints, you collect concerns, and you go into the root of each of them. You do a cap on each of them and then try to figure out what you need to keep improving. 

What's a concern that people have been expressing, let's say, in 2023? 

What has happened with Covid is a lot more consumerisation of our industry. Like you said, people are concerned about how fast will my report be delivered? What is the price? Can I get it on my app? The things which are more consumer oriented. But I think people are completely forgetting that the real value of the report is the rightness of the report, the accuracy, the fact that it was done by a qualified doctor, a super specialist in that segment, the fact that somebody looked at all the processes along the way, and whether it came to you in 5 hours or it came to you in 7 hours is not going to change your life, but that result will certainly change your life. 

To come back to the Rs 500 test that you talked about. What is it that bothers you most in this? Because I'm assuming that some of these, many of them are maybe venture capital, health tech kind of companies who are maybe funding it ahead to and maybe spending the same amount as you are, but definitely distorting the market. But is that your key concern, that the price is getting distorted or something? 

No, my key concern is this, that the minute you start to consumerise science so badly, the message you're passing to consumers….because of the lack of regulatory control and oversight, nobody knows what's happening in your labs behind the scenes. Nobody knows if you're running quality controls. Nobody knows if you're using good quality. There's an assumption that everybody's doing the right thing, and now I'm getting it cheaper. But that's not the reality. The reality is often there are significant shortcuts taken to compromise your costs and therefore you're able to offer it cheaper. 

My concern is there—that the fact that we are actually promoting through these schemes and things, you're promoting inaccurate diagnostics, which then doesn't help the patient and which actually creates a sullied image of the whole industry. Because at the end of the day, if good quality brands are not looking into science of what's happening and are just doing things by putting them on machines and releasing them,  that's completely inaccurate. 

Take a CBC, for example, a complete blood count. It's a common test, right? Now, what are the different ways it can be done? Some people will get something called a three part differential counter, where you'll get only twelve or 13 answers, information points in a CBC. Now you do it. You put it in a three part differential. You get 12-13, and you give it. Now, you can do this for even  Rs 150, no problem. But does that give you the data you need to solve your problem? The answer is no. Has a pathologist seen the complete blood count under a microscope? No. Has a pathologist signed it after seeing it? No. 

Versus what we would do, we would use a five part differential. We would give you 25 points of information. A pathologist would actually look at your platelets under a microscope and count them and see if there are abnormal cells in it or not. And then a haematologist, which is a super specialised pathologist in blood, would then sign off and say that, look, does everything look fine or doesn't it? Or put some comments on saying, look, I think there is a concern here. Now somebody will say, why does this matter so much? You take dengue. Your platelet counts fall below a certain level and you're not hospitalised, you can die within hours. You will die. Some of these things in science are so critical, which we've understood that when people commoditise, consumerise, and make it so flippant and casual is what annoys me, because we understand how significant it can be behind the scenes and taking it seriously is very important. 

Dengue is something that people would want to know very quickly. 

That's right. And those results should be given quickly because it's very critical.. So it's important that as a lab, we also recognise what is very critical. And you give it fast. So, for example, for a dengue or for a CBC, which is related to a dengue, we would give those reports in 4 hours and we would send a critical alert to patients or doctors to say, look, you have a dengue positive need to take action immediately. 

In a very broad sense, you're also a listed company. You have a stock price that's moving up and down, and therefore you're responsible to shareholders to be profitable and so on. How do you see… is there a contradiction between all that you said just now and then building a highly profitable company? 

I think that's true in every industry. Look, in every industry, there are players who will position themselves on the upper end of quality and service, and there'll be players who will position themselves on value and price, and that's across every industry. There's nothing different in our industry. I think what's very important as a business owner or as a business manager is to be very clear about who you are and follow your path and not get confused and distracted by what the 50 others are doing, me too guys are doing. 

We are very clear that doctors trust us, patients trust us, and the most valuable asset we have is our reputation and the trust that we enjoy. And we are not going to compromise that by cutting, doing shortcuts, and compromising here and compromising there to boost profits. There are enough other things you can do on operational efficiency, on productivity, on negotiations with vendors to actually manage to still show good financial results without compromising your quality. And people who have knowledge of the industry know how to do that. People who don't and who have come in sort of new just to make sort of hay when the sun shines will follow the easy way out, which is cutting quality to boost profits. 

And you mentioned partnering with hospitals. But hospitals also do their own testing, right? I mean, at least the big ones. Are you like a pop-up in a hospital or would some hospitals welcome you, others won't? How does it go? 

Usually, all hospitals, or even nursing homes have their own routine labs inside their premises. Now, a nursing home will do 50 varieties of tests in-house and they'll outsource another 50. A big hospital may do 300-400, but we have 4,000. They'll outsource the rest. So it does work as a pop-up or it works as a… they'll collect the sample and send it to us. We'll do the reporting and give back the report. Then it's up to the hospital whether they give our report or whether they put it on their letterhead and they give their report. 
 
Okay, so that happens as well. 

That is a mixed bag…That's a part of the B2B segment. 

Is that growing relative to everything else? 

It is. Our B2C is growing at double the pace our B2B is growing. So B2B… the first six months, if I look at last year, was growing at about 10% per year. B2C growing closer to 20%. We are actually very strategically focusing our primary growth driver as being B2C. Just a few years ago, we were at 35% contribution. B2C, we're at 53% now as an organisation, and we want to get closer to 60-65%. We will keep pushing B2C as we keep growing B2B  as well.

And the kind of test that you do, obviously, there is more, let's say value add in some tests, more margins and so on. Are you therefore not doing some tests that you were maybe doing some years ago, or are you still offering the whole package plus something else? 

We offer the whole package. So every test that's possible in India will surely be done by us. We probably offer the largest test menu, and we are adding about 100 tests, 250 tests every year. So it's about scourging sort of globally and finding the most important test, critical tests which need to be brought into India and bringing them in as pioneers and innovators to offer them to doctors first, because we are the ones who create the specialised market. We go to doctors and we actually create the awareness of the latest diagnostic tools available globally. And that's how doctors change their prescription patterns, to use tools which are more helpful in their diagnosis. 

What's a recent diagnostic, either test or machine that you would have brought? 

Going back to genomics and genetics…you take …there's something called NIPT, which is basically done, as I was mentioning, for pregnant women. So you have a foetus, let's say, at three months, usually at about 16 weeks or so. You do this test to figure out all the potential genetic disorders or whether your child is at high risk or low risk genetically. So is there a chance of down syndrome? Is there a chance of significant autism? Is there a chance of some neurological issue? We would highlight those. And then if it's a high risk child, the parent has a decision to make, whether they still want to carry or they don't want to carry. 

A very general question. Since you sit inside a diagnostic lab, are you tempted to use your own facilities often? 

Do I use it more than I need to? Probably not…

Because I know people who seem to be testing all the time when perhaps they don't need to. I think that's more a mindset than it is availability of labs. I think there are people who generally tend to be very concerned about their health and they want to do tests every few. Hypochondriacs are a good market for you…

If you have to label. But no, I mean, I do my tests when I need them. I certainly do an annual checkup every year and then as, and when I need it.

As you look ahead two parts to it. One is what is the kind of disease as opposed to conditions? We talked about cardiac, lung allergies, though we didn't spend too much time on the second two. But what are the conditions that you're seeing that we should be in a way, prepared for and perhaps should be testing ahead as we look at, let's say, the next year or so

Like I was mentioning, I think neurological disorders are growing very fast, and that's an area that is still quite undiscovered scientifically.

And younger people as well

Not so much in younger people, in more older people. We are seeing, of course, heart issues in younger people, 40s, which used to happen earlier, in 60s. Neurologically, we are seeing certain things happening now in the 60s, which we used to see happening in the 70s and 80s. 

There is a lot of space stuff which is still undiscovered. There's no treatment yet for Alzheimer's and all of these areas. But it's very important that at least we're able to diagnose it because even though there's no cure from a medicine perspective today, there's lots of work happening in clinical trials, and I think we're going to see a great number of breakthroughs in the next few years in these areas. 

What's the metric that you track on a daily basis which sort of reflects the health of the people who come to give you samples and so on? 

Say, the only thing I track on a daily basis, I don't track revenue, I don't track profit, I don't track the number of samples, or any of those things. But what I do track on a daily basis is customer feedback. And looking at our NPS, I always believe that patients, when they engage with us, are at their anxious worst. You've got something significant happening to somebody you love in your family, and how we take care of you and how we treat you with the amount of compassion and empathy at that time is very, very critical. And therefore, that, to me, is the most important KPI.