A bold new remedy for the sprawling and wasteful health care industry.
Where else but the doctor's office do you have to fill out a form on a clipboard? Have you noticed that hospital bills are almost unintelligible, except for the absurdly high dollar amount? And why, in health care, is the customer so often treated as a mere bystander—and an ignorant one at that?
The same American medical establishment that saves lives and performs wondrous miracles is also a $2.7 trillion industry in deep dysfunction. And now, with the Affordable Care Act, or Obamacare, it is called to extend full benefits to tens of millions of newly insured. You might think that this would leave us with a bleak choice—either to devote more of our national budget to health care or to make do with less of it. But there's another path.
In this provocative book, Jonathan Bush, cofounder and CEO of athenahealth, one of the fastest growing technology companies in the country, calls for a revolution in health care, one to give the customers Bush calls for disruption of the status quo through new business models, new payment models, and new technologies that give patients more control of their care and enhance the physician-patient experience. more choices, freedom, power and information, and at far lower prices. As he leads readers on an eye-opening journey through American health care, Bush makes a compelling case that this revolution is already underway. With humor and his tell-it-like-it-is style, he forms his analysis from his own rich experiences in the industry. He picks up insights and ideas from his days as an ambulance driver in New Orleans, an Army medic, and an entrepreneur launching a birthing startup in San Diego. In struggling to save that dying business—and to get paid—his team created a software program which eventually became athenahealth, a cloud-based service company that handles electronic medical records, billing, and patient communications for more than 47,000 medical providers nationwide. Through his astonishing career, Bush has incubated a wealth of ideas about how to reinvigorate health care in America.
In Where Does It Hurt? Bush calls for disruption of the status quo through new business models, new payment models, and new technologies that give patients more control of their care and enhance the physician-patient experience. He shows how this is already happening. From birthing centers in Florida to urgent care centers in West Virginia, upstarts are disrupting health care by focusing on efficiency, innovation, and customer service. Bush offers a vision and plan for change, while bringing a breakthrough perspective to the debates surrounding Obamacare.
You'll learn how:
None of this, of course, will be painless. Bush's plan calls for Americans not only to demand more from providers, but also to accept more responsibility for our health, to weigh risks and make hard choices—in short, to take back control of an industry that is central to our lives and our economy. Only by pushing for such choices will we build a flourishing health marketplace, one in which the government, entrepreneurs, doctors, and patients can work together to shape health care that we all want, deserve, and can afford.
"Health care has successfully resisted organizational innovation, to the detriment of our health and our economy. In Where Does it Hurt?, Jonathan Bush tells exciting accounts of current innovation, and irreverently imagines an attainable future in which a vibrant medical marketplace is driven by health entrepreneurs, of which he himself is a prime example. Patients, physicians and policy wonks alike would be well served to take the provocative and illuminating tour."— JEFFREY FLIER, MD
"This is a compelling, entertaining story—an insider's perspective on American healthcare by someone who has been closely involved in its reshaping. Few people amass Jonathan Bush's kind of experience or articulate as clearly what lies ahead. A lovely read."—Abraham Verghese
"Jonathan Bush is not only a brilliant visionary but he walks the talk when it comes to tackling the dysfunctions of our health care system. Reading this book will help you understand why things are as broken as they are and inspire you to be part of the fix."—Regina Herzlinger
"Where Does It Hurt? teaches us all that great entrepreneurship does for reform what yeast does for bread. Jonathan Bush has done it, and now he's sharing the recipe."— Governor Mike Leavitt
"Jonathan Bush is one of the most charismatic and outspoken people in healthcare IT. His passion for driving innovation is changing the industry. The tale of disruption in his book offers lessons for us all."— John D. Halamka, MD
"I loved this book. Jonathan Bush is a goggle-eyed radical foaming for revolution in the house of healthcare—with the crucial, page-turning difference that for thirteen years he's actually been delivering on it. His story alone is worth the price of admission. He's driven ambulances in New Orleans, remade child delivery in San Diego, and has built an Internet company that is transforming the way people practice medicine. And along the way you'll learn more about the real world of how healthcare works than should be possible for a book this interesting. Jonathan Bush is a singular new voice in American healthcare."— Atul Gawande
Upcoming EventsMay 14
Jonathan Bush is Chief Executive Officer, President, and Chairman of the Board of Directors of athenahealth, Inc. He co-founded the Company in 1997 and took it public in 2007 in the most successful initial public offering that year. Today, athenahealth remains one of the health care information technology industry's fastest growing companies.
Bush's views on health care and the idea for athenahealth were born from failures with the earliest iteration of its business model. Bush co-founded and operated a birthing clinic with the idea of franchising a network of clinics that viewed pregnancy holistically. Bush would soon realize that his birthing clinic vision was challenged by his business' own inability to track outstanding claims to insurers and get paid in a reasonable timeframe. This challenge would shape the formation of athenahealth as it is known today. As a result of the challenges with the clinics, Bush and his partners set about designing a solution to address the costly administrative inefficiencies that plagued their business. In doing so, they came to realize their circumstance was more typical than unique and that the solution they architected had great application and utility for the broader health delivery system. Given his vision for an information infrastructure that makes health care work as it should, Bush is focused on creating a true, win-win marketplace that enables a broad and efficient exchange of health information.
Bush's passion for health care extends beyond the evolution of athenahealth. Previously, Bush served on the frontlines of health care as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant in the health care practice of Booz Allen & Hamilton.
Bush is an active commentator on all things health care and a believer in free market economics. A well-recognized innovator and disruptor, Bush's vision has been chronicled in publications from the Wall Street Journal and Fast Company to National Public Radio and captured on the stage at events from Fortune Brainstorm Tech to The Economist's Ideas Economy.
Bush obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School.
A few weeks back, I shared my thoughts on why the incentive system in health care is broken, and ranted about the ridiculous amount of profit being created by some health systems (yes, including non-profits) that’s in opposition to what patients need and deserve. It’s not that I think profit is bad, quite the contrary. Profit is good, very good, unless it’s created in opposition to the market you’re serving which, in this case, happens to be patients. So, what’s the crux of the problem?
It’s not about profits or non-profits. It’s not about good people or bad people. It’s about the lack of frontiers.
The Frontier of Health Care
If you look at companies like Whole Foods, Apple and Southwest Airlines you can see they had everything to gain and little to lose early in their evolutions. They took on the status quo, which arguably was working and leading in their respective industries: ordinary grocery stores, utilitarian computing, and layovers topped with bad salads. These companies each saw a frontier where they could bring more to the market — widely available fresh, local food, Mac computers, and cheap direct flights. They innovated on the edge of established markets whose frontiers were behind them and, through their innovation, they found extraordinary profit.
This is what we need in health care. More disruptors – more of the crazy ones who are willing to tackle new frontiers. This is how things will get better.
So, How to Innovate?
The ugliest scab on health care is that it no longer reflects our humanity. Think about it. Approximately 18% of our GDP goes toward our health care, but we can’t shop for it as we would for other products and services. We can’t select the deluxe version and brag about it; and, on the flip side, we can’t scale it back to only what we want, and then do as we choose with the savings.
In health care, the frontier we must drive toward is shopping. We need many sellers and many new entrants bumping up against one another, and competing to service and satisfy many buyers (providers and patients). We need incentives and rules that introduce and drive a competitive market, as exists in every other industry. If we do, the result will not only be more choice, but better services and better, more cost-effective care driven by the pressures of competition.
In a free market, the power of giant, private organizations is balanced against others’ power through fair and regulated competition; and consumers get the power of choice in where to take their business. To get this same principle working in health care, a big hospital in Chicago should be competing against the big hospitals in cities like Cleveland, Dallas, Boston, and Los Angeles, for the same high-end business (heart surgery, cancer treatment).
In addition, the local community hospitals and regional startups of the world should be competing with the big hospitals for the routine, smaller stuff (appendectomies, colonoscopies)—procedures the smaller providers can actually do better and cheaper than the big guys. Thus, each tier is freed up to compete on its preferred battleground and, most important, do what it does best.
In an ideal world, everyone would compete on a level playing field, without the ability to use unfair market power to keep the other guys out of the competition. Consumers would vote with their dollars to determine the winners. When this is in place, market forces thereby punish bad companies and reward good ones, providing irresistible pressure on all providers to evolve and offer higher quality at lower prices.
Consumers are smart. If we give them half a chance, they’ll figure out very quickly which companies offer good service and which offer lousy service, who has bargains and who’s overcharging — even in a complex market like health care.
We need the scrappy, crazy ones, the geniuses, the thoughtful ones, to take on the biggest hole in our society and make health care what we all wish it could be.
Let’s begin this post with a few simple givens about healthcare:
As patients, we pay too much for healthcare. And, too often, what we get for that money doesn’t feel good. Some say the cause is the pernicious role of the profit motive in healthcare. I can’t believe I am saying this, but I agree. What’s wrong here? Why do we suffer as healthcare fails to deliver the personalized experience we count on in so many other aspects of our lives?
For one thing, it’s because no one knows who we are as patients. We show up at the doctor’s office and have to scribble the same information time and time again.
Why? Maybe there are a lot of reasons, but there is one absolute that requires us to sit down with that clipboard and share our personal details yet again: The technology infrastructure in health care is antiquated, light years behind what it should and could be.
Let’s say you cut your foot at the beach on the Jersey shore and go to the urgent care clinic a little ways inland. Why does it seem as if you are introducing yourself to the entire healthcare system for the first time? Because you have to. It’s highly unlikely that the doctor at that clinic can pull up your chart and see right away that you are allergic to bees, pregnant, have high blood pressure and are covered by (high deductible) health insurance. But it shouldn’t be.
That clinic doesn’t have your essential health care information because the incentive system in healthcare is broken. No one makes money when they share information, and no one loses money when information isn’t readily available.
But there is a lot of profit being made in opposition to what patients need and deserve. There are plenty of places to explore this phenomenon, but perhaps the one with the most irony is within the world of non-profit organizations.
Health systems, including non-profits, are acquiring doctors to increase their referral pool. In fact, 40% of primary care physician nationwide are employed by health systems, more than double the number employed in 2000. In simple terms, these health systems increase their market footprint by employing more doctors across a region, thus gaining more patients and ensuring that all care options lead back to the same health system – their own. Through consolidation, these systems also achieve bullying leverage against insurers which, in more than a few cases, has enabled them to raise prices on services delivered, even when the quality may not improve.
I feel compelled to highlight this much-publicized consolidation issue because it’s symbolic of the fact that health systems—even those that were created through charitable missions—are thriving within a system that is starved for improvement. You can literally see the profit at nearly every non-profit health system out there: The towering marble atriums, elaborate fountains and grand pavilions have become all too common.
No incentive for caregivers to share information. Redundant, impersonal experiences for patients. Consolidation that’s tilting the playing field.
So is it just me, or is healthcare broken?
Years ago during a leadership summit on an island off Boston Harbor, we as a company found ourselves unable to talk about how we may have failed each other individually. There had been some sort of sociopathic obstruction to the collective group. We soon realized that we needed to be the kind of company where executives and team members own up to their stuff, and we had to determine what it takes to do so. The hope is one would immediately think “I could have done this differently and I messed that up” instead of whining “Well, I was ready and you weren’t.” A self-centered attitude creates a defensiveness that pervades so much of life, particularly corporate life (and even personal life).
How do you create the opposite model? How do you get away from relying on the brainy kid who won’t share his knowledge with classmates for fear that will somehow dull the polish of his star? We found out during that Harbor island retreat. We decided then, that we wouldn’t have a star culture. Instead we’d build a company community of teachers and learners. We realized we weren’t going to just have staff who were the best and brightest in their class, but those who could also share their wealth of knowledge with others. If they couldn’t share the magic with colleagues, and in fact eventually render themselves obsolete with whatever they were good at, then we didn’t want them.
So, on this island, we had each leader walk alone for 30 minutes, to think about how and who they’d thrown under the bus, and then come back and tell the group. Most broke down and gave truthful self-aware acknowledgments, but some just couldn't see it and couldn't admit it. After that retreat, we ended up losing about ten of our top-performing employees. They were kinda pushed out.
We are now just finishing up this year's series of leadership conclaves at our facility in Maine, where we use what we've learned from the current year to set a course for the next. We make sure to have open, honest discussions about company business, and have our team of 75+ vice presidents and C-level executives coach one another on the “opportunities for development” that arise during our 360 peer review process. But we also put everyone through a treacherous ropes course – perhaps not as expected at an annual retreat such as this. But it is part and parcel of a foundational competency at athenahealth: Teaching & Learning. If you can’t do either of these, then you won’t last long with us, regardless of your pay grade. I want to use these leadership retreats to talk about how they can contribute to achieving otherwise-unnamed patterns of behavior. I’ve never seen an individual rise or fall based on their participation at a retreat, but there is this idea that when people get together to form a group, and that group suddenly has a collective block, those involved can’t move forward until it’s resolved somehow.
Since that week on the island, our mantra of Teaching & Learning has become infused in everything we do. athenahealth is the kind of company where a new hire can be pleasantly surprised when a supervisor or teammate takes the time to patiently teach whatever needs to be learned, until the new teammate gets it. If you are learning, it means you are absorbing new information that wasn't there before. If you are teaching, you are helping people handle new information they didn't previously know about or understand. We’ve applied this foundational block to programs like our Harvard Business Publishing-partnered Leadership Forum, with clients and prospects at our annual User Conference, and internally with a nascent Teaching & Learning initiative called athenaUniversity.
Some might ask why in the world a company that does online medical billing and electronic health records is climbing around on ropes. To our way of thinking, it’s how we can get to a place where we’re ready to do some invaluable learning—about ourselves. If you get scared among people who see that you’re scared of this or that thing, now you’re open! And your colleagues can either leave you hanging or fit in around you.
Stephen Baker is author of The Numerati, a primer for the age of Big Data, and Final Jeopardy: Man vs Machine and the Quest to Know Everything, the "biography" of IBM's Jeopardy computer, Watson. He was a senior technology writer in New York for BusinessWeek until 2009, and previously wrote for the magazine from Paris, Pittsburgh and Mexico City. He has degrees from the University of Wisconsin-Madison and Columbia University's Graduate School of Journalism. His dystopian novel, The Boost, is to be published in May, 2014. He blogs at TheNumerati.net and tweets @stevebaker.
James A. Levine
LEVINE | GREENBERG Literary Agency
Director of Public Relations and Corporate Communications
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