Skip to content

Reactions to Where Does It Hurt? An Entrepreneur’s Guide to Fixing Health Care by Jonathan Bush


Where Does It Hurt?: An Entrepreneur's Guide to Fixing Health CareWhere Does It Hurt?: An Entrepreneur’s Guide to Fixing Health Care by Jonathan Bush

My rating: 4 of 5 stars

Jonathan Bush, the irrepressible CEO and Co-founder of software company athenahealth, has published an engaging professional memoir mixed with a guide to opportunities for health care entrepreneurs.

Where Does It Hurt? An Entrepreneur’s Guide to Fixing Health Care is not the much-needed conservative rebuttal to Zeke Emanuel’s Reinventing American Health Care that I half-expected from the title. Policy-minded readers might be disappointed – in fact Bush quite practically focuses on the areas of health care that can be improved without relying on policy changes – but health care entrepreneurs and investors will greatly appreciate Bush’s observations and exhortations.

  • My reactions to Emanuel’s generally excellent book are here

To the first area, Bush wears his family lineage lightly. He acknowledges being “nursed at the right breast” and mentions his uncle George and cousin George, but reflects an independent, even iconoclastic point of view. The usual entrepreneurial narrative is here – starting a now-major software company in his basement, radically changing business models midstream, holding meetings with large customers and potential employees who had no idea just how shaky the early company was. Bush comes across as delighted to have beat the odds to create a meaningful company in health care and genuinely appreciative of the athenahealth employees who built the company. At no point do the personal or professional stories read like a preparation for the political stage.

As I see it, Bush’s anecdotal history of athenahealth, while interesting to those of us who admire the groundbreaking company, is secondary to his perspicacious identification of trends in American health care, how committed entrepreneurs can build big businesses at their intersection, and why health care will improve as a result.

Bush identifies three major themes, implying that businesses that exploit or accelerate one or more of these areas are large opportunities in health care entrepreneurship.

  1. “Shopping” – i.e., consumerism
  2. Hospital specialization
  3. Data shared on networks

Bush passionately believes (as do I) that the single best way to simultaneously improve the quality of health care while reducing its cost is to put the individual at its center, specifically to employ a retail model of consumer choice wherever possible. Whether or not you agree that consumers should be in charge of their own health care decisions, or that “shopping” is a model that should be applied to this most critical and expensive service in the US economy, the health care consumerism ship is sailing. Companies and technologies that help consumers make their own decisions – weighing effectiveness of particular treatments vs. their costs, choosing health plans on public or private exchanges, trading convenience over price when filling a prescription – will flourish in the coming years, and our health care system will be the better for it. (Bush repeats the oft-cited but irrefutable example of LASIK eye surgery as a medical procedure that has become extraordinarily more effective while becoming extraordinarily less expensive – a triumph of the power of “shopping” when unleashed in health care.)

Similarly, hospital specialization might have seemed controversial a few years ago, but seems unavoidable today. The consequences of hospital proliferation and growth are becoming obvious, as increasing numbers of regional hospitals close. It makes sense – not every hospital can be generally great at every kind of treatment. So they’ll start to focus on what the areas where they excel, and not offer services where they don’t. This trend implies that hospitals will need to go outside their immediate geographic areas for customers – and that as these hospitals look more broadly, consumers around the country will start to have better access to the best specialists. Companies that can help hospitals navigate this trend will do well – whether helping hospitals market to new consumers or transport them, helping employers negotiate with the best facilities for their employees’ care, or helping consumers discover where the best care is (and is not!) available.

Athenahealth itself was a pioneer in software provided “in the cloud” – connected to doctor’s offices and insurers via the Internet, rather than being installed on customers’ own servers. Of course interoperable software systems and data exchange have become the norm across all industries – generally health care sadly lags, but is coming along. Closed systems like that offered by Epic, the dominant vendor of hospital software, will go the way of the dodo (though Bush skirts the all-important question of how to know how quickly this will happen). Entrepreneurs will profit – and health care will improve – by helping data flow more easily, even to competitors’ software; by empowering consumers to own, control, and share their own health care data; by embracing a highly distributed, interconnected world.

Like Jonathan Bush himself, Where Does It Hurt? is energetic, scattershot, adamant, and ultimately optimistic. It’s worth reading by anyone interested in how technology-driven contemporary business models can improve the business of American health care.

N.B.: it’s not entirely clear if this book is a personal exposition or corporate document – the copyright is credited to athenahealth, with co-writing credit given Stephen Baker, apparently an athenahealth employee (several other athenahealth employees are also thanked for their contributions) – but its excited, ad hoc style certainly reflects Bush’s real world persona.

Reactions to Customer Centricity: Focus on the Right Customers for Strategic Advantage by Peter Fader


Customer Centricity: Focus on the Right Customers for Strategic AdvantageCustomer Centricity: Focus on the Right Customers for Strategic Advantage by Peter Fader

My rating: 4 of 5 stars

Customer Centricity is written for the executive rather than the daily practitioner. For this audience it succeeds – limited to a few key topics, brief enough to be read on a plane trip, free of academic jargon, supported with numbers just enough to get ideas across.

Fader’s key points are provocative and even counter to convention – that customer centricity is different from customer service, that product-centric organizational structures lead to diminished profitability, that traditional Customer Lifetime Value calculations are misleadingly flawed, even that customer centricity is probably not the best methodology for all types of businesses.

His advice to executives is to think of customers as heterogeneous, i.e., not in monolithic or averaged groups; and to have the discipline to maniacally measure and act on ever more precise customer data, even (especially) to allow certain kinds of customers to go away.

In my view, customer centricity at its limit customer becomes the Peppers & Rogers-style 1 to 1 marketing model that became popular in the late ’90s (and I still find quite compelling). You could view Fader’s take as the practical contemporary guidance, now that technology makes customer-centric organizations possible. The constraints that forced old-fashioned product-centric business models are falling away, and progressive practices like those suggested in Customer Centricity will become the norm. Companies might as well start making the most of them now.

Disclaimer: my wife and I were students of Fader’s at The Wharton School, are donors to the Wharton Customer Analytics Initiative institute he co-founded, and consider him a personal friend.

View all my bookreviews on Goodreads here

That's composer Carlisle Floyd toward the right, on a panel discussing his opera "Susannah". Soprano Patricia Racette to his right.


That's composer Carlisle Floyd toward the right, on a panel discussing his opera "Susannah". Soprano Patricia Racette to his right.

At Absinthe I always start with a Sazerac.


At Absinthe I always start with a Sazerac.

Reactions to Cadillac Desert: The American West and Its Disappearing Water by Marc Reisner


Cadillac Desert: The American West and Its Disappearing WaterCadillac Desert: The American West and Its Disappearing Water by Marc Reisner

My rating: 5 of 5 stars

Marc Reisner’s Cadillac Desert: The American West and Its Disappearing Water was originally published in 1986, and though its 1993 update is showing signs of age, the book remains an eye-opening survey of water distribution policy in the United States and its far-reaching contemporary consequences.

Despite its often egregious stylistic lapses and several come-and-gone unrealized doomsday pronouncements, Cadillac Desert is a generally readable and excellent survey of “how we got here” with respect to water. The story of US water policy is mostly a Western one, especially focused in California, where the topic remains front and center in policy discussions and electoral politics.

The breathtaking and ongoing scope of the unintended consequences of US water policy – the trillions of dollars wasted, the massive environmental destruction, why we pay billions of dollars to subsidize desert production of the same crops we also pay not to grow on actual farmland – is as elucidating and heartbreaking in 2014 as it must have been when PBS based a documentary of this book in the late ’90s.

The tragic lesson of Reisner’s far-reaching and well-researched story is that generally good intentions enshrined in public policy and administered by government agencies cannot survive the encounter with basic human traits of self-interest and greed.

Cadillac Desert is worth reading not just for the details of how the United States enacted its water “reclamation” and distribution policies, but also for the broader general caution against the subversion of public works.

A coda re: style….

If anything, Cadillac Desert recalls Robert Caro’s magisterial The Power Broker: Robert Moses and the Fall of New York in showing how the politics, economics, and execution of massive public works often betray the public in distressingly visible fashion.

Unfortunately Reisner lacks Caro’s almost laconic remove from the enormity of his subject, often over-indulging in passion at the expense of clarity. While scenarios like the following lend a bit of frisson to a potentially otherwise dry(!) topic, the judgmental tone and implied generalization undermine Reisner’s general credibility:

California was hit by the worst drought in its history [mid-late 1970s]; had it lasted one more year, its citizens might have begun migrating back east, their mattresses strapped to the tops of their Porsches and BMWs.

On to Texas…

On Fridays, the farmers cruise into town from eighty miles away, behind the wheels of their Cadillacs and big Buick Electras. After a conference with a deferential banker, they go off for drinks and a dinner of steak and lobster, then to watch a Texas Tech football game from fieldside seats.

How generalizable is this cartoonish situation, so inaccurate in its detail?

This time in Utah, a sadly typical and needlessly snide comment about citizens’ actually enjoying natural beauty, an activity Reisner seems generally to support (at least for physically fit tourists)….

Today Rainbow Bridge is visited mainly by overweight vacationers clambering out of houseboats and trudging up to stare briefly at the arch.

Just as bad as the self-indulgent asides are the stylistic ticks (e.g., “if not” is used jarringly and inconsistently as a sentence joiner at least a dozen times) and run-on sentences. Had publishers already done away with editors in the late ’80s? Reisner could have used some professional help.

Unless you owned reasonably flat land immediately adjacent to a relatively constant stream which did not, as most western rivers do for much of their length, flow in a canyon, complying with the Desert Lands Act was almost out of the question.

What? Who’s “you”, even?

When the vote was taken, the attempt to override Carter’s veto had barely failed.

What exactly happened? The override barely failed – meaning it passed? – and therefore the veto failed, so the original bill passed? Or the opposite? I couldn’t figure it out.

It’s a tribute to Reisner and the importance of his material that his meticulous research and engaging character sketches overcome even these lapses of style. Cadillac Desert is likely even a page-turner for readers with any interest in the topic.

View all my book reviews on Goodreads here

Lining up for Jack White's show in San Francisco.


Lining up for Jack White's show in San Francisco.