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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 sprinkled with 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 regardless of governmental action – but health care entrepreneurs and investors will greatly appreciate Bush’s observations and exhortations.

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

As to the personal story, 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 enterprise was. Bush comes across as delighted to have beat the odds to create a meaningful force in health care and genuinely appreciative of the athenahealth employees who built the company with him. At no point do the personal or professional stories read like a preparation for the political stage.

The anecdotal history of athenahealth, while interesting to those of us who admire the groundbreaking company, is secondary to Bush’s 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 has started to sail. 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 all hospitals 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, transport them from far away, or serve them remotely; 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, or what businesses could accelerate that timeline). 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.

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