CareTalk Podcast @ HLTH 2021 – Jonathan Bush: From Athena to Zus, with Firefly in the Middle

The Athenahealth Founder and CEO of Zus has come a long way from his ambulance driving days. He’s focused on solving thousands of problems for digital health founders and learning from his epic failures and great successes.

David Williams:

Welcome to Care Talk, America’s home for incisive debate about healthcare business and policy. I’m David Williams, president of Health Business Group.

John Driscoll:

I’m John Driscoll, the CEO CareCentrix. David, who do we have this morning?

David Williams:

Well John, first of all, we have to say where the heck are we? We’re in our booth and it has at health 2021, and it has no top on it so you’re hearing some noise come in before you hear the noise from our hosts and guests. But we have today Jonathan Bush from Zus Health, a godly sounding company. We’re going to find out what ungodly things he’s doing there.

John Driscoll:

Jonathan, welcome. How did you get to Zus or to Mount Olympus or to wherever you are right now? Maybe talk a little bit about you had sort of an interesting path to get here.

Jonathan Bush:

A long and winding road. Well, I think gile style, we all sort of iterate on our lives and learn from our failures vastly more than our successes. One of the many failures I had at Athena Health, which was my first company, was that the architecture was hard for other people to use. As they got more and more and more people, more and more people became to other people, certainly even within the company, but certainly without and as technology and care delivery started to merge ,more and more people wanted to control their own technology. It was just hard to help them do it on Athena and tried really hard to re-platform, spend a lot of money on it. Maybe it got got clipped for spending too much money on it.

John Driscoll:

Some would say that.

Jonathan Bush:

One of many good reasons for clipping me, but the thesis at Zus is that we are finally at a critical mass where there are enough new makers of care and tech together, care tech, that they would like a platform, that they would like a set of common tools that they can skip some of the easy bloaty work of patient registration and getting a 360, get the claims in now that nobody’s allowed to block you, but they can give you some pretty crappy data, pull that stuff together, normalize it, clean it up, get it into the chart so you don’t then ask your new member, new patient obvious questions that are already answered in their past and build stuff, build custom Athena nets, an EMR for …

John Driscoll:

Before you go there though, and at the risk of turning this into a therapy session, I’ve always been impressed with you. We both share a little bit of military background. We both served in the military. We both really believe in have a passion for reforming healthcare the right way. How did you go from direct care ambulance driver, military service to technology?

Jonathan Bush:

Well, I think that we want leverage. We want to be impactful. I loved driving an ambulance. I drove it in New Orleans from 6:00 at night to 6:00 in the morning and had some … It was really gift in a way to be brought into people’s lives, those moments of their lives that were so acute. But on a big night it’d be 12 lives, one an hour and on a slow night it’d be five lives.

had a little bit of a … I was the one who kept them alive from 2:48 a.m. to 3:07 a.m. and that’s huge. You get to see their lives, but it just didn’t feel like I was making full use of all my privilege, to use a popular term these days, and I wanted to. I wanted it to matter. I want it to matter. I wanted to do things that mattered. How could I leverage that?

It started with maybe ambulance companies could be rolled up so they weren’t just one in each city. Then AMR came and they kind of did that. I was like, “Oh, I missed it,” as if one company is all you need in an industry.

Then I got into other, could care be delivered in leverage with leverage? My time in the army where combat medics do all kinds of, which are people that were recently dumpster diving or drinking in the basement of Alpha Delta Phi, as the case may be, were suddenly given this great, within the constraints of their guidelines, [crosstalk 00:04:37].

John Driscoll:

You’re still stabilized save move. I mean, it’s really [crosstalk 00:04:40].

Jonathan Bush:

But you’re given huge things to do.

John Driscoll:

You’re saving lives.

Jonathan Bush:

I’m like, “Holy cow.” With radio contact and with some [inaudible 00:04:46], like, this is better. I mean, obviously it’s for the folks that are screwed out there in the world, but it’s actually better care in a lot of ways. Athena started actually as a birth center concept, a maternity concept with the idea of kind of doing what the army does, give the frontline responsibility to midwives and doulas and nutritionists.

John Driscoll:

I think I told you Harvard Business School, that that was not going to scale and I was completely wrong.

Jonathan Bush:

You were right. I believe Joe Lassiter was the judge of the business plan contest that we got kicked out of in the first round. I went to him, I said, “Hey, I’m devoting my life to this. Can you tell me a little bit about why I kicked out?” He said, “Well Jonathan, we tried to pick either risky doubles or sure-fire doubles or risky home runs. And I think the maternity thing’s kind of a risky double.” That was it. All right, thanks.

John Driscoll:

Go Red Sox. Exactly.

Jonathan Bush:

As we pumped into the thing and tried to do it, we found the only way we could really replicate our guidelines, our advice, our training across multiple locations was with a global Q, with a website, with some sort of technology that would never forget, never get bored, always be on.

John Driscoll:

And you built …

Jonathan Bush:

That was Athena.

John Driscoll:

But you also built the only independent healthcare technology company from scratch, over $5 billion. I mean, you may have been a bit of a wet exit from the C suite, but that build was pretty amazing.

Jonathan Bush:

It was a great joy.

John Driscoll:

We still are an industry that has very few big billion dollar healthcare technology. Healthcare’s disrupted [crosstalk 00:06:24].

Jonathan Bush:

What we’ve done is we’ve taken the multiple from four times revenue to 4,000 times revenue, and now you have a lot of multi-billion dollar exits, which is awesome for those [crosstalk 00:06:32].

John Driscoll:

But they’re not companies.

Jonathan Bush:

Not yet. Not yet. We’ve got Jerome Powell’s been busy pumping out dollars, so we’ve got a lot of them. Then we gave everybody COVID to worry about for a couple of years, which caused us to try a lot of this stuff. I feel like this time without the benefit of as many sort of dog whistle successes yet as we’d like to see. I mean, I think Lavango, again, maybe the multiple was high, but the company’s, [crosstalk 00:07:00] is sound.

John Driscoll:

It’s a real company.

Jonathan Bush:

Right. Teladoc, same thing. I feel like … CareCentrix.

John Driscoll:

CareCentrix, heck yeah. We talk a lot about the beginning and the end of the alphabet, the mountain tops, Athena, Zus. What about something more in the middle like Firefly. Can they really provide twice the healthcare at half the price or whatever it may be?

Jonathan Bush:

Better care at half the price. It’s the same. I mean, I’m not very many trick pony. It’s the same basic concept as the ambulance and the army with these phenomenal doctors that are poking their eyeballs out at these major academic medical centers, doing the same set of non-problem care all the time, all the time and being evaluated as their referral, they’re keepage or their leakage.

John Driscoll:

I literally talked to the CEO of one of the top two or three academic medical centers. He says he no longer talks to his wife at dinner because she spends all of her time catching up on typing in notes into Epic every night. It’s destroyed his life.

Jonathan Bush:

It doesn’t feel good. It doesn’t feel right. It’s not intellectually challenging at some point. If the game is lame, you kill your character. Doctors are sort of for a while now in kind of kill your character mode. Firefly’s offering a new …

John Driscoll:

It’s literally suicide rates and depression, drug use.

Jonathan Bush:

Depression, yeah.

John Driscoll:

But what does Firefly actually do?

Jonathan Bush:

Firefly says, “How about this? How about we only give you really sick people and then we give you a super cool team, seven people around you that are constantly connected, like one big breathing, sort of Bloomberg terminal of all of us on it. And we eight will take care of 5,000 people continuously.” With the technology that they’ve built and with this leverage in the care team and with the protocols they’ve built that give these, it could be just a frontline nutritionist, kind of a personal trainer type who just loves health and loves people’s health challenges and is a good active listener all the way up through a really good doc who’s got a lot of years on.

These guys can talk, can completely transform the model from, “Hey, if you’re sick enough, beat a path to me, take a clipboard, pull your pants off, sit on wax paper, wait around until you get the chills. Then you’ll get your six minutes with me.” That switched to the second anything comes up, drop it in the box, text it to me, just take a picture of it.

People go from, in the claims data, they’re going from one visit with a doctor every 19 months on average to 41 visits per year, constantly little things. I’m doing it. I never went to the doctor, never. The littlest things, and it turns out I understand my health. It’s not for me. It’s for people with mortgages and [inaudible 00:09:41] who can’t handle this shit. But as I use it, I’m like, “God, it’s better. I talk about emotional things.” I never go to the doctor for emotional thing. I’m fine. Just give me the shot or whatever.

David Williams:

If you have all these interventions, 41 times a year, do they make you change course every time? Is it going to end up spending more money if you’ve got a new intervention every time?

Jonathan Bush:

It’s like a Kanban. You’ve got one single thread of all these things, all the problems, all the tasks, all the messages, all the care plans that you got and didn’t do, the ones you did do. What are we learning about your social determinants? What’s going to work for you going forward. It gets better and better.

Each little encounter isn’t cancer. It’s just a little, it’s dating.

John Driscoll:

It’s relationship building.

Jonathan Bush:

Yes. Then what happens is when they do get sick, they don’t go to the emergency room in a blind thing, or ask a friend who you know at Mass General or whatever. They actually hit the button. Now you’ve got a lot of context. They say, “Go to the surgeon care, get this culture. You’ll be expected. You’re in room three. I’ll meet you there on screen if you’re confused or upset or have questions, just hit the button. I know where you are. I’ll jump right on with you and the PA on duty.”

John Driscoll:

Jonathan, you may know this story, but I think if you know people’s narratives, it changes the care. The VA has found when they can actually have people do a scribe and talk about what people have experienced, they actually thrive and get that, just sharing the stories with the care team, which is a novel idea. But it’s the best to build …

Jonathan Bush:

It’s not novel, which tragic is that [inaudible 00:11:17]. Recent research shows that if you shut up and listen for a while. No.

What’s also interesting is you look in the claims data, what percentage, not of dollars, but of claims is just doing that first layer establishment again and again, and again, that initial triage, we’re doing a bazillion. Every time you go to an urgent care, except Firefly members, name, history of illness.

John Driscoll:

They definitely get the documentation right. They get the documentation right.

Jonathan Bush:

They crush it. All those clicks just are bloat that just confuse the data about, we just want a strip culture. Don’t do anything else or palpate the abdomen. We’re not going to sue you. I’ll pay you instantly. No claims.

John Driscoll:

I’m buying face [inaudible 00:12:00]. You got a Zus man. The whole premise of healthcare data, you’ve got empires built on data dislocation.

Jonathan Bush:

Yes.

John Driscoll:

I have my particular data. I don’t share it ever.

Jonathan Bush:

Precious. Precious. That’s my data.

John Driscoll:

How are you going to break …

Jonathan Bush:

It’s a little spotty [inaudible 00:12:17] mistake of data, but it’s mine.

John Driscoll:

We are surrounded by large booths of data walls billed by the margins.

David Williams:

They are transparent, and not only that while we’ve been doing this interview, somebody came to take a picture of Jonathan and then a dog came sniffing over at our producer. I’m not sure how to interpret that.

John Driscoll:

Could be a bomb. But John psycho, how are you going to break down those walls because it is …

Jonathan Bush:

Well, here’s my new idea. Don’t ship data. Everybody just perch on the same pile. That’s basically the idea. Instead of shipping interoperable and you’ll call me and I’ll call you and we’ll squirt it into a lake, which we’ll look at occasionally and argue about who owns it. What if we just actually, what if I built for you either low code, no code or just really well documented API for everything you want to build. You can build it in one 10th, one 50th, 100th, the time that you would spend if you built it off on your own, and I building it, I give you an environment to build where the operational data store already has everybody in it, where the data’s already there. Now Spotify, most of us don’t download all these songs on Spotify. We just get a lens. Oh please. This guy. You’re letting anyone in now.

John Driscoll:

Nope. He’s not in the door.

David Williams:

He didn’t get in yet.

John Driscoll:

That’s what the dog … That’s dispatcher Brian from Press Ganey trying to harass Jonathan Bush.

Jonathan Bush:

He go very upset I made a Press Ganey joke because of the paper, they’re required to send paper forms, not your fault, Patrick. It’s just the law, but it makes for good jokes about paper forms in 2017, 2021. Anyway, not his fault. Press Ganey’s very nice, very good company.

John Driscoll:

They actually measure patient response, which is kind of something that’s shocking for a lot of hospitals. I think they do a pretty amazing job, but they do [crosstalk 00:13:59].

Jonathan Bush:

He’s over six feet and he’s Irish and he’s standing right behind me, so I’m going to be a very quiet.

John Driscoll:

Pretty big paper business, but just technically, is that possible?

Jonathan Bush:

I don’t know. This remains to be seen.

John Driscoll:

Don’t say that. You’ve got investors.

Jonathan Bush:

I know, but I can always just call Jerome and have him print me some more. No, the truth of the matter is, it is about this inflection point. You look around, there are many, many well-funded companies with very strong tech teams in healthcare for the first time. They have material, they round to 1% market share, all 6,000 people here probably around a 1% market share.

John Driscoll:

$20 plus billion in digital health in the last …

Jonathan Bush:

$22 billion in the first half of this year.

John Driscoll:

Last six months. Stunning.

Jonathan Bush:

Unbelievable and potentially a wave that crashes on the beach and runs back out to sea unless we grab it and hold it there with common tools, common data. All these guys are in a rush to build out a unique Firefly specific CRM, EHR, Udo specific, or Eden specific, Rhea specific, group specific. My bad. Clover specific. I’m reading the lines down the thing.

John Driscoll:

No. I met a 23 year old guy, wonderful guy, who wants to build the epic for pace programs. He’s 23 years old, Brown graduate, got a tech team funded.

Jonathan Bush:

There you go.

John Driscoll:

Rocking and rolling. But another version

Jonathan Bush:

[crosstalk 00:15:19] does all the beautiful, incredible network for in vitro fertilization. Every single one is on a different EMR. What if you could just give them an EMR only for in vitro? You’re going to build out registration and task assignment and prescribing and all that stuff just to be able to have a unique in vitro experience. What if you could grab those parts and then custom build the unique workflows that are unique to in vitro. There are so many use cases for that basic age old Regi Herzlinger focus factory concept that are here fully funded.

John Driscoll:

She always like you better than me.

Jonathan Bush:

Well, I kissed her ass. I mean just whew.

John Driscoll:

Jonathan, you get that. Now, going back to where you started in healthcare, let’s say you’re semi-successful and you’ve got half of the world going that direction. It’s going to reduce the cost of innovation. It’s going to create more transparency.

Jonathan Bush:

Exactly. Exactly.

John Driscoll:

It’s going to allow you to fast [crosstalk 00:16:11].

Jonathan Bush:

One VC partner meeting, a guy told me, he said, “You won’t believe what happened. Somebody in the partner meeting [inaudible 00:16:14] well because of the emergence of Zus, we’re expecting multiples on digital health companies to go down.” Said, “What?” He said, “Because now they won’t be able to say that they own that [crosstalk 00:16:25].” Are you kidding me? There’s so much unbuilt tech. Just because you didn’t build your own registration or patient data vault or whatever, that’s ridiculous.

John Driscoll:

You get there. What’s the impact on the patient? What’s the impact on the doctor? The patient who’s disconnected to doctors?

Jonathan Bush:

We’re so used to it everywhere. I mean Spotify and LinkedIn. We have taken for granted in much of our life, a common, reliable data object that we flick off wherever we need to. It’s always current. When our life changes, wherever we flicked it, it’s still current. If you change jobs, everybody’s, they have their LinkedIn link in their recruiting system or in their database or in their contact file or their whatever, it’s current, whatever happens. New song comes out from your favorite artist, you’ve got it. It’s not that you went out and got it. It’s that your lens knows that those are things to put in the glass for you. That’s got to happen in healthcare.

John Driscoll:

How’s that going to change [crosstalk 00:17:19]? That happens. What happens when you go to your doctor? What’s that interface going to be like?

Jonathan Bush:

I think the key to this is if enough of these digital health companies get on to Zus, Zus does a good enough job to earn it, that remains to be seen, and then enough of them do well with it, there’ll be a point at which they start to accumulate with their exhausts a pretty credible data graph of the American public.

Once that data graph starts to be big enough, deep enough, real-time reliable enough, now it’s sort of like better check Zus before operating. Now all of a sudden, all the people that guard their data and mote their data are like, “Yeah, I want to mote mine, but I don’t want to be wrong about the patient.”

John Driscoll:

Is that like the mapping of the human genome, but for practice? I mean, do you basically [crosstalk 00:18:06]?

Jonathan Bush:

Something like that. The mapping of the human phenotype, here’s this basic shit. We’re interested in all kinds of stuff. We’re talking to getting the link, the Fitbit feed, we really just kissing whoops ass dying to get them to put their data on and charge, accelerate their business model with it and 23 and Me. We want credit card. We want to have a lot of health related, not just these very rare, very bloated, very sort of fee for service claim-oriented data moments that come from EMR CCDs, but regular stuff as well. We think that the combination of those plus the software developer kit will convince a meaningful chunk of the HLTH crowd. Then if the HLTH crowd convinces enough of America, we’re going somewhere.

David Williams:

Well, Jonathan, speaking of having a crowd today, I always like going to a conference with you. I think last time we were at a conference together in San Francisco, you had pealed some guy off the pavement. Are we expecting something similar here today?

Jonathan Bush:

Yeah. That guy was a great actor, the guy who had the heart attack.

David Williams:

That guy.

Jonathan Bush:

That was odd, wasn’t it?

David Williams:

I thought it was weird.

Jonathan Bush:

Walking between meetings and there was a whole bunch of people standing around looking at this guy and it’s a not insignificant number of them had the whatever the JP Morgan thing necklace on, credential, and nobody was touching the guy. He was just there face down.

David Williams:

It wasn’t scalable.

Jonathan Bush:

I’m like, “Oh my god.” It took me a minute.

David Williams:

Speaks to your basic capacity.

Jonathan Bush:

Nobody’s [inaudible 00:19:42] advantage of numbing out whatever makes you not do that by doing it a bunch. But anyway, it was tragic. I probably did him no favors. He became alive for long enough to get rattled down to the city and die a couple days later, so it was too bad.

David Williams:

Well, anyway, from the small scale to the large scale, I mean, we talk a lot about companies here from A to Z. What about any kind of health reform? How does that plan [inaudible 00:20:08] going to the private sector?

John Driscoll:

Jonathan has no opinions about politics and health reform.

David Williams:

I’m getting him to …

John Driscoll:

No politics.

David Williams:

This is an opportunity to …

John Driscoll:

It’s beneath him.

David Williams:

This is an opportunity to think.

Jonathan Bush:

I aspire to … I don’t need it. Like in all of my marriage counseling, I don’t need it, but I would like very much if we could have sex tonight. I don’t need the Cures Act to not be scuttled, but I would like it very much. I would like it very much if the magical TEFCA committee of committees actually agreed on a standard for American to give their credential, give their permission to a tech company in a government acceptable way, whatever that may be, so that that tech company could go present this credential, this authorization to everywhere where there’s data and say, “Bitch, Betty wants this and she wants it here. She said so. You can’t say no. Give it to me.”

If that level of clarity makes it, and it could be a really complicated standard. We have the KYC law, which allows banks to open accounts online. It’s fine. It’s a bunch of dances you have to do. Show me an in-person address, letter, whatever, mailed somewhere. We know how to do this. We’ve done it before. There’s no reason we can’t do it again here where it’s so much more valuable, not that anti money laundering isn’t important, but compared to the health of the public, it’s …

John Driscoll:

The premise of all of the privacy stuff was to actually, A, protect you and B, allow you to be able to port your data. All we got was the first part.

Jonathan Bush:

Privacy and portability. [crosstalk 00:21:46].

John Driscoll:

And we don’t get it. It’s unclear that that gazillion dollar infrastructure …

Jonathan Bush:

Undo the HIPAA use click case, things are pretty liquid, compared to where it started.

John Driscoll:

Better.

Jonathan Bush:

We can pretty much get at anybody, at least for a shitty bloated PDF copy of stuff, something.

John Driscoll:

Paper.

Jonathan Bush:

I mean, we’ll clean it up. We can do stuff. The consumer use case is people, the guys inside the club don’t like these unwashed non-doctor guys come in the club. That’s where government steps in.

John Driscoll:

You’re also not a government bureaucrat. I mean, I think the privacy Taliban still is very happy to keep those walls.

Jonathan Bush:

Every great movement is plagued by its fundamentalists and its cynics, everything, Christianity, patriotism, privacy. There’s somebody who’s using it to twist the needle. We’re just doing it to protect privacy. No, you’re not. You’re screwing people. No, no. It’s about privacy. They don’t know enough to have their own data, for that be said by a billionaire over the years. Ridiculous.

John Driscoll:

Could’ve been a tech founder.

Jonathan Bush:

Then there’s the fundamentalist. There are people who are like, “I’m [inaudible 00:22:54], I’m protecting my … I got my MREs, I got my weapons. [crosstalk 00:22:58]. You ain’t getting my data. You ain’t getting my data.”

David Williams:

Back in the cave. Well, John, you would’ve been wrong to vet against the Taliban so I hope you didn’t place your bet there. But in any case …

John Driscoll:

I did bet against the Taliban. I lost that bet. I know why and I’m very angry.

David Williams:

Well, hopefully not going to lose against the data Taliban. In any case, before we go any further, we went from A to Z. I think that’s far enough. Jonathan Bush, founder and CEO of Zus Health, among many other things, thank you for joining us today at Health for our CareTalk podcast. I’m David Williams, president of Health Business Group.

John Driscoll:

I’m John Driscoll, the CEO CareCentrix. Thanks for listening. Please subscribe. Jonathan, thank you for joining us. [crosstalk 00:23:36].