Where Does It Hurt?: An Entrepreneurs Guide to Fixing Health Care By Jonathan Bush

A really eye opening perspective on what is at stake in considering the different philosophies on interoperability in healthcare IT. Also a good commentary on the need for disruption in an industry that consumes almost one out of five dollars generated in the country's GDP and how the industry can better foster a climate of innovation. 1591846773 A lot of very interesting takes on the medical / insurance industry. Bush gets a little wordy at times with personal anecdotes and stories, but overall interesting content. 1591846773 This is a very well written analysis of the issues making American healthcare too expensive, too impersonal, and an overall customer experience disaster. The style is crisp and conversational, and the book is well researched.

My only concern is Bush's absolute, dogmatic belief that the free market can fix all the ills of the system. Firstly, an efficient market depends on rational actors. People simply won't be coolly analytic when it's their health they are deciding on.

The only other significant miss in this book is that he never explains how deregulating healthcare will not lead to the same disaster that deregulating airlines and banks did. The industry is hurt as likely as others to consolidate into an oligopoly to maintain the status quo. (In fairness Bush spends considerable time discussing consolidation, but he does not write of deregulated consolidation and its ability to stifle innovation and throw up high barriers to entry.

Finally he doesn't address the role ever increasing income disparity in the US will play in the deregulated, transparent healthcare market he envisions. As I see it, health can descend into the disaster that is domestic air travel. A pretty damn good experience for the wealthy, but absolute misery for the rest of us. How will the hospital not devolve into the 90/10 divide that is the typical US flight with 30% of the crew fawning over 10% of the passengers, and leaving the 90% in squalid conditions?

Though my vision of the ideal future lies somewhat to the left of Bush's, I highly recommend this book. It starts a discussion that is long overdue in America. I also recommend watching Bush's TED Talk on URQS and large research hospitals prior to reading the book to get a sense of where the author is coming from. I also wish this book was mandatory for medical students. 1591846773 The author has no doubts about his vision for healthcare - he suggests more competition and less governmental influence. Greed is Good echoes bush; effective healthcare can only be made possible by letting healthcare - a nearly monopolized business into something like a restaurant business, where providers fight each other out for bringing in more patients to their enterprises by gaining that extra edge over others - cutting costs, offering better services. He also suggests that hospitals have to specialize in one service and master it , rather than providing a bunch of services. Just as you can get sell better bicycles in a specialized store rather than in a shopping mall or a hypermarket. Even though his examples are anecdotal, his reasoning seems to be convincing. These ideas are radical for someone like me ; whose experience with Indian hospital system has led to dissappointment and lack of faith in hospitals and medical care providers.

Jonathan outlines his career and proves that his money is where his mouth is, Athenahealth estimated at a billion dollars, is a cloud service and record management company for providers that according to him is poised to disrupt healthcare by backing new enterpreneurs in this field. Jonathan's wit and humor makes the book an easy read as compared to the other healthcare books that I'm struggling to finish. A good read for anyone dipping their feet into the business of healthcare. 1591846773 I fidget in classrooms, and my mind wanders.

if this were a real business, like a pizzeria or a nail salon, the hospital would have to seriously rethink its pricing model. Instead of pegging its invoices to Medicare or Medicaid reimbursements, or whatever it can get from private insurers, it would instead have to focus on the gentleman in my backseat as a customer. The service he needs at this stage in his life is not emergency care, but maintenance. In a free market, maintenance comes out of the customer’s pocket. Could an entrepreneur carve out a business by offering service at a similar price for hypertension or diabetes?

It’s gobbling up money that otherwise would go into wage hikes and productive investments.

From a business point of view, health care is the new oil. Those who can dig down through the morass of rules, paperwork, and bureaucratic obstacles can find new markets.

worth more than $4 billion (Nasdaq: ATHN). I’m cofounder and CEO. Our cloud-based service handles much of the paperwork, billing, and electronic patient records for more than fifty thousand medical providers nationwide.

If you face stage-three colon cancer or an exotic autoimmune disorder or, heaven forbid, find yourself attached Siamese-style to your twin, there’s no better place to be than a name-brand American university research hospital. The feats surgeons pull off burnish their reputations as miracle workers and lifesavers.

And what will they do with this information? It can be summed up in a single word: shopping. This has to do with making choices.

After you’ve read this book, I’m hoping, you’ll look at health care through the eyes of a customer buying a service—and demand alternatives to the elements you hate.

I wanted a career that would provide the lifestyle I grew up with—the comfortable house, college for kids, the vacations in Maine.

I buttonholed Larry and asked for career advice. To save lives, he told me, the best plan was to work on an ambulance and get to know a crack trauma unit. The top one, he said, was at Charity Hospital in New Orleans.

the schools were backward, and good jobs scarce. Practically the only pathway to advancement was to leave.

He went on to tell me that I could work for either device manufacturers or a drug company. Pacemakers and pills. That’s where the money was in health care. Or maybe I could land a job as a junior administrator at one of the university hospitals. (That was a path, as I saw it, to nowhere.)

In the end I landed a consulting job at Booz Allen. Consulting, I figured, would provide a good look at the options in the industry.

health maintenance organizations, or HMOs

From day one, however, I knew that I was a misfit in consulting. I didn’t have the patience to sit in a swivel chair all day, to pore over health industry studies and come up with reports and recommendations. I couldn’t concentrate on it. I couldn’t even spell well. Eventually someone would wake up and fire me.

Competition forces them to innovate continually. It’s why restaurants often change their menus.

The other type of niche operation is the focused factory. To thrive, it must do one narrow job extremely well, more efficiently than its rivals. Why am I telling you this? The old department store still reigns supreme. It is called the hospital. It attempts to offer every service under one roof. Liposuction, colonoscopies, sprained ankles, Csections, geriatrics, retina surgery—hospitals do it all.

And each one represents a market opportunity for a focused competitor who can offer that same service with efficiency, convenience, a smile, and better results. The model for this type of market is LASIK, the popular laser surgery to improve vision. When it was introduced in 1991, LASIK was viewed as risky and expensive. Insurance didn’t cover it.

They advertised—in the face of strict federal law against it. And many of the early customers suppressed their natural fears and distrust only because they had horrible vision. They were desperate. And many of them got only one eye done. This saved money and hedged against blindness. What has fueled its success? The competitive marketplace. Since LASIK surgery is not covered by most insurance plans, people have to compare different services, their satisfaction records, and their prices. In short, they shop around.

women with C-sections spent more days in the hospital, which brought in more revenue.

By 2010, the average price for vaginal deliveries was up to $30,000, and for C-sections $50,000, with insurance companies reimbursing an average of $18,329 and $27,866 respectively.)

Four million babies were born every year in the United States, each representing a potential profit of $1,500. Multiplying those numbers came to a tantalizing $6 billion.

we would run a ruthlessly efficient operation, with a laser focus on costs.

Word of mouth would drive business our way. We would start in one city, learn the ropes, and then expand.

practically everything I could learn at Harvard was relevant.

you have to figure out how to get paid by a confusing web of insurers, private and government alike, who are experts at finding reasons not to pay.

I had leadership skills that were not evident in the business plan.

We bought the San Diego practice from Bill and Mitch’s group of doctors.

Just nail it in San Diego, we figured, then raise more venture funding and take the business national.

written in codes that only the initiated understand.

Software start-ups on the Internet are a shining example. They launch their services on Apple’s app store or Android, or they hitch up with PayPal, and if they catch on, money literally flows into their accounts. They have automatic billing—no invoices, no permissions, eligibility requirements, authorizations, co-pays, no faxes or snail mail, in short, no nightmare. But equally important, they can follow what’s working and what’s not, and make fixes. They literally see what they’re doing. And what happens? Hundreds of thousands of entrepreneurs flock to the industry. They innovate and grow. It didn’t occur to me until later, much later, that solving the misery of payment and clearing the fog had the potential to become even a bigger business than a nationwide network of birthing clinics. The doctors who sold us the practice had many of the same ones, including the challenge of getting paid.

we were only getting paid on about 65 percent of the claims we were submitting. 1591846773

Some worthwhile ideas, but it takes some digging to get to them. Also, if you're going to hire a writer to write your book for you, you should probably find one who knows the difference between regime and regimen. 1591846773 Untimely to be reading Jonathan Bush's book given his recent less-than-graceful exit from the healthcare big stage, but nonetheless this book was worth reading.

Bush's famous vocalness and lack of filter comes through in the prose, and his unabashed pro laissez faire capitalist streak can come across as distasteful if not inappropriate at times on a topic as serious as healthcare, but his perspective is often interesting and insightful.

First of all, for the longest time I felt that healthcare technology suffered from being suffocated by proprietary data formats (see Epic and Cerner), and could use an injection of the open-source ethic from the technology world. My thought was always that someone like Google should buy up an EMR and establish that open-source data standard. Little did I know, AthenaHealth under Bush and colleagues have been fighting that good fight all this time. It's nice to see such a clarion voice argue for open data, patient ownership of data, and greater data fungibility and liquidity. Bush believes, as I do, when health data becomes LIQUID while still remaining secure (no easy task I admit), it will open the floodgates towards innovative use of data, and move through what he describes as the 3 waves: 1 - data helping healthcare orgs running businesses more efficiently (already starting to happen), 2 - data helping with diagnoses and treatment, the promise of PHM, and 3 - personalized medicine.

His central thesis is that healthcare needs more capitalism and less regulation: if we open up the demand curve sensitivity that laws shield healthcare services from, then we will get better innovation and outcomes in healthcare. The argument is complex, and at times I agree that more market forces will help, but other times he goes too far - naked market forces for insurance policies may unleash more chaos than he is describing, we can get adverse selections of healthy people into bare bones plans, and the sick into toxic risk pools, defeating the point of health insurance to begin with...

He has various other arguments that I like, insight and clearly laid out, with compelling anecdotes sprinkled in.

For example, Bush believes in healthcare we often overshoot the mark and try to make new things too fully formed. He thinks there is a huge vast middle class soft belly of healthcare org tech budgets running the in the thousands or tens of thousands, for which there is infinite potential for primitive innovation, technology solutions that solve simple problems in simple ways.

One other argument I like is that at a time in which docs (especially PCPs) are being swallowed up so at lightspeed by hospitals systems, they actually more leverage than they recognize, being at the heart of the next innovations to happen, since they will need to be at the heart of effective technology-enabled care management and care coordination, AND the fact that they still dictate referral flows. Maybe when they collectively realize this, this will impact the shape of the physician corporate landscape, and we'll see a resurgence of powerful medical groups once again counterbalancing the hospital systems, which Bush deems dinosaurs looking up at meteors. 1591846773 Kudos to the algorithm that suggested this book to me, because I would have never picked up Where Does It Hurt? on my own. Relying on an entrepreneur as a guide to the pitfalls of the modern US healthcare system is probably a terrible idea and Jonathan Bush's provenance (yes, he is a Bush Bush) does him no favors.

But despite my reflexive snobbery about 1) business books 2) written by business people 3) who are famous I found this book a really compelling read. The main story of someone trying to take on a bloated broken system easily has enough momentum to carry the reader along. And in all likelihood the ghost writer did heroic work crafting recollections of someone in the thick of bureaucratic battles into something zippy and readable with a coherent narrative.

Plus Bush is someone who is charming and winning even on paper. He is deeply concerned about healthcare and enters the industry as an Army medic and an EMT before becoming a consultant and entrepreneur. One of his key insights early on is that much of medical care can be handled by people without extensive training (medics, midwives, EMT's) supported by an active triage system. He then attempts to apply this insight to creating a series of birthing centers in San Diego that focuses on outcomes, customer experience and staffing.

It fails.

It is reborn though as a medical billing and software company that attempts to help other practices focus on medical service instead of paperwork (Bush's first company had to do both). It is this second endeavor's success that allows Bush to weigh in on what is wrong with healthcare in the US-the hospital system, which he sees as a cross between a medieval craft guild and an old-school department store.

In Bush's mind, the one-stop-shop of prestigious academic hospitals hinder innovation and prevent the delivery of reliable, low-cost healthcare to many Americans. His vision is that through healthcare technology, the old centers of service will be disaggregated into nimble niche providers that compete on costs and patient satisfaction.

Of course, there are flaws in the argument: does a customer model work when costs are not clear and value is hidden? Can a medical system really allow some patients to go unserved as many consumer business can? What about pharmaceuticals role in driving up healthcare costs? What about private insurance? How do other countries administer healthcare cheaply and effectively?

Bush also engages in the sort of rhetorical silliness that is de rigeur for any business book written in the past 15 years-what is old is bad, what is more like Amazon and Google is good. But the author has a sincerity in his beliefs that is compelling and no doubt his experience has lead him to some key insights about how to address the issues in US healthcare. 1591846773 Solid primer on the Health Tech industry

I would recommend this book to anyone who would want to learn more about the current state of health care and technology. Busch does a great job of breaking down how everyone plays a part in this overly complicated system and periodically plugs Athena Health. 1591846773 Relevant--but far from essential--reading for health professionals and interested patients.

The premise of the book is that healthcare should be disrupted by innovative technologies and competition-oriented business practices. When clinics and hospitals operate like normal businesses, then only the most efficient and cost effective medical providers will survive--to the benefit of the patient. And everybody else.

This vision of healthcare is essentially a free-market utopian fantasy applied to the most high-stakes industry.

This idea might sound obvious or dangerous, depending on your political temperament. Either way, it's interesting food for thought. Occasionally I found myself wanting to be convinced.

After all, there is probably an intelligent case to be made for a hyper-capitalist healthcare system. Just don't look for it in this book. The author does not even analyze the pros and cons of single-payer systems, let alone compare the healthcare systems of other countries to the system that he's proposing.

All in all, I'm glad I read it because it's relevant to my work and provided some new perspectives on the industry--as well as some insight into the branding of Athenahealth.

However, I'm also glad I listened to it on audiobook; I wouldn't have wanted to spend my time reading it in print. 1591846773

Free download ↠ eBook, PDF or Kindle ePUB ↠ Jonathan Bush

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? Why is it that technology in other industries drives prices down, but in health care it’s the reverse? 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 (Obamacare), it is called on 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, calls for a revolution in health care to give customers more choices, freedom, power, and information, and at far lower prices. With humor and a tell-it-likeit- is style, 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 start-up in San Diego. In struggling to save that dying business, Bush’s team created a software program that eventually became athenahealth, a cloud-based services company that handles electronic medical records, billing, and patient communications for more than fifty thousand medical providers nationwide.
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 physicianpatient 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: • Well-intended government regulations prop up overpriced incumbents and slow the pace of innovation. • Focused, profit-driven disrupters are chipping away at the dominance of hospitals by offering routine procedures at lower cost. • Scrappy digital start-ups are equipping providers and patients with new apps and technologies to access medical data and take control of care. • Making informed choices about the care we receive and pay for will enable a more humane and satisfying health care system to emerge.
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. Where Does It Hurt?: An Entrepreneurs Guide to Fixing Health Care