Athenahealth CEO's Book: 'Where Does It Hurt?'

20 Tests Healthcare CIOs Must Juggle

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Jonathan Bush wants you to get religion about tearing down the temple of American healthcare and rebuilding it.

"This is the bible," the Athenahealth CEO joked in an interview about his book, Where Does It Hurt? An Entrepreneur's Guide to Fixing Health Care (Portfolio Hardcover, 2014), co-authored by business journalist Stephen Baker.

The book, due for release on May 15, distills Bush's keynote stage rants about how much better the system could be if it operated more like the Internet economy. Athenahealth provides doctors with a combination of Internet applications and back-office services to simplify their businesses and clinical practices, and Bush is an evangelist for disruption on a larger scale.

In his vision, an expensive university hospital would never provide a service that could be performed less expensively somewhere else. The truly excellent hospitals would specialize more in what they are truly great at, flying in patients who need those specialties. As an early example, he cites a deal that the home improvement retailer Lowe's made to send heart patients to the Cleveland Clinic, flying them in if necessary. Lowe's employees will get better care, and even with the cost of travel, Lowe's saves money with a 25% discount for bulk business.

[The new picture of health? Read Health Systems First To Combine Radiology, EHR.]

One Internet-enabled change that's already happening: Digital medical images captured in one place can be read by radiologists located anywhere -- that way, images can be sent to a radiologist who may specialize in interpreting images of a particular body part or a particular disorder. However, in some places, that model is hobbled by laws requiring everyone involved in a patient's care to be certified in that state. In general, Bush argues, our laws tend to preserve the status quo, protecting the monopolies of the tertiary hospitals that pull in business on a regional basis. Though these are often nonprofits, they exert some of the most extreme lobbying leverage.

Where Does It Hurt? starts with the story of Athenahealth's origin (some of which I heard in a previous interview), including the time he spent driving an ambulance in New Orleans, followed by a stint as an Army combat medic training for duty in Operation Desert Storm (which ended before he could be sent to Iraq). After spending time consulting in the healthcare industry for Booz-Allen, he and another consultant, Todd Park, decided to reinvent the economics of maternity care with a chain of clinics organized around a small number of doctors supervising a much larger number of midwives. While struggling to get insurance claims paid for their services, they created the software that became the basis of today's Athenahealth.

The book is less about technology than it is about free market economics. While Bush is part of a famous political family (he's the nephew of President George H.W. Bush), he makes an effort to stay above the partisan fray, in favor of being suspicious of government intervention in general. One chapter -- "Government (or How My Cousin, the President, Almost Killed My Company)" -- deals with his panic over legislation from the George W. Bush administration that could create an advantage for competitors selling software over what we now call cloud software. He insists he couldn't simply pick up the phone and call his cousin, because it would have been embarrassing for both of them. Still, he had the confidence and connections to navigate the halls of Congress and get the language changed to "software and Internet services."

"But let's consider this process for a moment," he writes. "It has nothing to do with innovation or satisfying customers or delivering great results. It has everything to do with cultivating influence among politicians and regulators. To create a modern, caring and efficient health care economy, we have to create more spaces where entrepreneurs can compete in the marketplace -- and not in the corridors of Capitol Hill."

Bush doesn't like Obamacare, though he faults its political opponents for failing to offer a better alternative. Though the law encourages some consumerization of healthcare, "it's a trend toward the highest deductible allowed by law, which is not high enough for real shopping to occur." Since even a brief hospital stay will exhaust most deductibles, "it means the hospitals are immune from shopping, and that's not good."

If he writes another book, he says, it will be on what's wrong with the financing of healthcare. In his view, too much of the current, paternalistic thinking is based on a Rand Corp. study on the effects of healthcare cost sharing conducted in the late 1970s and early 1980s, prior to the possibilities opened up by the Internet and new ways of shopping.

"We've neutered healthcare's ability to be creative about getting people's money," Bush says. When medical professionals have to be creative, they learn the game of product management and product improvement. "Just look at the cost of braces and quality of braces from 1980 to today. An even better one is laser vision correction, which is largely not covered [by insurance]. We've gone from $3,000 per eye to $200 an eye for surgical correction of vision -- because there were so many people out there who didn't need glasses, and if they could be coaxed into it, they would get the procedure."

The trick is to achieve change without scaring people, Bush says. "Even Obamacare was too big a shock to the system. It wasn't that major a shift, right? It wasn't as big of deal as we made it, but look at how many headlines we made."

Here are some other highlights from our conversation:

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