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Healthcare’s Original Gangster: Jonathan Bush (Part 1)

Written by Andrew Le, MD

UpdatedFebruary 29, 2024

Welcome to the CEO Corner, where Buoy CEO and Co-founder Andrew Le, MD, sits down with industry leaders to chat about the provocative topics of healthcare today. Andrew recently spoke with Jonathan Bush, co-founder and former CEO of athenahealth, executive chairman of Firefly Health, Board member at SonderMind and Innovaccer, man about town in Boston circles, and (as Andrew nicely puts it in the opening of this exchange) the “OG”, or “original gangster” of digital health innovation. And they just about covered it all, from Jonathan’s professional journey to why young healthcare should be selling to employees right now – and the great opportunity that is, “the dog eating your homework."

This interview has been edited and condensed for clarity.

Andrew Le MD: It’s good to have you join us today. I still remember the first time we met at athenahealth’s offices, and then we met for breakfast at The Charles Hotel. I was so starstruck, and honestly, I'm still starstruck every time I see you. You're like the OG digital health innovator.

Jonathan Bush: I remember it so vividly. I've never been so complimented with a straight face before. I guess we're all softies inside in the end. It’s great to reconnect. It’s cool you’re doing a movers-and-shakers/CEO Corner section in your blog – I can’t decide if I’m a mover-and-shaker or amongst the moved and shaken. It has been some time since we’ve spoken.

Andrew Le, MD: I think the industry has always appreciated your candid nature. I’m excited to dive in because I feel like you've done so much, and you just continue to do so much. Maybe to start – for people who might have been hiding under a rock – tell us a bit about your background, and then how you got to where you are today.

Jonathan Bush: Well, I've been under a rock too, so I definitely want to respect my brothers and sisters of the rock-dwelling community. I'm the one-hit wonder, right? I started a business via my business plan contest at business school, and just kept going with it. athena [athenahealth] was started as a birth center company focused on maternity care. It was kind of a bundled episode company before that was a thing. And we found that that was a little... well, like most of my term papers at business school, a little in need of refinement. I think my exposure to refinement started with my shark paper in fifth grade: "Refine your thesis more downward and have more footnotes and spell better." A lot of that was brought up again in the early days of athena.

In 1997, Jonathan Bush and Todd Park created a software solution for dealing with the frustrating volume of paper records that their birthing practice generated — founding athenahealth in the process.

So [athenahealth co-founders] Todd, Ed and I refined, eventually narrowing athena down into one of the first industrial-strength read/write internet native platforms in healthcare. For us, it was a revenue cycle management company even before it became its better-known self, an electronic medical record company. We specialized in helping doctors get paid faster and more accurately.

It wasn't a true platform company as we've come to know athena today. But it did have some shared technology, or shared copy of the software, like a Salesforce. It also had some shared knowledge, i.e., shared insurance lists, shared payer rules, and shared connectivity to hospitals and labs and pharmacies and others. We would build one connection and then all of the table spaces would be shared.

That gave us leverage on the core job or frustration doctors faced in the late 90s or early 2000s, which was getting their claims paid. They were spending so much of their time figuring out which P.O. box was the right Aetna. There were 26 P.O. boxes at Aetna at the time!

But taking this technology and leveraging it against this really miserable job that had to be done for doctors and their staff and the practices was the kind of arbitrage that made athena a business. Docs could get paid faster because they were exposed to specific tidbits of helpful information. Automation of information was helping those at the chaotic front desk – the lowest paid, hardest working, most overwhelmed slice of the medical office staff – operate better and take a breath. Little by little, we followed the arbitrage to elsewhere in the office: the exam room, patient communications and medical records, and so on.

By the time I got fired, I actually got fired by my Board of Directors. It was a unanimous vote 22 years later... honestly, probably the best thing my Board ever did for me. It made it very easy to leave something I loved so much. At that time, athena touched about 18% of all doctor’s office visits in the United States. I’d say we were successful – but by that point, we were also sort of old school.

We called ourselves either "the youngest dinosaur” or “the oldest mammal." We were a generation behind as the generations went on.

"We called ourselves either "the youngest dinosaur” or “the oldest mammal." We were a generation behind as the generations went on."

Andrew: I love that. One of our industry’s most storied journeys over the last few decades.

Jonathan: Thanks for saying as much. I’ll leave ranking athena’s place in what feels like it will be an increasingly elongated period of positive healthcare disruption, to others like you in the industry Andrew, and the historians.

I will say that going from using a “corporate private jet” (a.k.a. my Jeep Wagoneer in the late 90s) to a real corporate private jet to having to sell the corporate jet because it looked “bad” because we were doing so poorly in the eyes of certain not-to-be-named activist investors was all things wonderful, humiliating and humbling. I don’t think we were doing quite as badly as the activist investor portrayed in his campaign to get ownership of the company and get me fired. But we weren’t doing as well as we would have liked. We were in need of a really aggressive re-platforming, and we had run out of time and support.

So, I left athena with no bills to worry about, and was able to start again. The dog ate that homework. And they always say, "Don't be mad when your dog eats your homework. You can do it again much more clearly now that you've had it out. You don't want to be constantly rewriting that old draft with all of its original misconceptions. Write it again, clean."

That's what I'm doing nowadays. Starting with a fresh new notebook. I'm basically trying to build up a portfolio of companies that can reliably deliver half-price, full-coverage healthcare. I wasn't able to get into Buoy, for which I forgive you. Buoy is a perfect example of something that would be in that portfolio, because you’re innovating on something that has it all wrong. The current manual and craft-brewed approach isn’t the answer in healthcare. It never was – and never will be.

Andrew: Sorry about Buoy. Maybe we can leave that door open?

Jonathan: I’ve always found open doors to be good practice.

Andrew: So, let’s come back to where you’re focused today.

Jonathan: Yes, focus. Another thing I heard quite a bit in school and then later in athena’s last year under my leadership.

Today, I’m working with Firefly, Innovaccer and SonderMind in the mental health space. I’m focused on removing a lot of the craft that makes healthcare expensive and replacing it with remote, virtual technology approaches that are better.

The New York Public Library. "Zeus on his throne gives birth to Athena" The New York Public Library Digital Collections. 1844 - 1861.

And then of course, I just started a company, Zeus, named after the father of Athena (not that I'm insecure...) that will be focused on enabling all of these marvelous digital health companies that we're seeing today. It’s backed by $14 billion in VC, focused on digital first-type enterprises in 2020; $8 billion in Q1 2021, oh my! The venture investments total back when I started was like, zippo, and just five years ago, in 2016, it was $8 billion. That means that this year, in just the first quarter alone, the industry has already raised as much as it did in all of 2016. And now Firefly is contributing $40m via Andreessen Horowitz towards getting Q2 going!

Andrew: Wow. Both on Zeus and the funding numbers. And congratulations to Firefly. I’m happy to say Buoy’s a small part of that 2020 funding activity!

Jonathan: Everyone should be. The numbers and funding are there because the opportunity is real and because there are dollars to be deployed. Drink from the fountain, Andrew! Zeus will hopefully make it super easy for these hundreds of companies to build up EMR, patient relationship management, and customer service platforms that are unique to their designs and their stories, and that can attach to a single national master patient index and a single national file for every American that wants one.

Andrew: That sounds like a very big idea at exactly the right time. As a young company in digital health, I know we would have and still could benefit from a company like Zeus.

In Part 2 of the conversation, Jonathan shares more about moving on from athenahealth, delights us with parallels between historical figures and his own industry journey, and lays out why employers are finally ripe and ready to move forward with digital health adoption.

About the participants:

Jonathan Bush, Co-founder and former CEO of athenahealth, executive chairman of Firefly Health, Board member at SonderMind and Innovaccer, man about town in Boston circles, and (as Andrew nicely puts it in the opening of this exchange) the “OG”, or “original gangster” of digital health innovation.

Andrew Le, MD, is the CEO and Co-founder of Buoy Health.