The Bush Health-Care Solution

No, not Dubya’s. The president’s first cousin Jonathan is an entrepreneur whose company, athenahealth, is trying to free doctors from the nightmare of insurance paperwork so they can get back to practicing medicine.

Jonathan Bush and Todd Park sat in their offices in a San Diego birthing clinic in 1997, listening to the urgent and beautiful sounds of a baby’s first gulps of air from the birthing room nearby. The cries were music for the two fresh-faced former Booz Allen Hamilton health-care consultants, 28 and 24, respectively, who had decided they’d learned enough to run a physician’s clinic better and more efficiently than the doctors could. On the advice of Bush’s wife, Sarah, who had trained as a midwife, they decided they would buy a birthing center, learn how to run it, and then franchise a nationwide network of clinics that viewed pregnancy as a holistic experience rather than as a disease. They raised $1.6 million from family connections, moved into flea-bitten apartments, dressed in khakis and blue shirts in hopes of fitting in with the Birkenstock-shod staff, and set up shop, fueled more by enthusiasm and idealism than experience. They named their company Athena Healthcare, after the goddess of strength and wisdom (and also because it started with the letter A).


But it wasn’t long before those cries of joy turned into wails of desperation — coming not from the babes upstairs, but from Bush, a first cousin of President George W. Bush, and Park. Their practice was in its infancy, but risked a premature demise. With no system to track their outstanding claims to insurers, they had no idea what was owed to them or when they might collect it. Caught in a classic cash-flow crunch, Bush and Park were going underwater faster than one of the expectant mothers in the birthing tubs above them.

Scrambling to find a solution, they hired Park’s little brother and computer whiz, Ed Park, who built a program to help them run the business. And they quickly realized that they were not alone. What they faced was, in fact, the norm: a vicious quagmire in which reams of paper, unprocessed claims, and insurance snafus were preventing doctors from doing what they had gone to medical school to do — help sick people get better — and often driving them out of business altogether. Although the pair loved their baby business, they couldn’t raise enough money to run it. The sweet spot, it turned out, was in harnessing the technology they had created to help other doctors run their practices.

And so Athena Healthcare became athenahealth, a company that takes over most of the administrative junk associated with running a doctor’s office. Somehow, Bush, athenahealth’s CEO, and Park, its chief development and chief marketing officer, transplanted their zeal for birthing babies into the less-scintillating world of claims processing — one of the most opaque, byzantine, and unsatisfying businesses out there. In doing so, they managed to create a corporate culture in which “athenistas,” as they are called, see their jobs not as processing claims but instead as saving the world, one messed-up strep-culture bill at a time. Today, athena, with $39 million in 2004 revenue, is the largest company in its fragmented field, handling more than $1.4 billion in claims annually. Its main product is a Web-based service that helps doctors run their practices more efficiently and more profitably.

Bush, whose father is Bush 41’s brother, says he’s had only one real conversation with the current president about his company. That came during a June 2001 visit to the White House. “We hung out for a little while,” Bush says. “I told him what I did. He said, ‘You’re not really the CEO!’ I said, ‘Yes, I am.’ Then he pulled out this spreadsheet and said, ‘I’m into this stuff. I think there’s a huge 20% cost opportunity that can be found through investment in IT.’ I was pretty thrilled that he valued what health-care IT could do.”

There’s certainly room for improvement. According to athena, there’s an average 72-day lag from the time a medical practice submits a claim to when it actually gets paid. Even worse, between 5% and sometimes 35% of the claims will never be collected, even though doctors spend up to 10% of their revenue paying people or buying systems to do just that. “If you told anyone else in America, ‘I’m going to pay you 65 days late, randomly deduct 5% of your paycheck without telling you, and make you pay me a tax of 8% to 10% of your paycheck,’ you would say that’s absurd,” says Park.

The notion of outsourcing billing services is hardly new in medicine. There are thousands of mom-and-pop outfits and many very large companies that do such work. But athena has some special features, starting with the fact that it takes 1% to 7% of a doctor’s collections rather than charging a flat amount. “The whole idea of risk sharing is their differentiator,” says Barbara Kelly, research director at Gartner. Athena may also be the only company that unites both the front and back ends of a doctor’s office. It checks that the patient has valid health insurance and verifies his copayment before he comes in. Athena then files claims on behalf of the provider, collects and deposits checks, and examines rejected claims to find out what went wrong. For its more than 4,000 customers, athena has reduced average days in accounts receivable to 47 and boosted revenue by 5% to 10%.


Chris Masciola, practice manager for Professionals for Women’s Health in Columbus, Ohio, signed on with athenahealth in 2001. “They blew us out of the water,” he says, cutting days in accounts receivable down to the high 30s, from 61.

What athena calls its “secret sauce” is its rules engine, a horrifyingly complex piece of software that tries to incorporate every single coding change, billing-address modification, or regulatory shift in the industry. There are currently more than 40 million permutations, each of which spawns constant changes and exceptions — if, for example, Aetna were to require a “Q” before any back-surgery-related claim number. In effect, athena has created a dynamic knowledge-management system in which employees and customers are encouraged to share what they learn.

There’s no question that the spirit at athena starts at the top. Bush, 36, a hyperactive Sean Penn look-alike with a penchant for off-color, surprisingly impolitic comments, is the big-picture guy with real-world experience; he volunteered and served in the Army as a combat medic and even spent a summer as an EMT in crime-ridden New Orleans. Park, 32, a voluble first-generation Korean-American with a small frame and a booming laugh, is slightly more bookish and earnest but equally energetic. The two talk over and through each other but rarely fight. “They’re a fantastic pair,” says David Knott, the managing partner of Booz Allen Hamilton’s New York office who hired them in the early 1990s. “The world is a better place because they are in it.”

Bush shares some mannerisms and background with his more famous cousin (neither distinguished himself early on, but both ended up at Harvard Business School; both make those funny arm-chopping gestures). He has fond childhood memories of his older relative, who would sometimes stay at Jonathan Bush’s family’s apartment in New York. “He was a really fun guy,” Bush says. “Like, a cool dude. We’re all fun, but he was definitely way fun.”

There are some big differences, too. This Bush lives not in Washington but in Belmont, Massachusetts, probably one of the bluest towns in one of the bluest states. He coexists comfortably with an employee whose vegetable-oil-powered car proudly displays its bush=satan bumper sticker in athena’s parking lot. This Bush has five kids and wears Lance Armstrong-style bracelets imprinted with athena’s logo and the words teach and learn to remind employees what the company’s culture is about.

And this Bush is so comfortable with himself that he merely reddens when Park shares the story of a trip they took to the Bahamas together when Bush’s first child was a newborn. While Bush’s wife was swimming, Park heard the baby cry hysterically and then stop abruptly. He ran to the other room, only to see Bush trying to calm his daughter by putting her to his, er, breast. “I have a very spiritual and crunchy exterior and a hard-core business interior,” says Park. “Jon likes to pretend he’s the hard-core guy, but he is the softest-hearted, most emotional, weepy, spiritual guy inside.” Bush, whose syntax can be reminiscent of Dubya’s, says the impulse to serve runs in the family: “What am I going to do, what’s my little avenue that’s sort of playing along the same lines, you know, impacting social good?”


He’s also driven to succeed, though — and that can sometimes mean learning from failure. Although athena is now growing at a 50% annual clip, it stumbled in 2002 when it mishandled the outsourcing to India of the electronic conversion of paper “explanation of benefits” forms — the form you and your doctor get that explains what was and wasn’t paid. Pandemonium ensued, as clients suddenly had no idea what services they were being paid for. This was exactly the kind of mayhem that athena had promised to end. The tech team mobilized to solve the problem, and Park came up with the idea of a guarantee, which offered a cash refund of up to 20% of the practice’s monthly fees if athena didn’t meet certain deadlines. “People in our space are not accustomed to getting this kind of response,” says Park. “It turned out to be a great brand-building moment for us.”

Next, athena intends to stake a claim to the potentially most profitable part of the market by digitizing the actual doctor’s appointment itself. The company is spending $2.1 million developing a product called athenaClinicals, an electronic service that will roll out in 2006 to track and measure everything from diagnosis to medical transcription to lab results. But many other larger and more-established companies are eyeing this market, too, so it won’t be easy.

Yet Bush and Park have the advantage of a committed team behind them. “I love this firm,” reads one recent response to an employee survey. “Many of us believe that we are doing more to save lives than Mass General! I don’t know if we are right about that, but the passion in the air when people are working to save lives is the best and most addictive drug I’ve ever been exposed to.” Now, there’s a prescription for success.

Jennifer Reingold is a Fast Company senior writer.