The Flaw Behind Everything Wrong With US Healthcare

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And I think that it's missing the forest for the trees. If you think about healthcare, I think it's the sine qua non of life. It's without which there is none. And it's actually, depends how AI-built you are, but your audience is probably pretty AI-built. If you imagine a life of pure abundance and you imagine Jevons Paradox does its thing, then the only good in our lives that does not have any diminishing marginal return is another healthy year. And so to me, at the limit, you should be spending every single dollar towards the health of your society. And so when we look at the US and say, oh, we spend 18% of our GDP, that's a problem. My question is, well, why? We've never used absolute numbers like that as a problem. The question is, are we getting what we want from that dollar amount? And that's the whole premise of Jevons Paradox is actually the market size increases as the cost per unit decreases. Now the cost per unit, the challenge is in the US healthcare system, the reason why it's 18% is because the cost per unit has been rising. We spend probably 50% of our healthcare costs on 5% of people. The US doesn't give up on a single person in that way. A lot of people look at the US healthcare system as this great anomaly relative to other healthcare systems. And I'm actually of the belief that the US healthcare system is actually a preview of what's to come for a lot of other countries. You look at the UK, its GDP percent of healthcare spent on GDP went from 6 to 12. You look at Germany, it went from 9 to 12. You look at the US, it went from 9 to 18. And same thing with our obesity rates. And so to me, again, back to what is more important for society to spend its money on? I couldn't imagine something that's more important than our health, but what we get for it should just be far greater. Yeah. So if you ground us in today's reality, I'm very curious for your state of the union of the system itself. You can picture the obesity rate chart that has, for the first time in a while, been a flatlined or came the other direction. I think GLP-1 is the primary reason why. Obviously, that's driven your business to an extraordinary degree. But beyond just that, give us your sort of state of the union. Here's what health is like in the US today. Give me a little podcast by itself. It's interesting to think about first, where does the money go? Usually if you want to understand the industry, you just follow the money. So let's say 30% to 35% is about hospital systems, 20% to 25% might be doctor's office. Another 9%, 10% would be drugs and pharmaceuticals, and then you see the remainder chopped up there. And then a lot of people will talk about, and back to our question a little bit around percentage GDP, the US healthcare system, I would say, is really fantastic, better than people give it credit for at acute care. Yes, it's more expensive, but we have higher cancer survival rates than the NHS. If you get cancer, you want to get cancer in the US. If you have a heart attack or a stroke, you want to have it in the US. Our survival rates are higher on average than other OECD countries. And we don't use more healthcare than other OECD countries. We have fewer hospital stays. Our hospital stays are shorter. We have slightly more procedures and scans, which whereas it nets out on a per unit basis and our prices are higher, and our administrative burden is much, much, much higher. And then a lot of people will talk about life expectancy in the US. It has an increase in the last 10, 15 years. But to me, a lot of that is not a reflection of our healthcare system. So there's kind of two buckets of the way we die. The first is like this fast clock, and that will bring down the average of the US life expectancy relative to other OECD countries. So that fast clock is like gun deaths, car accidents, overdoses, things like that, that'll bring down an average. But it's not the majority of the way we die. The majority of the way we die is with a slow clock, chronic disease, and that is massively been rising. As we mentioned, the last 20, 30, 40 years. So those two things are really the makeup of how illness happens in the US and how people die. And then that's how the money gets spent. Is he thinking about the whole thing? What is the most surprising thing that you've come to learn about the system that you think people may not appreciate fully? There's probably two things that I would say. One is I do think our healthcare system has one, if not two, but one central flaw from which all other problems stem. And the second is that the entire healthcare system is based on time horizons that are almost irrelevant to the individual. So that's what I think of the surprising thing, which is when you go into the healthcare system, there's a fundamental mismatch of incentives. And if I had to say what is the problem with our healthcare system, it is that the patient is not the customer. That's the problem that we're trying to solve at Roe. And I think you see it working, but that is the fundamental problem. And the reason being is, I mean, you see this in every business that you talk to, whoever controls the flow of money at the point of purchase, that's the customer. That's the stakeholder that everyone builds around. And patients, individuals, we pay for our healthcare. We just are not the customer in the majority of their actions. So our out-of-pocket expenses are the minority of our expenses. And we pay through our taxes and we pay through suppressed wages with our employer. And so you then look and say, okay, well, where's healthcare working? Where does it feel really good? And it feels really good where it's cash pay, where the patient is the customer. Can you give a favorite example of that? You look at LASIK eye surgery, cost comes down, quality improves, convenience improves. You look at breast augmentation, you look at cosmetic surgeries, cost come down, quality improves, convenience improves. You look at GLP-1s. All right, take GLP-1s, and they are like this beautiful foil for the rest of the healthcare system. Politicians and regulators have been trying to get transparent prices for 20, 25 years. What happens? Pharma goes direct. What happens to the prices? I call this, as my loving Jewish mother would say, the Fakafda prices of listaneh. You have $1,300 drugs that people are paying behind the scenes $300, $400 for. What happens when those go direct to consumer? That listaneh act gets entirely eliminated. When people are pointing fingers between insurance companies and PBMs and pharma, and who's to blame? They go direct. You remove the PBM and insurance company entirely. And normally branded drugs, every year, systematically, they go up 6%, 7%, 8% year over year until the patent cliff. My hope, and I think you're already starting to see this, more middlemen that do absolutely nothing are getting removed from the process. So they are able to capture the same, if not more, gross profit while prices come down. If you look at Lilly's earnings, prices come down, volume far outstrips it. And PBMs, to me, they are like the appendix of the healthcare system. At one point in time, they might have served some purpose, but it was so long ago that people can't remember what the heck it was. And it turns out when you remove them from the equation, software can do exactly what they would have done historically. And so you even see with GLP-1s, PBM goes away, insurance company largely goes away. People can debate that and whether or not it should and what they should cover. But for cash pay purposes, PBMs and insurance companies go away. Prices go from $1,300 to $149. And the people making the drugs are making more money. And so you can see that where it's working, the patient is in control and at the center. And then you usually have people give this criticism. One of the most common is asymmetry of information. In my mind, it's a little bit similar to the best form of government. So democracy is the worst form of government except for all the other ones. In my mind, the patient is the worst person to own their healthcare decisions except for literally everyone else. And when you go into our healthcare system today, they'll say there's asymmetry of information. You have to sign on the dotted line away anything and everything, and you're not reading that. But imagine you had recourse, which is get to vote with your feet. So if hypothetically, when we as a society, well, sometimes you have the price transparency laws for hospitals. And people thought that that was this amazing thing. That is epic lipstick on a pig. No industry could survive with its prices not being public. Any company that did that wouldn't get any customers. So rather than us praising that, we should see that as a symptom where if you hypothetically gave, let's say, I don't know what you give your employees for healthcare, what you spend on it, but let's say we spend $20,000 to $25,000 a year per person. If I magically gave them a credit card that could only be used for healthcare, and let's say $20,000 of it could be used on their healthcare expenses, and it would just roll over every year, and then some portion on catastrophic care, which is I think the ideal form of insurance. But you wouldn't have to make a law that says you have to make prices public. Businesses do that to earn a customer's money. And if they don't do that, A, if they don't make the prices public, they won't get their money. And then if they don't do a good job, they won't get their money. And so one of the reasons why in healthcare there's very little trust is because A, there's very, very little transparency, and they don't say what they're gonna do and then deliver it time and time again. And so where you see people feel that way in healthcare is actually where they're in control in that cash pay environment, or where insurance is 100% accepted, and it covers 100% of the cost, and it's basically like they have free money, and they have choice and foresight. So the idea to me is what we're trying to do at Rho is if we can aggregate patient spend, I think we can bend the healthcare system to the will of patients. I'd love to use Rho as just a great example, since you know all the data like the back of your hand. Give us a sense of the lineup of products right now, and what the pie chart looks like today. What percent are they spending on each of the major categories? Yeah, I have to. So we have four main categories. Rho is the leading provider of GLP-1s in the country. Public health is the number one category, then sexual health, dermatology, and fertility. And the fastest growing part of the business is GLP-1s. And oftentimes people will say, as this has happened, because we've grown over the last four years, we've gone from about a $250 million run rate to over a $3 million run rate. And we've done that actually with fewer people than we were in 2012, I'll tell the whole story. But the majority of growth, what's interesting is people will often say, well, those are just weight loss drugs. And that's really both fascinating for me when one, they were approved for diabetes, then they were approved for obesity and overweight, then they were approved for heart disease, then they were approved for sleep apnea and liver disease and kidney disease. And they're being studied for neurodegeneration and pain management and addiction and mental health and cancer prevention. And so you look and you're saying, yes, leading part of our business is just treating the leading causes of why humans die on Earth today. That's the whole clock that we talked about. So I used to be frustrated by that just moniker, and now it's like a badge of honor. It's by far and away the fastest and leading part of our business. So I actually would love to spend a few minutes on each of the four driving leading categories, obviously, starting with GLP-1s. Why have you been so effective? What has made you the leader? Why don't people just go to these new direct services that the pharma companies have? What is it about Rho that has allowed it to be the place of choice to go get this stuff? Yeah, it's a great question because people often ask about competition and differentiation. And so there's a bunch of different ways to talk about it. The first year point is like the proof's in the pudding. So Rho is the leading provider of GLP-1s in the country. We're probably signing up two, three, four, five times as many patients every single day as our competition. So there is clearly some differences. And so what is that? And then when you think about differentiation, a lot of times people, and I would love if this were the case, want this very specific answer. Like we offer this feature and someone else doesn't. And the thing is, is if I were to say that right now, I could point to those things and say, well, Rho is the most affordable to start. And Rho has the strongest formula. We're integrated with both Novo and Lilly. Well, Rho also has CashBank and we help people check their insurance. So we've helped actually over 1% of the US population check their insurance for free and then entirely with AI. You can get it mailed to your door. You can pick it up in person. We also have worked with our pharma partners to offer multi-month subscriptions where we can actually save patients $600 to $1,800 a year. And that's not available in an infinite number of places. So for many people, the membership actually pays for itself. But the truth is, is that differentiation in my mind, I'm a big believer that the only, only, only source of differentiation is continued innovation. We must be in search constantly of that next checkbox. And so we have to invent that next check every single time. Because if we stayed still, if the companies you love stayed still, Apple, Amazon, Google, wherever it may be, if they stay still for six or 12 months, you see this even in the AI races. Like every four weeks, there's another company beat another company. So if you stay still, it's great for consumers. And so again, that's where I love like the consumers. I love competition, especially in healthcare, because we have to fight every single day to continue to serve. Even when we started the company, the way we built the technology, we built an EMR from scratch. We built our own clear sort of a cap accredited lab, we built our own pharmacies, we built our own pharmacy software, built our own provider network, all of those are seamlessly integrated and they're built in a condition agnostic way. And we had been building this incredible platform for the previous four or five years before GLP-1s came out, leaned very, very hard into it, but we were able to quickly expand. And so when people think about us like a condition by condition, they actually should just think about a world-class care and treatment distribution platform that is all vertically integrated custom built software in service of helping that patient achieve their health goals. Is there anything interesting to double click on the options you have for serving something like a GLP-1, which is made by a couple of different companies, but not by 50? Is there anything interesting in that dynamic that, because there's relatively few suppliers, they would think it would have some sort of power and be able to capture more of the total margin that's being earned by all companies that are serving a customer at GLP-1? I think your assumption is right. And by the way, I think that should be the case. I think the inventors of GLP-1... GLP-1s should earn more, should grab more margin than the people who scale access to debt. I think that's normally what you see for the most part with some demand aggregators. And retail is an okay example here, it's not perfect, but Costco might be another example where they might have 15% margin on the good itself. They make the majority of their gross profit on a membership, but they have an incredibly durable and scalable business, and there's a lot of value for both the suppliers and customers of that instance. Is demand aggregator sort of the Ben Thompson idea? Is that how you think about the business? I think so. I'm sure he would have a more academic response of why we're not, because it's not zero marginal cost to serve the marginal person. But I think what gives us the reason why pharma comes to us is because we prioritize first and foremost what the patient wants and needs. You've seen other companies prioritize, in this space you've seen other companies prioritize their business over patient outcomes, and they are not as large. And so patients come to us knowing that we will help find for them the right drug, the right treatment, the right dose, based on how they prioritize cost, quality, and convenience, which is what a consumer cares about. I think that's why we've been able to integrate with both of the leading pharma companies is because they know and they want to compete in the marketplace. That is what they always want to compete in the marketplace over who can best serve patients across those things. And we facilitate that microcosm of the marketplace. What do you think the impact of GLP-1s is gonna be prospectively? There's been lots written about what it's done so far, the flattening of the obesity curve, the data is all very interesting. But if you think about it going forward, as I don't know what percent, maybe you could tell us if Americans are on one of these. People say 10 to 15%. Okay, it's a big percentage of Americans on the drug. What do you think the prospective story of GLP-1 class drugs will be? I'm interested both in the broader impact but also the generations of technology that this new one's coming out soon. Seems really fascinating. Welcome your thoughts on that. What's the story from here look like, Devin? There's the individual healthcare impact, there's the impact to the healthcare system, and then I think there's the societal impact. On the individual health impact, we talked a little bit about this, but they are upstream of the leading cause of the death, what they're approved for. Diabetes, obesity, liver disease, kidney disease, sleep apnea, heart disease. They're approved for all of those things already. Four years ago, they were just approved for diabetes. So that impact is tremendous. Then there's the healthcare system impact, which we talked about, which is I think they are fundamentally rewiring the healthcare system. And industries get rewired when large amounts of buyers care about one thing for an extended period of time. So we saw a lot of the healthcare system suddenly find out that telemedicine was a good thing during COVID. And what happened during COVID actually, as a specific example, you saw a lot of states relax the regulation that a healthcare provider could treat someone without being licensed in another state. One of the problems of our healthcare system is we have a fundamental supply shortage. We have too many people who need care and too few are provided. So one of the things we were trying to do at Roe is turn a luxury into commodity by turning a service into a product. So when you see that, but COVID ended, and suddenly we went back to thinking that when the human body crosses state lines, it's suddenly wildly different. You are going to see GLP-1s rewire. They've already started to rewire and ask the questions why does your employer get to decide what is covered by your health insurance and have such great influence on your healthcare? Because again, back to incentives and that first problem that we discussed, your employer, they care about you. You care about your employees, I'm sure you do. I deeply, deeply care about our employees, but that is plural. An employer cares about many employees over a shorter time period than their entire life. An individual cares about themselves and their family over their entire lifetime. That mismatch in incentives will naturally create suboptimal outcomes. So what you're seeing with GLP-1s is you are actually seeing the most popular drug of our lifetime, or drug class of our lifetime, seeing the most popular drug. The majority of the growth is directing consumer cash pay. Patients are able to vote with their feet, and what happens? All of the things regulators have been dreaming about for a really long time. Prices are transparent, they're coming down, there's more competition, and all of the amazing things. And the third and last one is the societal impact beyond the healthcare system. So if I can go on a little bit of a tangent on this societal one, which is the reason we started Rho is very personal to me, and it's I deeply believe, very simply, we help patients achieve their health goals, because when we do, we think we unlock their full potential. If you do that at scale, you unlock the full potential of humanity. And I was very, very lucky, I grew up with my dad, who is a doctor, and he saved my life. Having a general heart condition, I had a heart procedure when I was 18, but he helped me achieve my health goals to go chase after my life goals. And so he helped me navigate that procedure when I was 18. Right after, actually the main side effect of my heart medication was erectile dysfunction, which is obviously every 18-year-old scream in their first semester of college, like calling up, hey dad. And he helped me navigate that. And actually, I've never shared this publicly, but when I was 12, I didn't grow for about a year. I was already quite small, bullied a lot, and my parents fought with the healthcare system to get it covered, but to help me get growth hormone. So I took an injection in my leg every single day for about six years. So I entered high school like four, eight, four, nine, and I left like six, six, one. And so those three paths, if you think about it from my perspective, there was either a world where I was dead at 18, five, three, with erectile dysfunction, this is like not great, or six, one, and married to the most incredible person in the entire world. And I do think that it was because my parents and my dad were constantly fighting with the healthcare system. They set me on an entirely different trajectory as an individual. And the societal impact, whenever we as a society, whenever we attack the leading causes of death, just upstream, not downstream, but upstream when we attack those, you see the shape of society dramatically shift on the other side. So from year zero to 1800, our life expectancy is 30. And a lot of people will say, yeah, it's infant mortality. It's like, yes, it was infant mortality. It's also maternal mortality. It's also infectious disease, those big three. What ends up happening when we largely combat infectious disease and infant mortality and maternal mortality? They're no longer mourning the loss of children and spouses every single day. They invest in the kids that they have. Those kids go to high school, they go to college, women enter the workforce, we have the industrial revolution 40% of the population goes from making food to four, we get electricity from 10% of pounds to 100%. And all of that happened, I believe, because health is a precondition to progress. And so right now, if we think of the leading causes of death as the thing I just mentioned, those chronic diseases, if we can attack those upstream, I think we can shift the trajectory of our society in ways that we cannot predict, in ways that will be beautiful and amazing and can't wait to see what happens. Do you think that if you had to predict the percent of people on some form of a GLP-1 10 years from now or something, what would your prediction be from 10 or 15 today? 50 plus percent of people. You think it'll just be a standard whether or not you have the acute versions of the things that were originally on that label? Yeah, absolutely. What's interesting to me is if you think about it, so just pure raw numbers, 75% of the U.S. population has overweight or has obesity. So just based on that, that group is clinically eligible. And then we say, okay, well, that bottoms up. Then what about top down? What percentage of the U.S. population is metabolically healthy? 10, 12%? So they're even interested in taking it prophylactically for inflammation or geroprotective reasons. So you start sitting here and say, of course there are some people who should not be on this medication or they might not be able to tolerate it. But as we improve the tolerability and as we better understand a lot of their mechanisms of action, I think what we're seeing is it combats a lot of the environmental and genetic impacts that lead to chronic disease in society today. And then there's obviously the massive affordability question. But to me, A, I think the majority of people will be on it. I think statins are a good comp. You see 40, 50 million people on it. And these are much more effective, just the breadth of the label. Before we close out this chapter, the state of the union and the system, I love this notion of jobs over lives as one framework. Talk to us about what you're thinking here. Yeah, so this is one of those that might be a little bit more controversial, but we can do it. There's a conversation in healthcare that's happening right now. I also think you see it in other industries. Where people say things like healthcare must remain human. And I think it's the entire wrong question to ask ourselves. Not that I don't think parts of it will, but it's an obsession over inputs instead of outcomes. And I think that when you do that, you are not prioritizing patient health outcomes above everything else. And so I think tools, both humans and new technology, must earn their place. And the status quo does not get a pass just because of its current existence. And so I think driverless cars are a great example. In my mind, where we are having quite a bizarre conversation in my opinion, which is about 40,000 people a year die from car accidents. That is almost the same exact number as the people who die from breast cancer every single year. Nuts, nuts, absolutely nuts. Driverless cars in pockets have proven to be 10, 20 times safer than a human driver. So we basically, for certain types of cancer, have a cure. And the conversation is not, how do we have operation warp speed for this cure for cancer? It is a lot about and more about job displacement. And it's not that I want to diminish job displacement. It's that we should not, this is what we're talking about, we should not and we cannot prioritize jobs over lives. If we were talking about a cure for cancer and someone said, what about the people currently treating cancer patients without the cure? I don't even know that they would be able to, it was the stupidest idea ever. There's a story that I heard a CEO of a driverless car company say. They were speaking to a regulator and the regulator asked the CEO when they told them about the reduction of deaths, the regulator said, but what about the ordinance? And the CEO was flabbergasted. What the regulator was referring to is the ordinance from people who are dying in car accidents that can save other people's lives. A beautiful thing, having said that, what the CEO's response was, I don't know whether they said it out loud, but at least when they told me this is what they had in their head, was hopefully they're still in the original person. And so I think that we as a society, especially when it comes to health, must prioritize outcomes over inputs. The new thing must prove its worth. So it's not that, hey, technology automatically gets a free pass, it doesn't. It must prove, not that it's 1% better, but that it is substantially better than the status quo. But we, as a result, cannot give the status quo a pass. And I think we see that with driverless cars right now. And it's a very painful conversation and I do believe that the people impeding driverless cars where they are proven to be safe should have a body count attached to their name, truly. And I think we will look back on it as such. And I think that one of my biggest worries is related to healthcare, that we will have that same level of prioritizing inputs over outcomes. There was that great chart a couple days ago showing the total revenue of GLP-1s versus AI revenue. And the GLP-1s are bigger. It's kind of crazy. There's two cool things here. One is not only were GLP-1s larger from a revenue perspective, but individuals pay for GLP-1s twice the number of people pay for GLP-1s than pay for AI. So from a consumer's perspective, I think they're telling you, I think that is a problem with the AI narrative right now, that there's not enough of a consumer impact day to day. So the gap of real-time impact to the tens or hundreds of millions of people hopefully can be bridged. Vanta automates compliance so your team can spend less time on security reviews and more time getting customers. Vanta cuts audit prep by 82% and gives you instant up-to-date proof of trust without all the manual work. 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And no amount of AI enthusiasm changes that requirement. Ridgeline is built on exactly that foundation, which is why I believe that the firms that come out ahead in the AI era will be the ones running on Ridgeline's unified platform. If you're serious about your firm's AI strategy, Ridgeline should be part of that conversation, and you can request a demo at ridgeline.ai. I'd love to know how to tell the story about this crazy company turnaround that you've been through. The company's been around nine years and about four or five years ago, you went through a really fascinating period of time. But the company's like 10 times the size it was not that long ago. Obviously, GLP-1 is a big part of that. The company's charts look kind of like the GLP-1's charts, so that's one explanatory factor. But that hides a very fascinating story that I'd love you to tell in some detail because when I've heard it from you in the past, I just think it's such a cool, fun example, and I think you're willing to be raw about the details of it, for what entrepreneurship is like. Like, oh, cool, three billion bucks, that's a great business. Nine years and a lot of blood, sweat, and tears to get here. So yeah, maybe tell this very interesting history. Cool in retrospect, quite painful during it, but I agree with you. It started, I would say, the moment I knew we needed to reset. So we did refound the company in the summer of 2022, but the moment we decided we needed to reset was December 2021. I am on a plane, headed to visit my parents, and I'm looking at my laptop, and I'm looking at the previous year's performance. Now, mind you, 11 months prior, in January, we had raised $500 million at a $5 billion valuation, and we did almost every textbook mistake in the book. We confused our long-term... vision with our near-term strategy and we decided to do everything and hire everyone and try to do everything all at once. And that was a disaster. And I realized that. People are like, oh, how did you not realize that? As it was going, well, sometimes looking at quarterly results or annual results or good moments of reflection, it hit me like a ton of bricks, actually. So I'm on the plane, I'm looking at this, and we had grown 9% in 2021. We had hundreds of millions of dollars in the bank. And we were burning, but we were what I would call a zombie company, which is like you're not growing fast enough to get out of it, but you're not burning where you're going to die. So you are just a zombie walker. And we had a prep stack that could squash an elephant. It was like an $800 million prep stack. So I'm sitting there having worked 70, 80 hours a week. Our team had for years, for years, for five years. And our team had devoted themselves so much to our mission. And we might not even clear our prep stack. So it was a tough plane ride. As this is happening, at the exact same time, our people team had sent out a wonderful Christmas gift to every employee at the company. And mind you, it was 2021. We were trying to do everything right. This is a local New York City women's owned business that made macaroons. And it was beautifully packaged in this plastic package. And I see at that moment, I'm flying home for Christmas, I see a comment in the general channel of Slack and send a message to the whole company. And someone said, at here, next time we send out Christmas gifts, can we not do it in an ocean full of plastic? And I was like, I had steam coming out of my ears. I wanted to reply at here, you're fired. And I was so frustrated. Thank God for honest about Wi Fi on the plane because I didn't send a message just looked at it. And my first realization though, was bad, but my second one was way worse. The first one was I was frustrated with this person. The second one was even more frustrated with myself. Because no one gives a shit about the packaging. When you are winning as a company. We were literally and figuratively, we were macaroon soft. We were a soft company. It's not how I was raised on we wanted to build on our company culture was terrible. And so I shifted from looking at our financial results to I wrote a six page memo to my co founders. And the moral of this memo was basically, I deeply believe in our mission and vision. We have built an incredible technology platform and we have absolutely amazing people here. So I believe in the bones and I believe we can fulfill our mission. But here are the things that are wrong. And the single best way that I know how to fix it is by fully embracing a strong attract and strong repel culture. If we have that with great people with our technology platform, we clearly have the resources, I think we can go put a dent in the universe. If you disagree, we need to have this conversation. If you agree, then starting in 2022, I'm going to go rip some band-aids. Fortunately, they agreed. Then January 2022 happens, we move on from about seven VPs from January to May. And then May to June, we move on from about 20% of the organization. Now quickly, because I feel obligated to say this, which is, I think Silicon Valley has this odd, almost fetish with layoffs. I think they reward it too much, if that makes sense. When it happens, people are cheering it on. And I think, for me at least, it would have been A, a lot more efficient to have never done that in the first place. Second, it's the absolute worst part of the job to take someone's livelihood away. And the second, it's not, I don't like that person very much. And the third thing is, I talked about we part ways with VPs and 20% of the organization, but I'm a big believer, back to the strong truck, strong rappel, that I do believe, and it's not in a cheesy way that there's a fit component. It's not just, is this person talented, or is this person smart or not? I had an internship my junior year of college at Booz. There were 12 interns, and 11 of them got jobs, and I got fired four weeks into the internship. I didn't even know that was possible, to get fired from a consulting internship. But I did. Four weeks in, I was consulting for the Yellow Pages. I got fired, and I got put on the beach, and asked to do paperwork. And then seven weeks in, they asked me to leave. So I do believe that you can have people who are talented, but just not be in the right environment. So we move on from 20% of the organization. Then my co-founder, Rob, at the time, there were three of us, co-founder Rob, he passed the baton for the next leg of the relay race, so it was me and Saman, and I give him a tremendous amount of credit for doing that and recognizing that. I mean, he's still on the board, we're still close. And then we refounded the company, which has several components to it, which we doubled down on top talent. We put everything under the Ro brand, so we were Roman, we extended beyond men's health, we dropped the man, we put all of our different brands under Ro, one brand. We massively updated our ways of working, which involved rolling out new principles, one of which was actually, when sales say work hard. And when we were even rolling out that principle, people were like, do you mean care deeply? And I was like, that's another principle, I explicitly mean work hard, not ambiguous. And then we said, here's our new strong attract, strong repel culture. And we were very explicit, we said, look, we take full, full responsibility for not being clear about not just the what we're building, but how we're building it. So a strong attract, strong repel culture, in my mind, the best products, the best music, the best fashion, the best media, strong attract, strong repel, the same reasons why you might love something are the same reasons why someone else might hate it, doesn't make them a better or worse person. And the best analogy in my mind is like a restaurant, a steakhouse, don't go to a steakhouse if you're a vegan, and don't go to a vegetarian restaurant if you're a carnivore. And it doesn't mean, by the way, that Roe is beyond feedback, we love feedback, we're just very explicit where, if you were to give me feedback at Roe, I would tell you, is this a feature or a bug, try to eliminate bugs, we double down on features. So you should not go into a steakhouse and say, hey, this steak, replace it with a mushroom. You should say, that's a feature, not a bug, the fact that it's meat. But if you were like, hey, I ordered medium rare, and it's actually well done, that's a bug. If you're saying they don't have enough context to do their job, that's a bug. So fully embracing a strong attract, strong repel culture, and making the menu of that restaurant very, very clear to earn the right for, again, where people work is a gift, they spend the majority of their waking hours there. And so to me, that was essential in creating that strong repel culture, which is basically if I had to distill it, it's extremely heterogeneous backgrounds and expertise, but a homogenous way of working. We work one way or what, why, how is very, very clear. We explicitly articulated that and then said, opt in or opt out to this, another 6, 7% of people opted out. And now we're at September, October 2022. And we have grown 100% basically year over the year for the last four years. We were 600 people when I was on that plane, we're now 400 and change. And we've 10x the business. So we've 10x the business with 30% fewer people. I'm curious to what you would attribute having gone soft as a business prior to that refounding moment as advice to others out there, like, don't do these things. This is what got us in trouble. I'm curious about that as well. The first 100 people we hired, 95 of them we had known or worked with before. So our culture was just through osmosis. And if I had to distill our culture, it's very much extremely high performance and big heart and they're not balanced. They are both to 11. So if you come and you have a big heart, and you are not performance and metrics driven, you are going to think that I'm a jerk. If you are extremely performance driven, and you do not have a big heart, you're going to find a lot of what we do probably sappy and cheesy and why are we spending time talking about this, but it's that rare duality of both turned to 11. I think it's honestly it's how it was raised. That was the culture of how it started. And then we were not explicit about that, though. So we were kind of like a restaurant that said, come here when you're hungry, we serve food and then gave you the menu. The best advice I would have to founders is the best company cultures, I believe, are strong attract, strong repel. It knows who it is. And it continues to try and double down on the features and eliminate the bugs. But you have to articulate what that is so that you know what it is and everyone else knows what it is and be unrelenting and protecting it. So I think the biggest reason is my co-founders and I let it get away from us because we candidly let other people too much of other people determine what that was. But we also again, these were very good people coming into the company. But we owed it to them to be far more explicit about the menu than we were. So I would take full responsibility for that. And I think founders do have to think the biggest thing that was the turning point is I was never going to quit. And so the second you realize that you're never quitting, then you do have to make it a place that you absolutely love to work and you are going to be the only person. I think you and your co-founders are going to be only people that can truly, truly create that. And so that's what I would say to protect that strong trust. So back to this idea of, okay, 10X with two-thirds the people, how much of that is tailwind? How much of that is efficiency of the work of the people that's because of technology? It's a lot of both. You do not see this level of growth over this time period without riding also a massive wave. But there's a reason why there's one company that's the leading provider of GOP ones in the country by a sizable margin. If you look at credit card data, we'll probably signing up two, three times, second, third, fourth, fifth place. So I think that we are riding in the same way others are a generational tailwind, but we're doing it better than anyone else. And I think the same thing you compared earlier GOP ones to AI, and you'll look at Nova and Lily to open AI and Anthropic. There are many companies other than open AI and Anthropic that have the same tailwind that didn't ride it to the same extent. Anthropic is, I don't know how many years old. So you do have to have that wave, but like no different, you can probably tell by now I love analogies, but like no different than surfing. You have to catch it. And it's really hard to catch a tsunami. Other people let it ride right under them or crash on top. What are the other underrated ways that you've done that? First and foremost, I think you can build anything if you have the best talent. So we doubled down on our top talent from a compensation perspective, from an equity perspective, from a coaching and resourcing perspective, constantly investing in the best people. And I think if you look at that 400 people that are at row, we started with 600 and change and whittled it down. I deeply believe that our team is the best in the industry. That's first and foremost, because when you have an incredible team, you have a strong attraction on our pop culture. And then you also, one of the other things is ridiculous levels of focus. We leaned into sequential nature of building things versus parallel. And Johnny Ive talks about this and Frank Slootman talks about this, but you actually get way more done than you think when you build things sequentially versus in parallel. There's an impulse to build things in parallel because you see more progress across each thing over a shorter time period. So you almost have to be patient because if you're there over the first, let's say over a 98 time horizon, if I want to build five things, I can push a little bit of each one and 90 days later, I'm going to see more progress across all the things that I want to do. But if I just pushed on one of them, that one thing will be much, much farther and it will have a much greater impact. The analogy that I might give is it's kind of like only working on the first 10 years of a compound interest curve and never getting to year 30. That sucks. You lose all of the benefit. But if instead you have ridiculous levels of focus and you do things sequentially, and the thing that you were doing next builds on the first thing. And so we leaned heavily into sequential versus parallel. And that is one of the things that ridiculous level of focus is one of the things and the entire company, there was very little context switching and it started actually because I didn't feel that we were moving fast enough in December, like 2022. Just after this, we had launched our beta program and I started a daily steer meeting at 8.15 in the morning with our entire leadership team. And we met every single day at 8.50 for two straight years. Could it be 10 minutes? Could be 15 minutes? Could be five minutes? Could be an hour and a half until everything that we needed to do that we needed to align on and decisions that need to be made were made. And what ends up happening is for that, for example, it was very difficult where you and I are talking and it's Monday at 8.50 and it's like, great, you're owning this next step. You can't show up on Tuesday without having pushed that thing forward. And then you definitely can't show up on Wednesday without having pushed that thing forward. But if instead, if we meet on Monday, we don't meet Monday through Friday, but we just meet on the following Monday. So many other things come up where, oh, I got sidetracked with this and this is where I didn't know, which was there was a stack ranking of this. You cannot do that within a 24 hour time period. So the speed of the organization, the alignment just was second to none. And we will do that consistently when we need to put a jetpack on certain teams or initiatives. But there was a bunch of things. The other thing that I think we did is we killed long term roadmaps and it's quite painful for people. And I tell them that they think we're crazy. I wouldn't advocate this for every company. And my push to people when they read that or when I say that is that don't miss the forest for the trees. It's not that nothing we did at the organization would be planned past six months. And it's not an excuse for a lack of rigor. It's actually that in an era like the one we're in right now, where both GLP ones and AI, that industry is changing so rapidly, spending a lot of time on long term roadmaps is like printing out MapQuest instead of using Google Maps. It is false precision. It's a giant waste of time. Any new piece of thing that changes the course, steps three through 17 are immediately irrelevant. And you've just wasted a ton of time. And you will have a much better idea of what step three to four should be once you've done one, two and three. And so I think doing that, we got very good as an organization of living with longer term uncertainty, but short term precision rigor. And I think it's kind of similar to your concept. I don't want to put words in your mouth, but it's kind of similar concept of avoiding being overly goal oriented. It's that same thing, which is our long term goals and vision is very, very high level and simple and unchanging. We help patients achieve their health goals. When we do, we unlock the full potential of the human. We do that at scale. We unlock the full potential of humanity. How we do that in the short term and day to day, we can respond to the data that we see. We can respond to what patients tell us. We can respond to new inventions of new treatments, a regulatory change, whatever it may be, AI coming. So it allows you to, I think, be cheesy phrase, but stubborn on the vision, flexible on the details. Yeah. Speculate a little bit on where you think we go next as a healthcare system in the US. There's all these amazing companies discovering drugs, using AI. I'm sure the medicines that help you achieve your mission for your customer are going to proliferate like crazy. Just speculate on where you think things are going. What has you excited? What has you worried? I think we are at the beginning of this patient revolution. I do, do believe that partially because of the systemic failure that is happening. And you talk about tailwinds, there's the GOP one tailwind, but I actually think there's three tailwinds to our business. The first is that human biology is coming online. So that's everything from self-reported symptoms to your lab tests, your genetics, to your wearable data, but your biology is coming online. So number one tailwind, biology coming online. Number two, what used to require a specialist now requires a prompt. When we first started, people would ask us questions like, what type of doctor am I going to get online? First, they dramatically underestimated how flawed the existing healthcare system was and how many doctors were burnt out and fed up and needed an alternative way of life. So we have really high quality doctors who get to work from home and see what's going on. And that's what we're trying to do. So we have really high quality doctors who get to work from home and see what's going on. see their kids in the same way that we see that today in tech, but I think what's interesting is to see investor sentiment change where they're paying 100K a year for a concierge doctor and they're paying Claude for 20 bucks a month and it's way better. So, used to require a specialist, now requires a prompt. Third is, there are now treatments that do radically shift the quality and quantity of people's lives. They're just not evenly distributed. Some people live in the future, it's just not even the distributed kind of thing. And we think about Roe being the largest provider of GLP-1s in the country. Some of the questions that we start to ask ourselves is, okay, well, why do men lose less than women wearing on GLP-1s? Why do people of Hispanic descent lose less than Caucasian people? Why do some people lose 35% of their body weight and other people lose five? Why do some people experience side effects and others don't? You add on genetic data, you add on wearable data, you add on ongoing lab tests, you add on self-reported data. So, you add on all of these and the question that you constantly ask yourself back with medicine being trial and error is, can you get up the faintest footsteps of a disease just like a whisper? Because if you can do that, that's where you can really shift the trajectory. So, those three tailwinds of biology coming online, AI, what used to require a specialist, now requires a prompt, and current and new treatments that both leverage that but then allow you to actually turn the service of concierge care into a commodity anyone can access, that can create that patient revolution. And I think we can go even further than that. Not just concierge care online, but I think we can get a whole new form of healthcare for the price of Netflix. I think you're on a GOP-1. I am on a GOP-1, yeah. So, what is your pitch to the person, actually pitch me, I'm not on a GOP-1, I don't think I traditionally would have been the form factor of a person that would be on one. How would you pitch people in the general populace that are curious about this technology, let's call it this method? So, I'm on several different drugs. I'm a big believer in all of the things, diet, exercise, sleep, drugs and supplements, community, those are basically the five things you can do for your health. So, back to that incentive structure, which is first, the time horizon that I am looking to reduce risk for myself is radically different than the typical healthcare system is measuring risk. They're measuring risks on 10, 15 year time horizons. I think, I'm pretty confident I'm gonna be good when I'm 45. I'm worried about 55, 65, 75, and a lot of chronic disease are area under the curve problems. How long do you spend at elevated LDL levels? Or, how long do you spend with metabolic dysfunction or insulin resistance? So, they're area under the curve problems. As far as the pitch that I would make to you, I wouldn't say you must be on a JLPT or you shouldn't. There would be, first, what are your health goals? Then, you would say, what are some family history, trying to understand, and then also your risk tolerance, your risks and benefits. And then, ultimately, you're gonna have to, ideally, you work with a provider to understand what combination of treatments might be right for you. And I don't give that answer of, hey, work with a healthcare provider to see what might be right for you. It sounds like an ad at the end of it. But it's actually because that's truly how it should function. My, quote-unquote, health stack has been built up over the last 10, 15 years with my dad. AB testing, different drugs, adding them on top of each other, taking some off, adding others on, measuring my blood test values and other metrics along the way to dial in for me based, working backwards, for my health goals. My dad had his first heart attack and stroke when he was actually 39. He had to stop practicing medicine. And there's a blessing and a burden about that, which is he got the thing that he loved the most taken away from him at that time, but he also became a stay-at-home dad and I got to spend a lot of time with him. And in many ways, I'm sure a therapist would have a lot to say about this, but in many ways, I feel like I'm trying to recreate him a software. I'm trying to give him to everyone, keep him alive forever in some way, shape, or form. But as a result, I've been very aggressive when it comes to heart disease. So my cholesterol, when I was 30 years old, was 230, my ApoB was 100+, my LDL was 130, 140. I was eating and exercising and doing all the things that are in your control, but my genetics were such that I needed additional support. And so I started a statin, then I started Zetiose, brand name for ezetimibe, then I added Repatha, which we've talked about, and then I added a GLP-1. And my LDL went from 130 to 70 to 80 to 60 to 10. My ApoB went from 90 to 60 to, when I get my ApoB, I have a less than in front of it. There's like a search party out for my ApoB. I'm very proud of that. So I'm willing to be disproportionately aggressive here relative to maybe the population. And so that, to me, would be the conversation that you would ideally have. And so we go from there, saying what's really important to you, what are you trying to achieve, what are your risks, and then you'd analyze the risks and benefits of each decision. So for that one, as an example, I'm fascinated by the LDL thing, the area under the curve. I have no history of heart disease in my family, luckily, but I take Repatha because my LDL is really high. And so you and others have convinced me of the merits of this, along with great doctors, et cetera. But something like that, let's just stick with that example. Okay, so you're on several things to bring it from 130 to 10, what are the trade-offs in your mind associated with that specifically? How do you think about what the benefit is, probably years of life or quality of life, but how much? And then what the costs are or the risks are associated with that? So with any one of them, they have risks and benefits, and I've actually dialed in the dose to where I don't experience day-to-day side effects from any one of those. But I have tried where up, when I started with a statin, and I first asked myself, should I increase the dose of my statin, should I add Zetia, should I add Repatha? And so I dialed in each one of those things independently, went off some, went on some, to see the marginal impact of each one, as well as to make sure I could isolate if I were experiencing side effects. Was it dose-related, was it drug-related, was it potentially a combination of certain treatments? And so I was able to find the regimen with my doctor to be able to navigate that. So with anything, the downside is really costs and side effects. And then I think about it, which is interesting to me, which is the asymmetric downside of getting a heart attack or a stroke for me. To me, when I think about it, I take these medications, they're remarkably safe. The side effect profile for me is incredibly favorable, and it's a couple hundred dollars a month, and that is worth decreasing my risk of heart disease by literally whatever percentage it ends up doing. That might not be the case for everyone, but I actually think you're going to see, like Repatha's a great example of where I hope you're going to see, one, prices come down. What happened when it went direct, went from $600 a month to $200? Went down 60, 70%, and hopefully it gets lower. There's a new oral coming out, an oral PCSK9, it's actually an oral peptide, PCSK9. And the way that that was discovered, and I think this is a great example of where AI can be tremendously helpful from a healthcare perspective. So where AI is really, really good, as we all know, it's where there's a ton of structured data, when there's a verifiable reward, and there's a really tight feedback loop. That's where math and coding really thrive. Problem with medicine is it's trial and error, a lot of the data's unstructured, and the feedback loop of death or heart disease takes a really long time. And so the PCSK9 is sort of a beautiful example of, can we do a more of that, and can we do it faster? So there's a Dallas Heart Study, the year 2000, they had about 3,500 patients, half black, half white. Those patients get genetic testing, they get scans, they get imaging, and they get cared for on an ongoing basis. 2006, the researchers realized, so six years later, the researchers realized that it turns out there's a group of people in this study that have a faulty PCSK9 gene, and they have basically LDL levels in the 30s to 40s. And they have a 85 to 90% risk reduction of heart disease, no matter what they did. Drink, smoke, cheeseburgers, whatever, they were not dying of heart disease. And they could die of anything else, basically, except for heart disease. From 2006, 2015, you have Amgen invent Repatha, a biweekly injection. Now you have others that are up every month, every six months. Now you have Merck invent an oral peptide this year that got approved, and it's an oral PCSK9. From year 2000 to 2026, so almost a quarter of a century, to invent an oral version that mimics that quote-unquote faulty gene, but that, if taken early enough, might largely prevent and eliminate the leading cause of death in the US. That's unbelievable. But it took us six years from genetic testing to discovering this faulty gene. 6% of a century, 26% of a century to get it out. That's too long. Think about the number of lives that could be saved. Not to be too cheesy or sappy, but it's kind of similar to your question around what's the kindest thing anyone's ever done for you. When I heard your answer to that question, it was beautiful and powerful, and you said the reason I care about it so deeply is these little acts of kindness can shift the trajectory of someone's life. And the question is, can you do the same thing with health, where it's just a little small nudge in the very beginning of an illness? And I think you can. I think we can start to do that. I think we're on the cusp of another shift of that zero to 1800, where life expectancy was 30. For the last seven years, we went from 71 to 79. How do we have that next big inflection? I think we can get there. It seems like the right time to ask more about this comment you made, that you're trying to recreate your dad in software. Yeah, say more about that. I think he's changed my life in so many different ways. It's hard to, I've never been asked the follow-up question on that, and it's hard to put into words the impact that I think he's had on my life and how much he inspires me, but I try. I guess at my core, I do believe that the best way that I can have a positive impact on the world is to give people more healthy, happy years. And if you can do that, then they can chase their life goals. And I guess I grew up around someone, my dad, who devoted his entire life, every second of every day, that man is just trying to give additional healthy years to people, because I think that's who he thinks, and I believe this to be the case. That's who he was born to be. And I've seen up close and person the impact that that's had on myself and loved ones. And I love the written word, and I love technology, because it is an incredible form of leverage. I'm still reading books that were written 2,000 years ago, and technology obviously scales a small group. People can have a tremendous impact on the world. And so I saw the impact that my dad had on the loved ones, myself, around us, but he was limited by those he could speak to directly or those whose hands he could hold. And so if I can recreate that with software and operations and technology and give that to other people, it would be hard for me to think about a life better spent than trying to do what he did for many, many people, for millions of people. Do you say more about this idea of the thing you were born to do as a notion, what you've observed in others that seem to have found that thing, why you believe that that's a thing in the first place, what it's like being in that versus not sure at points of your life you weren't in that state? Anything else you could share about that idea? I think a lot of stories make more sense in retrospect than during. I don't know that when I was younger, I felt that I was born to do what I'm doing today. But when I look back and see how I got here, it makes perfect sense to me. And I think the same thing actually about my wife, too. She runs a YouTube channel. Actually, after everyone here has fully watched all of Invest Like the Best, every single one, and you're looking for something else to watch, she runs a YouTube channel called Huge If True. Not just a YouTube channel, like one of the best and biggest ones. I would actually argue that she's the best journalist on the internet. She's very good. She's very, very good. She's definitely my better half. But the incredible thing is when she talks through why she does it, she will say when people see a better future, they help build it. And people will ask her all the time. They'll say, how did you get into this? Why do you love to explain things to people? And she said she's only realized this in retrospect, that I think she was born to do the thing that she's doing today, which is she grew up, her two parents were lawyers, and her dad was a corporate litigator but also did pro bono death penalty cases. And both of their parents would talk about them at the dinner table with Cleo when she was a little girl, nine, 10, 11, 12, death penalty cases. But he would obsess over opening arguments, closing arguments, and every little phrase. And what she saw, though, was if you could explain something to a group of people, to 12 people of your peers, if you could explain something to them where they understood something new about the world, that you could change the trajectory of someone's life. And that is why her dad was so passionate about what he did. And so she grew up in a household understanding that education and educating people in a powerful, simple way can change the future. And so she now, to this day, wakes up and gets to try and do that at scale. And I think only, as we've talked about, because we both are founders, and I think look back and say, well, it kind of makes sense how we ended up here, but it was less intentional than this is what we were meant to do. Maybe even pitch a little more what the benefits are when you find that thing, how it feels to be doing that thing. Oh, it's such a gift. You don't feel like you're working. It's so energizing. I skip to work every single day. My team at this point knows on Friday, never say, have a good weekend, because I will respond. I can't wait till Monday. I think there's no greater gift than working with other people to have a positive impact on the world. And so when you find that, of course, there's personal and professional life, but when you find harmony between those two things and you don't feel like you are, quote, unquote, working, it's like a bizarre phrase to me. It's how we spend the majority of our waking hours. That's why I think at Rowe, where talented people work is a gift. We have to earn that gift, and you take that responsibility super seriously to your point, when you find the thing that you were meant to do, I think you stop thinking about it like work. 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The best AI and software companies from open AI to cursor to perplexity use WorkOS to become enterprise ready overnight, not in months. Visit workos.com to skip the unglamorous infrastructure work and focus on your product. One of the things that's interesting to me today is there aren't that many great new, well-known consumer businesses. Building them is extremely difficult, but when you have consumer distribution, it's one of the most powerful things in business. So if I go back to that original beachhead with Viagra, wherever the other drugs were, talk about all those aspects around that first beachhead. It's a great question. In healthcare, there's this thing that a lot of digital health has this graveyard of startups where people focus on need, and need and need alone. And I think the key that we have always believed at Rho is we start with what patients want and find the overlap of need. It's not that they just want it and they don't need it. We start with want, and it's very specific that it's want to start overlap with need. Because if I went to your doctor and said, hey, Patrick's doctor, what does Patrick need? They would say, with all of the confidence in the world, exactly what you needed. Now, if I went to them and said, hey, what does Patrick want? Well, they'd say, I don't know, you ask? So it naturally puts you in a patient-centric position and one of selflessness and egolessness, where you are in service of what the patient wants. And that's how I think we've activated consumers in healthcare, is we are completely willing to be misunderstood. When we first started, the New York Times called us restaurant menu medicine, as if this was a bad thing. I was like, people have great experiences at restaurants. You go, give a menu, and then there's prices, and then you select what you want. So I think we were very, very comfortable being wildly misunderstood, as long as the patient outcomes and the patient was at the center of everything we did. People often ask us, well, how do you assess risk at the company? And I will always say, never at the expense of a patient, always on their behalf. We will push, we will take risk as a company if we are fighting on behalf of patient health outcomes. And the new thing, again, the new thing, the data, the new model, it always has a higher burden of proof, as it should. So we bring the data. We've published data on the outcomes, we've published data on our side effect response times. Basically, every single time you send a message to Roe, that's routed through an LLM, we've analyzed the topic, we've analyzed the issue. If you've mentioned a side effect, that side effect gets structured, task is created, it's assigned to a healthcare provider, an SLA is attached, and we have a 24-7, sub-30-minute response time for your side effect. That's an entirely new form of healthcare. So you gotta bring the receipts if you're gonna ruffle feathers. And then on the marketing side, I was in the commercials early on. It wasn't where I said, hey, I need to be a self-promotional CEO, and this is my first extended podcast ever in nine years. But it was more actually where I was in the commercial because with marketing and how we think about a lot of these things is, there's sort of two components here and we do this to this day. One is we talk a lot about you need data to move the brain, you need a story to move the heart, and you need both to move a human. And so that was one component to our marketing where I challenged the idea for many people of who could have erectile dysfunction. And then the second thing is with great marketing, I do think, particularly with things that have stigma attached to them, weight loss, reproductive health, mental health, ED, whatever it may be, what our marketing does is it tries to create permission structures on behalf of people who need that product or service by doing two things, massively shifting the Overton window so that we're the extreme, so that they never have to be. And the second is by telling stories that deeply resonate with them. So Serena Williams is a great example of this. She's a ambassador for Row Body for Jill Collins. She is one of one as a human being. Greatest of all time tennis player. But she's one of millions when it comes to her health journey. Mother of two, was doing everything right, diet, exercising, the scale wouldn't budge, and she was having health challenges on the other side of having two kids. A number of people, I was speaking to a patient this week who was almost in tears saying what seeing Serena Williams did for them. They felt comfortable and they said, if Serena needs this, then it's okay if I need it. And you've seen us with the same thing with Charles Barkley or the same thing with Chrissy Metz or the same thing with Megan Fox and ED. Megan Fox, for a certain generation, could tell people to get a colonoscopy and they'd be like, done, you know? And the fact that she's like, hey, sex is an important part of relationships. It's okay if you need support. The fact is you're taking a step forward and that actually shows a commitment to your partner. And I love that. So that just creates a permission structure for someone who sits there and says, well, I don't know what my partner's gonna think. And so I think all of these things try to really touch on each other. Let me just say one bit more until I'm so intrigued by these methods about, I would phrase it as like stigma as a signpost towards latent demand, unmet demand. What have you learned about that idea of stigma? There's a lot of potential energy there. And when there's a lot of tension on a subject, that's something that a lot of consumer founders can tap into. Now, I think the way that we've tapped into that is always having what I would argue is the moral high ground. The more controversial you are, but at the same time, if you can look back and say, in the fullness of time, history will be on our side, you can be as loud and loud and loud as possible. And so that to me is like, even take 2lp1s, when we were pushing, we originally had this, I put in quotation, controversial subway campaign where the only thing that we did, we show people that were clinically eligible, using the medication, and then said a weekly shot to lose weight. It was literally instructions. And it caused this massive kerfuffle. Why? People were very uncomfortable by the idea of people using injections to lose weight. And we knew that. But people misunderstood the negative health impacts of carrying excess weight. They thought of it like a shortcut. You take myths in society, like the myth of, oh, obesity is just a lack of self-discipline or willpower, and you can poke at that. Oh, only X, Y, or Z people need medication, or only X, Y, or Z people should be treated for ED, or whatever it may be. Take another one as an example relates to 2lp1s, where people are oftentimes talking about, how do you go off of, when do you go off of? And people should be able to go off medication whenever they want. They should do it safely, and there should be no judgment if they wanna try and achieve their health goals without medication. But it's very interesting, and a sign of the stigma, that people want, when it comes to weight loss medication, they talk about it as if they're shocked, and they do not want people to need the medication on an ongoing basis, where, unlike any other form of actual medication or behavior. So as an example, what do people think is gonna happen when they stop taking their cholesterol medication? And what do people think is gonna happen when they stop taking birth control? Right, it's not gonna be a surprise. And then as opposed to behavior too, you can't just do one pushup, you can't eat one salad. Basically, any medication, any behavior, you need to continue to do on an ongoing basis, to continue to get the benefits. The fact that that makes people's stomach churn, when it comes to weight loss medications, is a far greater reflection of how they feel about that. And so when there's tension in something, that shouldn't be the case, when it's just intellectually wrong and societally charged, it creates an opportunity to play with that from a society. What have you learned about doing these campaigns? Megan Fox, I think, was the most recent one. And I remember seeing it. Obviously, you struck some major chord. What have you learned about, I'm interested in the nitty-gritty details here, like picking her versus the 10 other people you might have picked, or the nature of the visuals, or the copy, or the release, working with celebrities as a thing to draw brand attention? There's so much here. I'd be remiss if I didn't start by saying, this is my co-founder Saman's superpower. So I'm LARPing when I'm here, talking about this. He is absolutely world-class at this, and I think you can see it in Ro's performance and brand awareness. Now, if I'm trying to channel him and echo him here, from a celebrity's perspective, yes, it's about creating permission structures, but he is very, very strict. Megan is a very unique use case, but if you think about Charles, and Chrissy, and Serena, and Trisha Paytas, and we have two or three coming out soon, all of them are on the product, because it's so important to him and to patients that they are authentically sharing their experience, and that's what he crafts the campaigns around. If you look at a Charles Barkley commercial, it's Charles. It's unscripted, it's him in front of a camera, he's making jokes, having fun, but he's also sharing his authentic story there. Serena comes into a shoot, and she is locked in. She is going to be the best commercial shooter of all time. Literally, phones away, she's locked in, lighting, director, sound, everything, positioning, it's remarkable. The cool part, as a total side note of working with all these people, is that you see why they are who they are, because they are, to the nth degree, why they are the best in the world at what they do is very evident within minutes of meeting them. So that's just a cool thing to see. But on the celebrity front, it's about really finding these authentic stories that create permission structures. Why they are more useful now than even five, 10 years ago is because the bar to create high-quality-looking ads is very low. With AI, what would qualify as a beautiful ad 10 years ago on Instagram that someone would have spent a ton of time on is 10 seconds, minutes now. And no money. And no money. So how do you break through the noise when everyone's just looking at pretty good-looking stuff? Well, you see Charles Barkley's face, or Serena's face, or Megan Fox's face. You cannot replicate those in an age of AI. So I think that that is powerful to do. Back to this stigma idea. What are the stigmas today that interest you? So now, that first campaign, the summit campaign, now it's totally normal. The window has shifted. Where has the window not yet shifted where there's stigma that you find interesting? Back to the earlier question that you asked around people taking medications prophylactically, or on the earlier side of what would be considered early, is fascinating to me. Because first of all, on the way here, I must have passed 15 bars from my office. And that is literally an exchange of poison for entertainment. Full stop. You turn 21, you can do that. And then half of my TV ads are about it. And then you take medicine, something that has literally, it is the most studied thing that humans put in their body. And there's a randomized controlled trial for it. There's clear risks and benefits. And then by the way, in order to get it, you have to talk to an expert and engage with them. And in order to keep getting it, you have to keep talking to them. But then the idea of advertising that on TV is like, whoa, whoa, whoa, whoa, whoa. Versus poison, totally fine. Cheeseburgers, totally fine. And I believe, I love cheeseburgers. But this difference where those are obviously a health net negative, the question is whether enjoyment outweighs that. And we can have that conversation in society. But over here, there's at least a probabilistic equation of whether the benefits dramatically outweigh the risks. Someone is engaging with an expert in that and they're doing it on an ongoing basis. So to me, this idea, like sometimes when I tell people that I'm on these medications, they're shocked as I see them literally drink poison. And that's not a knock on that at all. Someone should be able to do that. But it's the difference between those two that I find quite surprising. Are there other things that I guess the prompt would be like the hottest takes you have? Differences of opinion versus your peers, versus the industry, versus the world, where you feel most alone in what you believe? I feel very lucky, but I think that there's a lot of, I understand why there is, but there's a lot of obsession over the founder. And I think that maybe other founders don't. But I feel like I have an incredible support network. And I think in particular, I would say my spouse. I don't know that founders who have very, very supportive spouses talk about it a lot, to be honest. Cleo and I have taken turns, actually. We met very, very young. We met when I was 19 and she was 17. And we started dating a few years later. We've been together 13 years. And in New York City, we grew up together. We have taken turns financially supporting one another, actually. So when I first started Ro, we were living in a friend's apartment together. We had the smaller room, he had the master. She was on a journalist's salary, buying both of us breakfast, lunch, and dinner. And so I would not be the person I am today or be able to run Ro if we weren't together. And so I think there's just a lot of people along the way in these journeys that it's usually just assigned to one person. I would say the same thing with our team. Our team is absolutely incredible. So that's probably one of the things that I think there's a lot of founders that. A lot of worship. They believe their shit doesn't stink and it's kind of exhausting. Not a lot of hard-ass founder wife guys. Yeah, yeah, yeah. There you go, it's true. That's true. It seems macaroon soft, but I actually think it's the opposite. It's been incredibly fun. It's so cool to hear all the lessons that you've learned doing this twice, I guess, if you refounded it halfway through. And I do think that these tailwinds that you've taught us about today are the two most interesting in the entire world and I sure hope they keep blowing. You know, my traditional closing question when I do this, what is the kindest thing that anyone's ever done for you? So I've thought about this because I listen to your podcast all the time and I think I was inspired by your answer, which is when I was 15 years old, I was at boarding school and I was very homesick. I missed my parents tremendously and they came to visit me and my dad and mom watched me play sports and they took me out to dinner and my way of expressing my love to them because I was homesick was I was kind of mean and my parents knew it. They knew that it was just me acting out in that way and when they were leaving, my dad asked my mom to drive and my mom has an autoimmune disease and so he normally drives. And so, again, back to what we said before, sometimes you realize things in retrospect. I didn't realize at the time that something was different explicitly, but implicitly I did. I was like, that's odd. Then my dad got in the passenger seat and he rolled down the window and something in his voice changed where he looked at me and he just said, tell me you love me. And I completely switched and I said, of course I love you, I love you so much. And take care, I love you too. And he drove away and he looks at my mom. I've only found this out later. He looks at my mom and he says, take me to the hospital. I'm having my fourth heart attack. And I asked him after. He fortunately made it. He didn't think he was gonna make it. I asked him after. I was like, hey, seconds matter. What were you doing? And he goes, well, first, it was two seconds that I didn't think I was gonna make it. And the second is I didn't want your last words to me to be an argument. I wanted them to be I love you. And one of the most selfless things that he could have done, but what it did for me, I think the gift that he gave me was to never let the love that you feel for people go unspoken. And so to this day. Today, when I hang up with him, my friends, I will say, I love you. And I got my co-founder, it took me six years. I say I love you to him. When we hang up a Google Hangout, when I hang up on the phone, I tell him I love you. And I do, I love him. And so I think at such a young age, feeling the fragility of that, and being able to put your hand on the stove with unspoken love, and not doing that ever again, is something that I think I'll always cherish for him. Incredible story, very unique. I've done a lot of these. I haven't heard one quite like that. Thank you so much for your time. Thank you. If you enjoyed this episode, visit Colossus.com. You'll find every episode of this podcast complete with hand-edited transcripts. You can also subscribe to Colossus, our quarterly print, digital, and private audio publication featuring in-depth profiles of the founders, investors, and companies that we admire most. Learn more at Colossus.com slash subscribe. Patrick O'Shaughnessy is the CEO of Positive Sum. All opinions expressed by Patrick and podcast guests are solely their own opinions and do not reflect the opinion of Positive Sum. This podcast is for informational purposes only and should not be relied upon as a basis for investment decisions. Clients of Positive Sum may maintain positions in the securities discussed in this podcast. To learn more, visit psum.vc. You know how small advantages compound over time? That's true in investing and just as true in how you run your company. Your spending system is your capital allocation strategy. Ramp makes it smarter by default. Better data, better decisions, better economics over time. See how at ramp.com slash invest. As your business grows, Vanta scales with you, automating compliance and giving you a single source of truth for security and risk. Learn more at vanta.com slash invest. 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