0:00If I had to say like what is the problem with our healthare system, it is that the patient is not the customer. Whoever controls the flow of money at the point of purchase. That's the customer. That's the stakeholder that everyone builds around. We just are not the customer in the majority of the interactions. Right?
0:13You have like $1,300 drugs that people are paying behind the scenes $3, $400 for. No industry could survive with its prices not being public.
0:34I've got a [music] first question based on our last phone call which was something you told me which just really stood out. What percent of GDP do you think healthc care could or should be 10 15 years from now?
0:47I think it should be as high as possible. 50 70 everyone's always complaining it's too high. Everyone's always complaining it's too high and I think that uh it's missing the forest for the trees. If you think about healthcare, I think it's the sinquon of life. It's without which there is none. And it's actually depends how AI pilled you are, but your audience is probably pretty AIDS. If you imagine a life of pure abundance and you imagine Jeban's paradox does its thing, then the only good in our lives that does not
1:16have any diminishing marginal return uh 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 uh the US and say, oh, we spend 18% of our GDP, that's a problem. My question is like, well, why? We've never used absolute numbers like that as a problem.
1:35question is are we getting what we want from that dollar amount right and that's the whole premise of Jeb's paradox is actually like the market size increases as the cost per unit decreases now the cost per unit the challenge is in the US healthare system the reason why it's 18% is because the cost per unit has been rising we spend probably 50% of our healthare 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 healthare system as this great anomaly relative to other healthare systems and
2:04I'm actually of the belief that the US healthcare system is actually like a preview of what's to come for a lot of other countries. You look at the UK, its GDP percent of healthcare has spent on GDP went from 6 to 12. You look at Germany, it went from 9 to 12. Uh you look at the US, you know, went from 9 to 18. And same thing with our obesity rates. And and so to me, again, back to like 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
2:34should just be far greater.
2:35Yeah. So, if you ground us in today's reality, I I'm very curious for your state of the union of the system itself.
2:42And you know, the bit you can picture the obesity rate chart that has for the first time in a while kind of flatlined or kinkedked the other direction. I I think GLP1's the primary primary reason why. Um obviously that's driven your business to an extraordinary degree, but give us beyond just that. like give us your sort of state of the union. Here's what health is like in the US today.
3:04Could be a whole podcast by itself.
3:06Um it's interesting to think about like first where does the money go? Usually if you want to like understand an industry, you just like follow the money. So let's say 30 to 35% is about hospital systems. 20 25% might be doctor's office. Um another 9 10% would be drugs and pharmaceuticals and then you see the remainder sort of or sort of chopped up there. A lot of people will talk about and back to our our question a little bit around percent of GDP. The US health care system I would say is
3:34really fantastic better than people give it credit for at acute care, right? So yes, it's more expensive, but we have higher cancer survival rates than than the NHS. Like if you get cancer, you want to get cancer in the US, right? If you have a heart attack or a stroke, you want to have it in the US. Your our survival rates are higher on average than other OECD countries. And we don't use more healthcare than other OECD countries. We have uh we have fewer hospital stays.
3:58Our hospital stays are shorter. We have slightly more procedures and scans which whereas it sort of nets out on a per unit basis and then our prices are higher and our administrative burden is much much much higher. Right? Um and then a lot of people will talk about life expectancy in the US. It hasn't increased in the last sort of 101 15 years. To me a lot of that is not a reflection of our healthare system.
4:20Right? So there's kind of a two buckets of the way we die. Um the first is like this fast clock, right? And that will bring down the average of the US uh life expectancy relative to other OECD countries. So the that fast clock is like gun deaths, car accidents, overdoses, things like that. That'll bring down an average. Um but it's not the majority of the way we die. We actually the majority of the way we die is the slow clock, right? Chronic disease. And that is has massively been rising over the last as as you mentioned
4:48in the last like 20 30 40 years. So those two things are really like the makeup of how illness happens in the US and how people die and then that's how the the money gets spent.
4:59If you think 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?
5:08There's probably like two things that I would say. One is I do think our c our healthare system has one if not two but like one central flaw from which all other problems stem and the second is that the entire healthare system is based on time horizons that are almost irrelevant to the individual right so that's I think the surprising thing which is like when you go into the health care system there's a fundamental mismatch of incentives and I think that
5:37that is if I had to say like what is the problem with our healthare system it is that the patient is not the customer.
5:42That's the problem that we're trying to solve at row and I think you see it working but that is the fundamental problem and and the reason being is and you probably I mean you see this in every business that you talk to whichever whoever controls the flow of money at the point of purchase that's the customer right that's the stakeholder that everyone builds around and patients individuals we pay for our our healthcare we just are not the customer in the majority of the interactions right so we our out-of- pocket expenses the majority of our expenses then we pay through our taxes
6:11And we play through suppressed wages with ARM. And so you then look and say, okay, well, where is healthcare working?
6:18Like where does it feel really good and it feels really good where it's cash pay? Um where the the patient is the customer.
6:26Favorite example of that, you look at LASIC eye surgery, right?
6:29Cost comes down, quality improves, convenience improves. You look at breast augmentation, you look at cosmetic surgeries, costs come down, quality improves, convenience improves. You look at GLP1s, right? Take GP1s and they are like this beautiful foil for the rest of the healthare system. Politicians and regulators have been trying to get transparent prices for 20 25 years, right? What happens? Pharma goes direct.
6:51What happens to the prices? Well, this as my loving Jewish mother would say, the faka prices of like list to net, right? You have like $1,300 drugs that people are paying behind the scenes $3 $400 for. What happens when those go direct to consumer that list to neck gets entirely eliminated? that like 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 over year until the
7:21patent 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 right while prices come down if you look at Lily's earnings prices come down volume far outstrips it right and you know PB PBMs to me are like they are like the appendex of the healthare system like at one point in time they might have served some purpose but it was like so long ago that people can't remember what the heck it was and turns out when you remove them from
7:50the equation software can do exactly what they would have done historically and so you even see with GLP1s like 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 PBM is an insurance companies go away, prices go from $1,300 to $149 and the people making the drugs are making more money, right? And so you can see that where it's working, uh, the patient is in control and at the center. And then you usually have people give this criticism
8:20like um, one of the most common is asymmetry of information. In my mind, it's a little bit similar to like the best form of government. So like democracy is the worst form of government except for all the other ones. In my mind, like the patient's the worst person to make their to own their healthare decisions except for literally everyone else. And when you go into our healthare 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 res recourse which is you get to vote with
8:47your feet. So if hypothetically like when we as a society will sometimes you have those price transparency laws for hospitals and people thought that that was like this amazing thing that is like epic lipstick on a pig right no industry could survive with its prices not being public any company that did that wouldn't get any customers right so rather than us praising that we should see that as a symptom where if if you hypothetically gave let's say I don't know what you give your employees for healthcare what you spend on them but
9:16let's say we spend 20 to2 $25,000 a year per person if I magically gave them a credit card that could only be used for healthare 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 if a if they don't make the prices public they won't get their
9:46money and then if they don't do a good 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 going to 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 that 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
10:15foresight. So the idea to me is what we're trying to do at Row is if we can aggregate patient spend, I think we can bend the healthare system to the will of patients.
10:24I'd love to use row as just like a great example since you know all the data like the back of your hand.
10:29Give us a sense of like the lineup of products right now and like what the pie chart look like looks like today like what what percent are they spending on each of the major categories?
10:38Yeah, happy to. So we have four main categories. So Rorow is the leading provider of GLP1s in the country. cardio metabolic health is our number one category. Then sexual health, dermatology and fertility. The the fastest growing part of the business is GLP1s. And oftentimes people will say as this has happened, right, because we've grown uh over the last four years, we've gone from about a $250 million run rate to over a $3 billion run rate. And we've done that actually with fewer people than we were in 2021, which story, but the majority of growth, what's interesting is people will often say,
11:08well, you're like those are just weight loss drugs. And that's really like that's both fascinating for for me when it's like one that's like 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 nerve degeneration and pain management and addiction and mental health and cancer prevention. And so you look and you're saying like yes we are you know the leading part leading part of our business is just treating the leading
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13:35So, I actually would love to spend a few minutes on each of the four driving leading categories. Obviously, starting with GLP1s. Why have you been so effective? Like what has made you the leader? Why don't people just go to these new direct services that the pharma companies have? Like what what is it about row that has allowed it to be the place of choice to go get this stuff?
13:53Yeah, it's a it's a great question because people often ask about like competition and differentiation. And so there's there's a bunch of different ways to talk talk about it. Like the first to your point is like the proof's in the pudding, right? So RO is the leading provider of GLP1 in the country.
14:05We're probably signing up two, three, four, five times as many patients every single day as our competition. So there is clearly like there's some difference.
14:14And so what is that?
14:15And then when you think about like differentiation, a lot of times people and I would love if this were the case want this like very specific answer like we offer this feature and someone else doesn't. The thing is is if I were to say that right now I could point to those things and say well ROW is the most affordable to start and ROW has the strongest formula. We're integrated with both Novo and Lily. Well Rorow also has cash pay and we help people check their insurance. So we've helped actually over 1% of the US population check their insurance for free. Done that entirely
14:44with 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. that's not available uh in in an infinite number of places, right? So for many people the membership actually pays for itself. But truth is is that differentiation in my mind I I'm a big believer that the only only only source of differentiation is continued innovation, right? Like we must be in in
15:13search 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, whatever it may, 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 beating another company. So if you stay good for consumers, it's great for consumers.
15:33And 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 and the way we built the technology, right? Like we we built an EMR from scratch. We built our own clea certificate cap accredited lab. We built our ownies. We built our own pharmacy software. We built our own provider network. All of those are seamlessly integrated and they are built in a condition agnostic way. We had been building this incredible platform for the previous four or five years before
16:01GLP1's 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 like care and treatment distribution platform that is all vertically integrated customuilt software uh in service of helping that patient achieve their health goals.
16:20Is there anything interesting to double click on the options you have for serving something like a JLP1 which is made by a couple different companies but not by 50?
16:29Yeah. Is there anything interesting in that dynamic that um because there's relatively few suppliers they you would think would have some sort of power and be able to capture more of the total margin that's being you know earned by all companies that are serving a customer of GLP1.
16:45I think your assumption is right and by the way I think that should be the case.
16:48Like I think the inventors of GLP1s should earn should grab more margin than the people who scale access to that. I think that's normally what you see for the most part with some demand aggregators and retail is a okay example here. It's not perfect, but like Costco might be another example, right? Where they might have 15% margin on the good itself. They make the majority of their uh gross profit on a membership, but they um have an incredibly durable and scalable business. And there's a lot of
17:18value for both the suppliers and customers in that instance. is demand aggregator sort of the the the Ben Thompson idea like is that how you think about the business?
17:28I think so. I'm sure he would have like a more academic response of like why we're not because it's not zero marginal cost to serve the marginal person.
17:35But 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. And you you've seen other companies prioritize in the 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,
18:03the right treatment, the right dose um based on their based on how they prioritize cost, quality, and convenience, right? Which is what a consumer um cares about. And so I think that's why we've been able to integrate with both of the leading uh pharma companies is because they know and 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 GOP ones is going to be perspectively? Like there's been lots
18:32written about what it's done so far, the flattening of that curve of the obesity curve. Like the data is all very interesting, but if you think about going forward as I don't know what percent maybe you could tell us of Americans are on one of these people say like 10 to 15%.
18:45Yeah, it's a big big percentage of Americans on the drug. What do you think the perspective story of GLP1 class drugs will be? So I'm interested both in the broader impact but also the generations of technology that seem to um this new one's coming out soon seems really fascinating. Welcome your thoughts on that. Like what's the story from here look like?
19:03There's the individual healthcare impact, there's the impact to the healthare 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 causes of death, right? What they're approved for, diabetes, obesity, liver disease, kidney disease, sleep apnea, heart disease.
19:21They'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 uh healthare system impact right which we talked about which is I think they are fundamentally rewiring the healthare system. Industries get rewired when large amounts of buyers care about one thing for an extended period of time.
19:42Right? So we saw a lot of the health care system suddenly find out that tele medicine was a good thing during co and what happened during co 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. So one of the reason one of the problems of our healthare system is we have a fundamental supply shortage. We have too many people who who need care and too few to provide it. It's one of the things we were trying to do at Rose turn a luxury into commodity by turning a
20:10service into a product. So when you see that but co 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 GLP1s rewire. They've already started to rewire and ask the questions of like well why does your employer get to decide what is covered by your health insurance and have such great influence on your healthcare? is again back to incentives in that first problem that we discussed.
20:35Your employer, they care about you. You care about your employees. I'm sure you do. I I 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. Right? An individual cares about their themselves and maybe and their family over their entire lifetime. That mismatch in incentives will naturally create suboptimal outcomes. So what you're seeing with GLP1s is you are actually seeing the most popular drug of
21:04our lifetime or drug class of our lifetime. Seeing the most popular drug, the majority of the growth is direct to 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 then the third and last one is the societal impact beyond the healthare system.
21:26If I can go on like a little bit of a tangent on this societal one which is the reason we started row um is very personal to me and it's I deeply believe like very simply we help patients achieve their health goals because when we do we think we unlock the full 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
21:54I was 18. Um, 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's dream in their first semester of college, like calling up, hey dad. And he helped me navigate that.
22:15And I was actually I've never shared this publicly but when I was 12 um I didn't grow for about a year and I was already quite small bullied a lot and uh my parents fought with the healthcare system to get to get it covered but to help me get growth hormone. So I took a injection in my leg every single day for about six years until I left. So I entered high school like 4849 and I left like 661.
22:42And so those three paths, if you think about it from my perspective, there was either a world where I was like dead at 18, 53 with erectile dysfunction, which is like not great, or [laughter] 61 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 healthare system. Like they set me on an entirely different trajectory as an individual.
23:06And then on the sidal impact whenever we as a society whenever we attack like 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 years 0 to 1800 our life expectancy is 30 and a lot of people will say yeah it's it's it's infinite mortality. It's like yes it was infant mortality it's also maternal mortality is also infectious disease those big three. What ends up happening when we
23:34largely combat infectious disease and infant mortality and maternal mortality?
23:39They're no longer mourning the loss of children and spouses every single day. They invest in the kids that they have.
23:44Those 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 homes 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
24:11those 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.
24:22Do you think that if you had to predict the percent of people on some form of a GLP1 10 years from now or something?
24:28Yeah. What would you what would your prediction be from 10 or 15 to 50 plus% of people?
24:32You think it'll just be a standard whether or not you have you know the acute versions of the things that were originally on that label?
24:39Yeah. Absolutely. What what's interesting to me is if you think about it so just pure raw numbers 75% of the US population has overweight or has obesity. So just based on that that group is clinically eligible. And then we'd say okay well that's bottoms up.
24:52Then what about top down? like what what percentage of the people the US population is metabolically healthy 10 12%. So they're even interested in taking it prophylactically right for inflammation or geroprotective reasons.
25:05So you start to sit here and say you know there of course there are some people who should not be on this medication or it might be uh 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, it is I think what we are seeing is it it combats a lot of the environmental and genetic impacts that lead to uh chronic disease in in society today. So um and then there's obviously the massive affordability
25:34question. But to me uh a I think the majority of people will be on it. I think statins are a good comp. You see like 40 50 million people on it. Um, and these are much more effective. Uh, just the breath of the label.
25:46Before we close out this chapter of like the state of the union and the system. Yeah. Um, I love this this notion of jobs over lives as like one framework.
25:53Um, talk talk to us about what you're thinking here.
25:56Yeah. So, there's this one of those that might uh be a little bit more controversial, but we can we can do it.
26:03There's a conversation in healthcare that's happening right now. I also think you see it in other industries where people say things like health care must remain human. 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, right? And and I think that when you do that, you are not prioritizing patient health outcomes
26:31above 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 it's of its current existence. Right? 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 uh a year die from car accidents. That is almost the same exact number as the people who die
27:00from breast cancer every single year.
27:01Nuts. 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.
27:25And it's not that I want to diminish job displacement. It's that we should not and this is what we were talking about.
27:30We should not and we cannot prioritize jobs over lives. We were talking about a cure for cancer and someone said like, "But 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
27:58the regulator asked the CEO when they told them about the reduction of deaths, the regulator said, "But what about the organs?"
28:09And the CEO was like flabbergasted and they what what the regulator was referring to is the organs 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.
28:33Right. 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 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
29:03driverless 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 my 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 GLP1s versus like AI revenue and it's like bigger, you know, the GLP1s are bigger. It's kind of crazy.
29:29Well, there's there's two cool things here. One is um not only were GLP1s larger from a revenue perspective, but individuals pay for GLP1s twice the number of people uh pay for GLP1s that then pay for AI.
29:43Yeah. So from a consumer's perspective, I think they're telling you I think that's a that is a problem with the AI narrative right now that there's not enough of a consumer impact day-to-day. Um so the gap of like real turn real time impact to the uh tens or hundreds of millions of people hopefully can be can be bridged.
30:02I'd love now to tell the story about this crazy company turnaround that you've been through. company's been around 9 years and about four or five years ago you went through a really fascinating period of time and you said the number kind of casually earlier but the company's like 10 times the size it was not that long ago. Obviously GLP1's a is a big part of that and um the company's charts look kind of like the GLP1's charts and so that that's one explanatory factor. Yeah.
30:28But that 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 like such a cool fun example and I think you're willing to be kind of raw about the details of it for what entrepreneurship is like. like, oh cool, three billion bucks that, you know, that's a great business, but like nine years and a lot of blood, sweat, and tears to get here.
30:51So, yeah, maybe tell tell this very interesting.
30:53Yeah, cool in retrospect. Quite painful during it, but um but I agree with you.
30:57Uh yeah, it started I would say like the moment I knew we needed to reset, right?
31:05So, we we did refound the company in the summer of 2022, but the moment we decided we needed to reset was December 2021.
31:16I 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 like almost every textbook mistake in the book. It's like 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
31:45a disaster. And you I realized that like people like, "Oh, how did you not realize that as I was as it was going?"
31:50Well, you know, sometimes looking at quarterly results or annual results or good moments of reflection, it kind of hit me like a ton of bricks, actually.
31:56So, 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 uh we we were what I would call like 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 like a zombie walking around. And we had a prep stack that could like squash an elephant. We were like, it was like an $800 million price stack. So, I'm sitting there having worked 70 80 hours a week. Our team had for years for 5 years. And our team had
32:28devoted themselves so much to our mission and we might not even clear our prep stack. And so I can't like it was a 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's 2021. We are trying to do like everything right. This is a local New York City owned, women's women's owned
32:57business that made macaroons and it was beautifully packaged in this plastic packaging. And I see at that moment again flying home for Christmas uh I see a comment in the general channel of Slack and which is sends 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 [laughter] and I was like I had like steam coming out of my ears. I wanted to
33:25reply like add here you're fired and I was so I was so frustrated. Thank God for honestly like bad Wi-Fi on the plane because I didn't send a message just like you know looked at it. And my first realization though was bad but my second one was way worse. Like the first one was I was frustrated with this person.
33:41The second one was I was even more frustrated with myself because no one gives a about the packaging when you are winning as a company, right? We were like literally and like literally and figurally we were macaroon soft. We were like a soft company and it was like it's not how I was raised. is not how we wanted to build. It's not our company culture. It was terrible. And so I shifted from looking at our financial results to I wrote like a six-page memo to my co-founders. And the moral of this memo was basically
34:11the c like I deeply believe in our mission and vision. It you know we have built an incredibly techn 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. Like if we have that with great people with our technology platform, we clearly have the resources. I think we can go put a
34:38dent 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.
34:47Fortunately, 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 like kind of obligated to say this which is I think Silicon Valley has this odd almost like fetish with layoffs. I think they reward it too much if that makes sense. Like when it when it happens people are like cheering it on. And I
35:17think for me at least uh it would have been a like a lot more efficient to have never done that in the first place. Second, it's the absolute worst part of the job to like take someone's livelihood away. Um and the second it's not like I don't like that person very much. So, and the third thing is, you know, I talked about we we part ways with VPs and 20% of the organization, but I'm a big believer back to the strong chong repel that like it's I do believe and it's not in a cheesy way like that there's a fit
35:46component. It's not just like is this person talented or is this person smart or not like I I had an internship my junior year of college at at Booze. There were 12 interns and 11 of them got jobs and I got fired four weeks into the internship. I didn't like I didn't even know that was possible to get like fired from a consulting internship, but I did.
36:04Four weeks in I was consulting for like the yellow pages. I got fired and I got put on like the beach and asked to do paperwork and then seven like seven weeks in they asked me to leave. So I I do believe that you can have people who are talented but just not be in the right uh environment. Um so we move on from 20% of the organization.
36:23Then we uh my co-founder Rob at the time there were three of us. co-founder Rob, he passed the baton um for the next leg of the relay race. So, it was me and Simon and I give him a tremendous amount of credit for doing that and recognizing that. Um and he's still on the board.
36:38We're still close. Um and then we refounded the company which had like several components to it, which we doubled down on top talent. We um put everything under the Row brand, right?
36:50So we were Roman, we extended beyond men's health. We dropped the man. We put all of our different brands under row, one brand.
36:57We massively updated our our ways of working, which involved rolling out new principles, right? One of which was actually when solic 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. Like not ambiguous. And then we said here's our new strong attract strong repel culture. And we were very explicit. We said look we we take full
37:25full responsibility for not being clear about not just the what we are building but how we are building it. Right? So a strong attract strong repel culture in my mind like 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. The best analogy in my mind is like a restaurant, right? Like 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
37:55way that Row is like beyond feedback. Like we love feedback. We are just very explicit where if you were to give me feedback at Row, 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 like a feature, not a bug.
38:15Um, 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. So, if someone tells me 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 which again where people work is a gift. They spend the majority of their waking hours there. And so to me like that was essential in creating that again that
38:44strong strong culture which is basically if I had to like distill it it's extremely like heterogeneous backgrounds and expertise but a homogeneous way of working like we work one way at row our what why is very very clear and so that uh so we explicitly articulated that and then said opt in or opt out to this another 6 7% of people opted out and now now we're at like September October 2022 to and we have grown 100% basically year-over-year
39:12for the last four years. We were 600 people when I was on that plane. We're now 400 and change and we've 10xed the business. So, we've 10x the business with 30, you know, percent fewer people.
39:24I'm curious to what you would attribute having gone soft as a business prior to that refounding moment like as advice to others out there like don't do these things like 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.
39:44And that was the, you know, if I had to distill our culture, it's very much like extremely high performance and big heart. Like if you have a and and they're not like balanced, they are both 211. 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 like why are we spending time talking about this?
40:14But it's it's both it's that rare duality of both turn 11. I think it's honestly it's how I was raised. And so that 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. And so the best advice that 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
40:43articulate what that is so that you know what it is and everyone else knows what it is and be unrelenting in protecting it. 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 like again these were very good people coming into the company but we weren't we owed it to them to be far more explicit about the menu than we were. So I I would take like full responsibility for that and I think founders do have to like if a founder I think the biggest thing that was the turning point is like
41:09I was never going to quit and so the second you realize as a founder like you're never quitting then you do have to make it a place that like you absolutely love to work and and you are going to be the only person I think you and your co-founders are going to be the only people that can truly truly create that and so that's that's what I would say to protect that strong. So back to this idea of okay 10x with a third two-thirds the people how much of that is tailwind how much of that is efficiency of the work of the
41:38people that's because of technology like it's it's it's a lot of both like you do not see this level of growth over this time period without riding also a massive wave right but there's a reason why you know there's there's one company that's the leading provider of GP1s in the com in the country by a sizable margin if you look at credit card data we're probably signing up two three times second, third, fourth, fifth place. So I think that we are riding in the same way
42:07others are like a generational tailwind but we are doing it better than anyone else. And I think the same thing you know you you compared earlier GLP1s to AI right and you'll look at uh Novo and Lily to open AI and anthropic right there are many companies other than open AI and anthropic that have the same tailwind that didn't ride it to the same extent right like anthropic is I don't know how many years old you so you do have to have that that wave but like no different you can probably tell by now I love analogies but like no different
42:36than surfing like you have to catch it and it's really hard to catch like a tsunami other people let it ride right under them or crash on top.
42:44What are the other underrated ways that you've done that?
42:47So, first and foremost, like I think you can build anything if you have the best talent. So, we double down on our top talent. Um, from a compensation perspective, from an equity perspective, from a coaching and resourcing perspective, um, constantly investing in the best people. And I think of those, you know, if you look at that that that 400 people that are uh that are at row like we started with 600 and change and whittleled it down and like those I deeply believe that our team is the best in the industry. That's first and
43:16foremost because when you have that and you have like when you have an incredible team, you have a strong attract strong repel culture and then you also one of the other things is ridiculous levels of focus but like we leaned into sequential nature of building things versus parallel like um and Johnny I talks about this and Frank Slutman talks about this um 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
43:45see 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 90-day 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 than and it will have a much greater impact. And it's kind of like the analogy that I might give is
44:14it's kind of like only working on the first 10 years of a compound interest curve and never getting to year 30. It's like that sucks. You lose all of the benefit. But if instead you have ridiculous levels of focus, you do things sequentially and the thing that you are doing next builds on the first thing. And so we leaned heavily into sequential versus parallel. Um and that is one of the things like that ridiculous level of focus is one of the things and and the entire company there was very little context switching right and and it and it started actually
44:43because I didn't feel that we were moving fast enough uh in December like 2022 like just after this we had launched our beta program and I started a daily steer meeting at 8:50 in the morning with our entire leadership team and we met every single day at 8:50 for two straight years. could 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 um and and decisions that need to be made were made. And what ended up
45:12happening is for that, for example, it was very difficult where if you and I are talking and it's Monday at 8:50 and uh 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 push things forward. But if instead if we meet on Monday and then we have we don't meet Monday through Friday but we just meet on the following Monday so many other things can like come up you know where oh I got sid track with this and this is important I didn't know which
45:41was there was a stack ranking oh this came 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 I think we did is we killed long-term road mapaps and it's like quite painful for for people when I tell them that they think we're crazy. They don't I wouldn't advocate this for every company. And it's not even entirely like my push to people when they sort of read that or when I say that is that don't
46:10miss like the forest for the trees. It's not that nothing we did at the organization would be playing past 6 months. And it's not an excuse for a lack of rigor. It's actually that in an in an era like the one we are in right now where both GLP1s and AI that industry is changing so rapidly [clears throat] having spending a lot of time on long-term road maps is like printing out map quests instead of using Google maps.
46:34It 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, right? And so I think doing that uh we got very good as an organization of living with longer term uncertainty but short-term sort of precision and rigor.
47:02And 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 to your concept of like avoiding being overly goal oriented.
47:10It's that same thing, which is like 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 a human. We do that at scale. We unlock the full potential of humanity.
47:27how 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 in 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 things that the medicines that help you achieve your mission for your
47:57customer are going to proliferate like crazy. Yeah. Just speculate on like where you think things are going, what has you excited, what has you worried?
48:05I think we are we are at the beginning of this patient revolution. I do do believe that partially because of a systemic failure that that um is happening. But there's three like you talk about tailwinds.
48:19There's the GLP1 tailwind, but I actually think there's like three tailwinds to our business. The first is that human biology is coming online, right? So that's everything from self-reported symptoms to your lab tests to 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, well, what type like who
48:47am I going to what type of doctor am I going to get online? First, they dramatically underestimated how flawed the existing health care 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 their kids in the same way that we see that today in tech.
49:05But I think what's interesting is to see investor sentiment change where they're paying 100K a year for a concierge doctor and they ping 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, right? They're just not evenly distributed, right? Like some people live in the future. It's just not evenly distributed kind of thing. Think about row being largest provider of GLP1s in the country. Some of the questions that we start to ask ourselves is, okay,
49:35well, why do men lose less than women when they were on GLP1? Why do people of Hispanic descent lose less than uh 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.
49:54So, you add on all of these and the question that you constantly ask yourself back with medicine being sort of trial and error is like, can you get at can you get at like the the faintest footsteps of a disease like just like a whisper, right? Because if you can do that, that's where you can really shift the trae. 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 uh
50:23allow 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. like not just concierge care online, but I think we can get a whole new form of healthcare for the price of Netflix.
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51:34to accelerated. Ridgeline also wants to help asset and wealth managers understand and improve their firm's growth trajectory. So, they built an interactive dashboard that lets you see how your firm compares to 16,000 peers. If you file a form ADV, your firm is already in it. Visit ridgeline.ai/trajectory to see where your firm stands. Then talk to Ridgeline about how you can do more with the team you already have. I think you're on a GOP1.
51:58I am on a GP1. Yeah.
51:59So, what is your pitch to the person?
52:02Actually, pitch me. I'm not on a GOP one. I don't like I I don't think I traditionally would have been the form factor of a person that would be on one.
52:10Like, how would you pitch people kind of in the general populace that are curious about this technology? Let's call it this um this method. So I'm I'm a big believer in taking uh in both all of the things diet, exercise, sleep, drugs and supplements, community. Those are the basically the five things you can do for your health. So back to sort of that incentive structure which is first the time horizon that I am looking to reduce risk for myself is radically
52:38different than the typical healthare system is measuring risk. They're measuring risks on 10 15 year time horizons. I'm pretty confident I'm going to be good when I'm 45. I'm worried about 55, 65, 75. And a lot of chronic disease are under the curve problems.
52:52How 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 like the pitch that I would make to you, I wouldn't say like you must be on a GP1 or you shouldn't. There would be first like what are your health goals, right? Then you would say what are you know some family history trying to understand and then also your risk tolerance your risks and benefits right and then ultimately you're going to have to ideally work you
53:21work with a provider to understand what combination of treatments might be right for you um and I don't give that answer of like hey work with a healthcare provider to see what may right for you like sounds like an ad at the end of it but it's actually because that's truly how it should should function my quote unquote like health stack has been built up over the last 10, 15 years like 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 uh metrics
53:49along the way to dial in for me based working backwards for my for my health goals.
53:54My dad had his first heart attack and stroke when he was actually 39. Had to stop practicing medicine. And there's sort of a blessing and a burden about that which is uh 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. Um and in many ways I'm 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 as software. I'm trying to give him to to everyone, keep him alive forever in some way, shape or form. But uh but as a
54:24result I've been very aggressive as when it comes to heart disease. So I'm on my cholesterol when I was about 30 years old was 230. My apo was 100 plus. My LDL was 130 140. And I was eating and exercising and doing all of the things that are in your control. But my uh genetics were such that I needed additional support. And so I started a statin. Then I started uh Zedios brand
54:53name for a Zetto. Then I added Rapatha uh which 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. Right?
55:07My APOB went from 90 to 60 to when I get my APO I have a less than in front of it. There's like a search party out for my APO and I'm very proud of that. Um so I'm willing to be disproportionately aggressive here relative to maybe the the population. And so that to me would be like the conversation that you would ideally have. Yeah. And so we'd we'd go from there and saying, "What's really important to you? What are you trying to achieve? What are sort of your risks?"
55:32And then you'd analyze the risks and benefits of each decision.
55:35So for that one as as an example, um I'm fascinated by the LDL thing and the area under the curve. Like I have no history of heart disease in my family luckily, but I take because my LDL is really high. And so you and others have have convinced me of the merits of this along with, you know, great doctors, etc. 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 tradeoffs in your mind associated with that specifically? And like how do you think like how do you think about what the benefit is?
56:04Probably years of life or quality of life, but how much and then what the costs are or the risks are associated with.
56:10Yep. Um, 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 these. Yep. But I have tried were up when I started with a statin. Um, and I first asked myself, oh, should I increase the dose of my statin? Should I add Zedia? Should I add Rapatha? And so I dialed in each one of those things independently, went off some, went on some to saw to see the the the marginal impact of each one, as well as um to make sure I could isolate if I
56:40if I were experiencing side effects. Was it dose related? Was it drugrelated? Was it potentially a combination of certain treatments? Um and so was able to find the regimen with my doctor to be able to navigate that. Um so with anything the downside is really like costs and side effects. Um and then I think about it which is interesting to me which is the like asymmetric downside of getting a heart attack or a stroke for me. Right?
57:06So to me when I think about it like I take these medications they're remarkably safe. Um, 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 like literally whatever percentage it ends up doing.
57:23Yeah, that might not be the case for everyone, but I actually think you're going to see like where path is a great example uh 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, right? went down like 60 70% and hopefully it gets lower. There's a new oral coming out and 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
57:51be tremendously helpful from a healthcare perspective. So where AI is like 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 really tight feedback loop right that's where math and coding really thrive right problem with medicine is it's trial and error. a lot of the data is unstructured and the feedback loop of like death or heart disease takes a really long time right 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
58:19heart study was the year 2000 they had about 3500 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 of uh risk reduction of heart
58:49disease no matter what they did.
58:51Drink, smoke, cheeseburgers, whatever.
58:53They were not dying of heart disease. They were dying. They could die of anything else basically except for heart disease.
58:58From 2006 2015, you have Amgen Invent Repatha, a bi-weekly injection. Now you have others coming, the others that are up every month, every six months. Now you have Merc invents an oral peptide uh this year that that got approved and it's an oral PCSK9 from year 2000 to 2026 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
59:27and eliminate the leading cause of death in the US. That's unbelievable, right?
59:32But it took us six years from genetic testing to discovering this faulty gene, right? Like 6% of a century, 26% of a century to get it out. That's too long.
59:43Like think about the number of lives that could be saved. Not to be like too cheesy or sappy, but it's kind of similar to your question around like what's the kindest thing anyone's ever done for you. 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."
1:00:03And 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?
1:00:11And I think you can. I think we can start to do that. I think we're on the cusp of another shift of that, you know, that 0 to 1800 where life expectancy was 30. For the last 70 years, we went from like 71 to 79, right? How do we have that next big inflection? And I think we can get there.
1:00:27Seems like the right time to ask more about this comment you made that you're trying to recreate your dad in software.
1:00:32Say more about that.
1:00:36You know, he 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 um and how much he inspires me. But I I guess at my core I do believe that the best way that I can have a positive impact on the world is
1:01:04to 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 who and 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. Like that's who he was born to be. And I've
1:01:37seen up close in person the impact that that's had on myself and loved ones.
1:01:45and the idea of I love like the written word and I love technology because it is an incredible form of leverage, right?
1:01:55I'm still reading books that were written 2,000 years ago and technology obviously scales a small group of 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, you know, hands he could uh hold. And so if I can recreate that with software and operations and technology and give that
1:02:25to other people, it's hard for me personally. I'm sure others can whatever it is for them, but it's hard for me personally to it's it's 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.
1:02:45Can you say more about this idea of B thing you were born to do as 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 I'm sure points of your life you weren't, you know, in that state.
1:03:00Anything else you could share about that idea?
1:03:02I think a lot of stories make more sense in retrospect than during like 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 kind of makes perfect sense to me.
1:03:19And 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. Um, she runs a YouTube channel called Huge If True.
1:03:35Not just a YouTube channel, like one of the best and biggest ones.
1:03:38I would actually argue that she's the best journalist on the internet.
1:03:42She's very, very good. Uh, she's definitely my better half. But the incredible thing is when when when she talks through like why she does it. She will say uh when people see a better future, they help build it. And people will ask her all the time, they'll say, you know, why how did you get into this?
1:04:01Why do you 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 uh was a corporate litigator but also did proono death penalty cases and he would talk about them uh the two of them both both of their parents would talk about them at the dinner table with Clea when she was a little girl 9 10 11 12
1:04:30death 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
1:04:57that education and doing and educating people in a powerful simple way uh can change the future. And so she now to this day you know wakes up and gets to try and do that at scale. And I think only as we've talked about like kind of you know because we both are founders and I think look back and say well it kind of makes sense how we ended up here but didn't it was less intentional than
1:05:26this is what we were meant to do.
1:05:27Maybe even pitch a little more like the what the benefits are when you find that thing like how it feels to be doing the thing.
1:05:35Oh it's such a gift. You don't feel like you're working. It is uh it's so energizing. Like I skip to work every single day. My team at this point knows to never on Friday never say have a good weekend because I will respond I can't wait till Monday. And I think there's like no greater gift than working with other people to have a positive impact on the world. And so when you find that like a lot of people there's of course there's like personal and professional life but when you find
1:06:04harmony between those two things and you don't feel like you are quote unquote like working it's like a bizarre phrase to me. Um it's how we spend the majority of our waking hours. That's why I think at row like where talented people work is a gift. You have to earn that gift and you take that responsibility super seriously. So when you find the thing that you to your point like when you find the thing that you were meant to do I think you stop thinking about it like work and it's just you just follow the rabbit hole of your brain.
1:06:33One of the things 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 like one of the most powerful things in business. So if I go back to that original beach head Yeah.
1:06:48um with Viagra or whatever wherever the other drugs were, what were all talk about all those aspects around that first beach head.
1:06:56It's a 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 row is we start with what patients want and find the overlap with need. It's not that they just want it and it doesn't they don't need it. They we find the overlap. We find 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 I said, "Hey,
1:07:25Patrick's doctor. Um, what does Patrick need?" Right? 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?"
1:07:37Well, they'd say, "I don't know. I got to ask him."
1:07:39So it naturally puts you in a patient centric position and one of like selflessness and egolessness um 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. Um when we first started um the New York Times called us like restaurant menu medicine as if this was like a bad thing. I was like people have great experiences at restaurants. you
1:08:08go, you have a menu and then there's prices and then you select what you want. Um, 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 do. People often ask us like 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
1:08:37the 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 row 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.
1:08:58It's assigned to a healthcare provider.
1:09:00An SLA is attached and we have a 247 sub30minut response time for your side effect. That's an entirely like new form of healthcare. So, you got to bring the receipts if you're going to ruffle feathers. And then on the marketing side, like I was in the commercials early on. It's not something that like it wasn't where I said, "Hey, I need to be a uh like self-promotional CEO. Um, this is like my first extended podcast ever in nine years. But it was more actually where I was in the commercial because with
1:09:29marketing and how we think about a lot of these things is there 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, 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 like 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
1:09:57loss, reproductive health, mental health, ED, whatever it may be, do what our marketing does is it tries to create permission structures on behalf of people who need that product or service by uh doing two things. Massively shifting the Overton window so that we're the extreme so that they never have to be. Right? And the second is by telling stories that that deeply resonate with them. So like Serena Williams is a great example of this.
1:10:24She's a uh ambassador for a robot for JLP1. She is one of one as a human being.
1:10:31Greatest of all time tennis player, but she's one of millions when it comes to her health journey, right? 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. The 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. Right? And you've seen us with the same thing with Charles
1:11:00Barkley or the same thing with Chrissy Mets or the same thing with Megan Fox and Ed. Right? 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 say, "Well, I don't know what my partner's going to think." And so I think all of these things try to really touch on each one of those.
1:11:29May maybe say one bit more to I'm so intrigued by these methods about I would phrase it as like stigma as a signpost towards latent demand like unmet demand.
1:11:40What What have you learned about that idea of like there's a lot of potential energy there?
1:11:44Yeah. And when there's a lot of tension on a subject, that's something that a lot of consumer founders can like tap into.
1:11:50Now, I think the way that we've tapped into that is always having what I would argue is like the moral high ground.
1:11:56Like 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, right? And so that to me is like even take take GP1. Like when we push when we were pushing, we originally had this I put in quotation controversial subway campaign where the only thing that we did was show people that were clinically eligible using the medication and then said a weekly shot to lose weight. It
1:12:24was literally instructions and it caused like this massive curl. why people were very uncomfortable by the idea of people using injections to lose weight and we knew that um but it was but people misunderstood the negative health impacts of carrying excess weight.
1:12:40They 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 right. Oh, only xy orz people need medication or only xy orz people um should be treated for ED or whatever it may be. Take another one as an example relates to GLP ones where people are often times talking about um well how do you uh how do you go off of them? Like when do you go off of them?
1:13:09And people should be able to go off medication whenever they want. They should do it safely and there should be no judgment if they want to 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 they do not want people to need the medication on an ongoing basis unlike any other form of actual medication or behavior. So, as an example, like what do people think is going to happen when they stop taking
1:13:38their cholesterol medication? Probably going to go up, right? What do people think is going to happen when they stop taking birth control? Right? It's not going to be a surprise. And then as opposed to like behavior too, you can't just do one push-up. You can't eat one salad. basically any medication, any behavior you need to continue to do on agoing basis to continue to get the benefits. The fact that like that makes people's stomach churn when it comes to weight loss medications is a far greater
1:14:06reflection of how they feel about that. And so there's ten 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 societal.
1:14:21What have you learned about the doing these campaigns like Megan Fox I think was the most recent one. 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 um the nature of the visuals or the copy or the release like working with celebrities as a thing to you know draw brand attention.
1:14:41Yeah. Give us like your There's so much here. I'd be remiss if I didn't start by saying like this is my co-founder Simon superpower. So I'm like laring when I'm here talking about this.
1:14:53He is absolutely world class at this and I think you can see it in in Rose's performance and brand awareness. Now if I'm trying to like channel him and and echo him here from a celebrity's perspective again it is about yes it's about creating permission structures but he is very very strict person. Megan is a very unique use case but we think about Charles and Chrissy and Serena and Trisha Pis and we have two or three uh
1:15:21coming out soon. all of them are on the product and so because it's so important to him and uh to patients that they are authentically sharing their experience right and that's what he crafts the campaigns around right if you look at a Charles Barkley commercial it's Charles it's like unscripted it's him in front of a camera he's making jokes or he's having fun right but he's also sharing his
1:15:50authentic story Right. Same thing like Serena comes into a to a shoot and she is like locked in. Like 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. You like the cool part as a total side note of like working with all these people is that you see why they are who they are because they are like
1:16:18to the nth degree. why why they are the best in the world at what they do is very evident within like minutes of meeting them.
1:16:25Um so that's just like a a cool thing to see. But on the celebrity front, so it's it's about really finding these authentic stories uh that create permission structures. Why they are more useful now than even 5 10 years ago is because the bar to create highquality looking ads is very low. Right? With AI, you what what would qualify as like a beautiful ad 10 years ago on Instagram that someone would have, you know, spent
1:16:52a ton of time on is like 10 seconds now and no money.
1:16:57So, how do you break through the noise when everyone's just looking at like pretty good looking stuff?
1:17:02Well, you have you see Charles Barkley's face or Serena's face or Megan Fox. You cannot replicate those in an age of AI. So, I think that that is is powerful to do.
1:17:10Yeah. Back to this stigma idea. What are the stigmas today that interest you?
1:17:15Like so now that first campaign, the sub the subway campaign like now it's like totally normal, right? The the window has shifted. So where has the window not yet shifted where there's stigma that you find interesting?
1:17:26Back to the [clears throat] earlier question that you asked around people taking medications like prophylactically or on the earlier side of what might be or what would be considered early is fascinating to me. Um because first of all, like on the way here, I must have passed like 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
1:17:53TV ads are about it, right? And then you take medicine, something that has literally it is the most studied thing that humans put in their body, bar none. And there's a randomized control 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.
1:18:17But then the idea of like advertising that on TV, it's like, whoa, whoa, whoa, whoa, whoa. Right? Versus like poison, totally fine. Cheeseburgers totally fine. And I believe like I love cheeseburgers. But this difference where those are like obviously a health net negative. The question is whether enjoyment outweighs that. and we can have that that like conversation as society. But over here there's at least like a probabilistic equation of like whether the benefits dramatically outweigh the risks. Someone is engaging with an expert in that and they're doing
1:18:46it on an ongoing basis. So to me this idea like sometimes when I tell people that I'm on these medications, they're like shocked as I see them literally drink poison.
1:18:56And that's not a knock on that at all. Someone should be able to do that. But it's the the difference between those two that I find like quite surprising.
1:19:06Are there other things that I guess the prompt would be like the hottest takes you have like differences of opinion versus your peers versus the industry versus the world like where you feel most alone in what you believe.
1:19:22Feel 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 and I think that maybe this is maybe other founders don't but I feel like I have an incredible like support network and I think in particular I would say like my spouse like I don't know that founders who
1:19:50have very very supportive uh spouse houses like talk about it a lot to be honest.
1:19:55Um like 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 we grew up together. We have taken turns financially supporting one another actually. So when I first started row I was like we were living in a friend's apartment together.
1:20:15We had the smaller room. He had the master. She was on a journalist salary buying both of us like breakfast, lunch and dinner. And so I would not be the person I am today or be able to run row if and if and 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 kind of like just assigned to one person. I would say the same thing with our team. Um like our team is absolutely incredible. So that's probably like one of the things that I think there's a lot of founders that a lot of worship.
1:20:45They believe their doesn't stink and it's kind of exhausting. So yeah, that's not a lot of hard ass founder wife guys.
1:20:53There you go. It's true. It's true. It seems weak. Seems macaroon soft, but I actually think it's the opposite. [laughter] This has 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.
1:21:12And I sure hope they keep 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?
1:21:19Uh, so I've thought about this because I listen to your podcast all the time. Um, and I think I was inspired by your answer, which is when I was 15 years old, uh, I was at boarding school and I was very homesick.
1:21:35I missed my parents tremendously. and they came to visit me and my dad and mom uh 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. Uh 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 he normally drives.
1:22:05And so again, back to what we said before, sometimes you realize things in retrospect. Like 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 he said, "Tell me you love me." And I I completely switched and I said, "Like, of course I love you. I love you so much." And he said, "Good. I love you, too." and he
1:22:33drove 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."
1:22:41And I asked him after, he fortunately made it. He didn't think he was going to make it. I asked him after. I was like, "Hey, like seconds matter. Like what were you doing?" And he goes, "Well, first I it was two seconds and I didn't think I was going to 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.
1:23:05And it's like 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 when I hang up with him, my friends, I will say I love you.
1:23:27And even to this I got my co-founder. It took me six years. I say I love you to him [snorts] 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 having someone being able to like put your hand on the stove with unspoken love and not doing that ever again is something that I think God will always cherish for him.
1:23:53Incredible story. Very unique. I've done a lot of these. Haven't heard one quite like that. Thank you so much for your time. 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/invest.
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