Ahead of the Curve: Amir Dan Rubin

0:00:43.7 Host: Welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Our guest today is Amir Dan Rubin, who has spent more than 25 years leading transformational healthcare organizations. He's also a proud University of Michigan School of Public Health alumnus. Rubin led the rapid growth of One Medical, a primary care provider that focuses on patient experience, and then partnered with Amazon. He is now pioneering new fronts at Healthier Capital to invest in visionary health startups. He recently joined DuBois Bowman, Dean of the University of Michigan School of Public Health for a conversation to reflect on his journey so far, and where he and the healthcare industry are going next. This conversation was part of Ahead of the Curve, a leadership speaker series from the University of Michigan School of Public Health. We know you'll enjoy Rubin's insights on leadership, innovation and on making healthcare more accessible and efficient. Whether you're in healthcare, aspiring to lead or simply curious about the future of the industry, you don't want to miss this conversation. So let's dive in.

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0:02:01.3 DuBois Bowman: This is a special moment for me as well. We launched Ahead of the Curve back in 2020, and immediately upon developing the concept, I thought of Amir. And so this is a moment that I've been waiting for to be able to host Amir on Ahead of the Curve. And so what we're gonna do now is to really just try to delve a bit deeper just into some of your experiences along the way. And I wanna start really at the beginning in thinking about your time at Michigan Public Health. Most of you know that Amir earned his MHSA at Michigan Public Health. His wife Nicole, earned her degree at Michigan Public Health as well. And as I understand, they met at orientation. So we have some students with us here today. I hope that our students are able to see you not only as an inspiring model, but that they're also able to see some of themselves in you in the future in their careers. And so I wanted to just ask you, if you reflect back to your time in Michigan Public Health, if you will maybe comment on classes, experiences, people who were especially formative to you during that time.

0:03:08.5 Amir Dan Rubin: Yeah. Well, first comment is don't skip that pizza party on the lawn of SPH 1 'cause you may meet your significant other. So that actually was the first day, and then I saw Nicole again in the bookstore. So we like to say our origin story together is pizza party bookstore. Gosh, there's so many incredible people that were big influencers. So many incredible faculty members and peers. Having Dr. Mike Chunn back here who we had for Econ and Rich Hearth and Rich Lichtenstein back here, and of course Professor Griffith and so many, many incredible faculty and incredible peers. It's so fun seeing so many of our colleagues here and we are really connected this Michigan, I don't know what's the nice word that we're saying, the Michigan family but it's an incredible group of people.

0:04:07.1 AR: We were very energized to transform healthcare, very collaborative group. So many of those experiences were really seminal. And coming back here, we still have the cinder blocks of SPH 1. I know the campaign is launched. Hopefully, we'll do something with the cinder blocks. Eventually, they've managed the test of time, I guess but it's incredible. And just incredible the history here of the people and what's been done across health management and policy, HBHE, epidemiology, biostatistics, and across departmentally and across the university. So we took advantage of all of that. Having the School of Public Health and the Department of Health Management policy within the University of Michigan, I think is also an incredible advantage.

0:04:58.2 DB: Yeah, thank you for those comments. We are trying to do something about the cinder blocks, just so everyone knows. And your comments really just about the Michigan Public Health family and network, it's real, it's something when I talk to our students about, I share when I talk to prospective students, but it's nothing like being on the inside and being a part of it and seeing it work and seeing it play out in real time. And Amir, I know that you play an active role in doing so, so I really, really appreciate your efforts there. So the next question I'd like to ask, the field of healthcare is evolving very rapidly. When we train, we're training our students, not just for entering the workforce at present, but really foundational skills that they'll be able to draw upon for years to come. And so, thinking about our students today, what are some of the skills that you think are important for them to develop and focus on during their training if they wanna contribute to the field as cutting edge leaders?

0:06:01.2 AR: Well, first of all, it's been amazing interacting with the students. What an incredible group of enthusiastic smart go-getters. So A, I think the students are off to a good start. I think a few things. First of all, be passionate about what you're doing and be prepared to work very hard and to get after it and go get it. You gotta go get it, and I know Michigan students do that. One has to persevere quite a bit in healthcare. And we have so many healthcare leaders here who will attest to it. It's almost an impossible industry to be in management. It's just like you have state and federal policies. You have multiple missions. You might have research, education, patient care. You have pandemics thrown at you. Is there anything more challenging than like having to run an organization of healthcare providers in the middle of a pandemic when you have no idea really what's happening?

0:06:57.9 AR: So you have to be very mission-driven. I think ethical values driven, but also perseverant and be action oriented. So I think those are traits that I've certainly seen in my colleagues here and across U of M and certainly in the student body and other great healthcare organizations. I think you have to learn to continuously learn. Some of the things I was talking about in my talk on AI, they didn't exist a year ago, like not on the planet, right? And like within a year. So you have to learn how to keep learning, keep being inquisitive. I think having a combination of analytic skills, being facile with technology, having great communication skills, having a little bit of chutzpah and gumption to get in there, stir that in a pot I think are some of the traits that I see in our student body and I think will serve them well.

0:07:50.2 DB: The intellectual curiosity and agility, those have always been important, but no more important than now, just as rapidly as things are evolving. So again, just as a recap, you became CEO of One Medical in 2017, which at the time was a venture capital backed private company, which then went public in an IPO in 2020. And then One Medical was acquired subsequently by Amazon and that was in 2023. And so in a very short timeframe, that's really, really, really significant change. And so I wanna start really in the early phases of you had this concept and a vision of a new model. And can you talk us through your vision for the company as you began your tenure as CEO?

0:08:38.6 AR: Actually the things we are doing at One Medical are kind of common knowledge to people. The question is, can you get product market fit? Can you get anybody to buy it? Can you find a way to distribute it? Can you find an economic model to make it work, and can you finance it? Actually, when I was CEO at Stanford University's health system, we had built a salaried model primary care group. We were actually the first to do video visits on Epic. This was 15 years ago. There was no APIs. We hacked it. We were the first to build an app on it. Very hard to do, however, ultimately in a tertiary academic medical center as a model. And so it's like, okay, these are concepts, these are not unknown concepts. Do we think we could build a model that can stand on its own?

0:09:23.0 AR: The concepts I don't think are that novel. And hey, what if you give people what they want? They want nice people to talk to them really quickly, 24/7 on demand, and they don't wanna have to pay at the margin. It has to come somewhere like, so that's kind of there. And so we're like, okay, well what if, what if we charge them a little bit upfront and what if we could do it asynchronously, and what if we could use AI to automate that and so we can take the cost down? What if in the office we didn't have medical assistance, which we don't. The physician or clinician will greet the patient. What if the clinician then walked the patient back, they did all the vitals themselves? What if then they walked the patient back up, went and cleaned the room and saw the next patient, but had no nights, no weekends, no calls, salaried model and 30 minute appointment, would they take that trade off?

0:10:05.4 AR: These were kind of the things that we were working on. These were the hypothesis, but I don't think they were per se novel or unique to us. It was how do we put these together in an economic model, in a execution model that then we can scale, we scale to 31 markets physically and digital health across the country. The execution is really hard. Can you run a 90 net promoter score in a one minute wait 24/7 in multiple states and cities? That, you can't just lean startup, just roll up your sleeves and do it. You have to build consistent tech and ops and systems and team. And then we went from hundreds of people to thousands of people and hiring doctors and clinicians across markets. So that became then I'll call it an execution challenge.

0:10:56.1 DB: If I can really dig in right there. So you had the early days where you were very successful and really established proof of concept, right? You knew you could do it. You knew the model would work, and so then there was opportunity to scale. The scaling is not without risk, right? And so how did you scale the company in a way that was sustainable and didn't overwhelm the operations with growth that was too rapid?

0:11:23.3 AR: Yeah. Well I'll say I didn't overwhelm the operations. You might ask some other people in the teams and say, well, 'cause you're kind of going to breakneck speed. But I think it starts with having an operating system in a way we do things, otherwise, one can't, I don't believe scale in a sustainable way. You could hire great talent, but if you're like, Hey, go figure it out. We tried to have our operating system, the One Medical way we do things, and that's from everything from how we interview. What are the questions? What's the process? What do we do when you onboard? What are the kind of things, for example, we'd interview physicians and we'd say, would you mind sitting at the front desk in a moment and just answering some phone calls? We don't want you to do that, but would you do it?

0:12:03.8 AR: We had these different little approaches, techniques, things we would do, but these were by design, we had three types of physical design. It used to take us three months from construction to go live. We got that down to one day, kind of wheeling processes, everything from supply and setup to furniture and everything and the like to how do we train on our clinical protocols and practices. We had medical advisory councils, we had different subcouncils, whether it was LGBTQ Care or BIPOC Care or mental health. And we had clinical experts, but everybody would be in weekly rounds and then we would train, we would standardize. We had our own kind of tenure process. We called it the star provider program. So we'd actually have monthly exams, we'd give them case studies and then over a few years, if one performed well there and your metrics were good, you were promoted. We didn't have incentives on a daily basis, but it was kind of an upper out. And if you did, you went up, but they were processes and systems we scaled.

0:13:08.9 DB: Yeah, that's fascinating. And often we hear criticism of tenure and so it's nice to see that similar concepts adopted in a different area.

0:13:16.2 AR: There was no guaranteed tenure, however. They just got to the next stage, but really we wanted everybody to succeed. And so part of that is, is this the right fit? It might not be the right fit. Not everybody may want to clean their exam room. It may not be the right thing for you and that's okay, but this is how we're gonna do it here.

0:13:34.3 DB: Yeah. And another question I wanna ask about during this period of rapid growth for the company, another thing that is significantly impacted is culture. And I wonder if you can just comment on how you went about that culture change journey and whether there were the non-negotiables that had to be there, whether small or large, but the other inevitable parts of the culture that will shift in how you handle that in your leadership.

0:14:06.0 AR: Well, a few things were certainly non-negotiable. And again, we tried to define these as much as we can, and we improved them over time. We call them our DNA and our, our service ethos and experience ethos. Those were non-negotiable. So we were gonna treat each other with great courtesy and dignity and respect, and we were gonna treat all of our interactions, all of our consumers that way. And we would all be trained and practice and we'd go observe every week in the field, how we were doing this and we would measure at the individual level. And that was non-negotiable and that's how you can sustain 90 net promoter scores across the country at scale with thousands of people. But I didn't come up with the standards, the team did. Our behavioralists came up with those standards, our pediatrician came up with. I'm like, what's a good experience?

0:14:55.7 AR: What do you tell somebody when they have a bad diagnosis? Is there best practices? It doesn't mean everybody's saying the exact same things. Let's role play, let's practice this. We had people who were more senior in their career who had a lot of experience and some that had less, and those kind of things. Our core DNA, we were human-centered and Team-based and driven to excel and intellectually curious. And those were kind of the traits that we were looking at people. We wanted a very inclusive and welcoming environment as an organization. We were about 70% women, about 45% people of color on our team, that was really important as well. We were looking for people that this is the culture and environment they wanted to be in. And again, it's not a right or a wrong culture, but it's the one we picked and this is how we were gonna do it. And if it's not a good fit, that's okay but this is how we wanna operate.

0:15:49.7 DB: So now I wanna just ask you to reflect on maybe some leadership lessons learned along the way. Are students in the audience, some of them will be future CEOs. And for anyone in the audience who's interested in being a CEO, what are some of the best lessons that you've learned in your CEO positions?

0:16:08.3 AR: Have a great and supportive family because these roles are all encompassing, and so you have to love it, and you have to believe in what you're doing and you have to believe in the mission. I know so many people in this room and I know how hard they work. It's 24/7. Deans jobs aren't exactly easy these days. Dean Bowman with all that, all the challenges in universities. So like, you have to love it. You have to be driven, you will get a lot of nos. I like to call them not yets in the entrepreneurial world and they're just not ready for the yes. One has to work hard, one has to persevere, one has to have support. And thus you have to balance that into your life in the sense of I believe in this, this is part of who I am. I'm mission driven. So I think that's been an important part, and something that I've learned, I guess, or experienced over time.

0:17:10.3 AR: I like some of the tenants from Lean, an old CEO of Toyota for Fujio Cho used to say, go see, ask why and show respect. So I got some good simple advice, right? Be respectful, go see for yourself, but ask why do we do it this way? Healthcare is so complicated. We often find that we don't exactly know why we're doing it this way, and actually pretty much nobody knows the end-to-end process in healthcare. So get in there, try to understand it, and be connected to team members, but also customers. For example, I color code my calendar green were customers, whether those were patients or employers. If I don't have a lot of green on my calendar, if I'm not in the field, if I'm not in the sites, I know it's not gonna be good over time. Like need to have that balance. And you learn a lot by being out there and you gain respect for the needs of patients and families or employers or whoever the clients might be, and certainly of the team and what they're facing on the ground. So that, those would be some, some takeaways I've had.

0:18:08.4 DB: Great, great. So as I wanna ask you just for your thoughts, so you've been wildly successful at One Medical, you presented and commented on the problem statement to begin. And with your success, you lowered a lot of barriers to healthcare access, like the waiting many months to get an appointment, simplifying the process and allowing patients to be able to do many things from their cell phone. And so I wonder if you've seen changes in patient expectations, right? Whether or not there's a shift that will prompt other healthcare delivery systems to change, and perhaps some of that prompted not just by One Medical now as a precedent, but maybe even from the pandemic.

0:18:53.0 AR: Yeah, well certainly there's many amazing healthcare institutions and are working on these challenges. I think what we were able to do at One Medical is at some level, just be very overt about it. Like, the patient wants to talk to you now within a minute or two and doesn't want to pay. Is there a model to do that? And how would you monetize that? Well, maybe we could save downstream. Maybe that would've those specialist visits and maybe there's some trade-offs. Well, maybe if we gave the provider more time, they wouldn't need to refer 'cause they could deal with the diabetes and COPD and CHF and some mental health issues, because they had the time. So some of it was designing models both on the consumer side, but then how do you operationalize that? And some of that's really hard to do in existing organizations because you have existing technology, you have existing economic models.

0:19:44.1 AR: So sometimes this is why startups can be a good environment to do this. And again, many of them will fail. They're very risky, [laughter] And when you take capitation, this is not huge insights to the many health plan leaders. But as I often said, risk is risky. [laughter], you know, you can lose your shirt. And so there's also reasons not to necessarily flip existing business models upside down in big important community-based institutions. But this is where kind of I turn to technology and I think we can automate a lot of the administrative and some of the clinical intake processes in both our kind of bigger, larger health systems, health plans as well as in these kind of more startup organizations.

0:20:27.2 DB: Terrific. Terrific. So if we'll go now to the point where you're in communication with Amazon and you told us a little bit about the driver of We'll need to own you. But I wanna just peel back and ask you about some of those early conversations, the rationale from your perspective. Right. What did you think were some of the benefits and possibilities of having a partner like Amazon? And then if you're comfortable, maybe even things that you're nervous about.

0:21:01.3 AR: I've always liked big mission statements. So at One Medical it was to transform healthcare for all [laughter] through a human centered and technology powered model. And I was like, "Well, Amazon's getting close to all. I mean that, I mean, they're closer than One Medical was on its own." So that was kind of interesting. And there was a lot of, at some level shared DNA, obviously they were way, way larger than us, but Amazon combines, if you will, logistics and tech. They have two divisions. They call one division stores. And we were in stores, which I kind of enjoyed, like we're in the store. And then tech, you think Amazon Web Services, well, at some level One Medical combined logistics and tech. We had clinics, stores, physical sites, and we were building software in tech. We both had membership subscription programs, and we both had really high obsessions with customers and we both had focus on execution.

0:21:56.4 AR: And so at some level, they were really a great alignment in terms of what we were trying to do. And certainly Amazon's done this in unbelievable scale. And so that was exciting. But they had recognized that healthcare is, as I like to say, idiosyncratic. [laughter], you know, sometimes it's sounds like idiotic and crazy, but I meant idiosyncratic, right. It's one has to understand all the different payers and they would ask like really, really thoughtful questions. And then they had a lot of smart people, obviously. So that was a really nice fit. I think with anything, with any integration, one always wonder is how that's gonna work. But the nice thing is we were a clinical model. We weren't another fulfillment center being integrated into a larger fulfillment center. So our clinical experiences has been great. It's continued to be great. It's grown dramatically. It's on the Amazon webpage. We're on the front of the Amazon webpage talking about cost of acquisition. That's nothing we could have ever, ever afforded and thought of and has brought us to new heights. So that's been really compelling.

0:23:04.5 DB: Yeah. And I wanna ask us also about the role of data, right? That data is an important driver in the One Medical model and Amazon certainly has lots of data. Did you see that as an opportunity to build on what One Medical was already doing at the time?

0:23:20.6 AR: Absolutely, but, and [laughter], lemme say first the but, we were very, very deliberate. So the One Medical information is completely separated from Amazon information. And that's actually part of what took us a while to launch One Medical on Prime. Even the fact that you clicked on One Medical isn't known in the other parts of the organization. So we were very, very thoughtful, intentional about that. So there's amazing resources at Amazon, but we have to be very careful and thoughtful about how we do that. And now starting to leverage a lot of, not so much data per se, 'cause we're trying to keep that distinct, but more, I'd say kind of the AI capabilities and leveraging these large language models. And we happened to be hosted on AWS, I got even better pricing on AWS as being part of, they do charge us though internally that kind of resource, because we were also building our own software and technology.

0:24:14.7 AR: So leveraging that bigger team was remarkable. And the talents there were things that we just couldn't afford as a startup. So I'd say it's really more on the analytics and capabilities, certainly on the digital marketing, they had incredible capabilities. So we would do our own kind of AB testing online, but they had teams and teams and teams of peoples who are expert experts on this. So that was super fun, leveraging that kind of capability and comparing what got more activation, including in trying to get people to engage on their clinical care, what would activate people the most in terms of following up on your blood sugar or your high blood pressure or like. So leveraging those kind of insights and capabilities were pretty remarkable.

0:25:03.8 DB: Terrific. And, so now that moves into the present, at Healthier Capital, some of the kinds of things that you're working on, the excitement around AI, but what prompted you to move in that space? And then I'd like to just ask, you know, what you hope to accomplish?

0:25:20.9 AR: Yeah, I think what prompted me is, I think now in retrospect, I kind of like the steep part of the curve. [laughter] I don't know if I've always been ahead of the curve, but I like the steep part of the curve. And, so I'm pretty excited about how technology can intersect with healthcare now. And there's a certainly a big place for a large organizations to do that. But, and the technology is this, this new, a lot of it is also being tried out first in this startup arena. And so that's where I wanted to turn my energies.

0:25:57.0 DB: There was a question from the audience at the time of registration, hope the member is currently here. But I'd like to just ask, you know, who provides advice to someone at your level, and what role do you believe that seeking guidance plays in success?

0:26:15.1 AR: Yeah. Well, if you're fortunate enough to marry a graduate from the Department of Health Management and Policy at the University of Michigan, you get a lot of great free consulting advice. Nicole has got a distinguished career in her own right and has been a CEO and an executive in a lot of boards. And so I will definitely talk with things with Nicole. So that's a great, great source. I don't know if this was a Rich Lichtenstein quote. Over time, you learn more and more about less and less, and then you wake up and you realize, I know everything about nothing. You know, like, so, continue to be humble. You know, I certainly know a lot less than I thought I knew.

0:26:58.2 AR: Like even when I was younger, I was like, I got this. And now I'm like, I really didn't know much about that and that's okay. Once you dive in, I'm continuously learning from everybody. I learn a lot by talking, going out in the field and talking to, now talking to startups and team members, and making rounds, talking to clinicians, researchers. There's incredible research faculty at Michigan and elsewhere. I'm continuously looking to learn. And so I don't think I necessarily know that much, but I think I'm curious and I enjoy learning and I wanna keep learning, and I love engaging with people on learning.

0:27:39.2 DB: Terrific. So we're all very proud of you as an esteemed alum. But I wanna also take some time just to make a few comments about the many ways that Amir and Nicole give back to the school. So last year, you and Nicole, gave a transformational gift to establish the Ruben Department Chair of Health Management and Policy. In addition to this generous gift you give of your time and you serve on the Griffith Leadership Center Advisory Board, Nicole is a very engaged member of the school's Dean's advisory board. And again, today is the official launch of the university, a campaign. And you and Nicole don't have a lot of extra time on your hands, but you agree to be a part of the national co-chairs for the university campaign. And then you commented in your remarks, I know that when we've spoken, you commented on how you like to look for opportunities to hire University of Michigan students, whether in internships or in permanent positions. And so, just if you can share your thoughts on what drives you to stay engaged and give back to the University of Michigan School of Public Health.

0:28:54.3 AR: Well, I think the way to make significant change is through organizations. That's why I love management so much. And it's also really hard to make change, but organizations have a big lever. And you think about the University of Michigan at all levels, the levers that it has to improve people's lives. Many people in the room might be even first generation going to college, whatever people's backgrounds are. I mean, this is a transformational experience for individuals, for communities, hopefully, for the world. And that SPH1, I mean, transformed management of diseases, polio and otherwise. And we have so many leaders in the HMP program who have run and are running these incredible institutions. So an opportunity to engage with leaders, invest on making change in the world and positive change in the world. And if you can do it with like-minded people, it's a great privilege to have that opportunity.

0:29:54.4 DB: Terrific. We're nearing the end of time, and so I'll just offer an opportunity for you to provide any final remarks of advice to our audience, but especially our students in the room.

0:30:04.5 AR: Don't take any advice you hear too much to heart. [laughter] work hard, persevere, get after it. There's a lot of opportunities here. At some level, I felt like nothing's due to me, nothing's owed to me. You gotta go out, you gotta get it. If you wanna make the impact, you wanna do something, go get it. If you don't, that's fine. Your time here is short. It goes very, very fast. And then you find your time in your career and your professional life and your family life is very, very fast. So, I don't know, I seem to make it even shorter by just packing it in. So I would say, you know, get after it. I heard Jerry Seinfeld speak at my kid's graduation. He said, "Everybody wants to find a passion." And he said, "Well, you know, passion is sweaty. You know, just find something you like a lot because your passion may shift, you know, so you can be passionate about something, but be open."

0:31:00.6 AR: Like, I still don't really know what I wanna do in healthcare. I just know I wanna make significant positive impact in healthcare and kind of why I've done different things. I'm like, well, that sounds great. That could be interesting. And again, I like the steep part of the curve. Maybe I wanna be ahead of the curve, but I know I like the steep part of it. And so I'd say be open to learning, the world changes, problems evolve, solutions evolve. I'd say be open-minded, get after it, take initiative and take advantage of all the opportunities that we have here at Michigan.

0:31:32.7 DB: Terrific. Let's give Amir a round of applause.

[applause]

0:31:36.6 DB: And Amir, I wanna thank you just for your time, your words of wisdom and your words of inspiration for sharing your experiences that we all can draw lessons from. I hope you can join us for our next episode of Ahead of the Curve, which will be held on January 16th, and it will be a virtual event, and it will feature Gina McCarthy, former administrator of the Environmental Protection Agency. And so thank you again to Amir and all of you for joining us, and all of you who joined us via livestream as well. And Amir, if you'll join me in saying Go blue, one, two, three, go blue.

0:32:18.9 Speaker 5: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us and hope you learn something, they'll help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Be sure to follow us at, UMICHSPH on Twitter, Instagram and Facebook so you can share your perspectives on the issues we discuss. Learn more from Michigan Public Health experts and share episodes of the podcast with your friends on social media. You are invited to subscribe to our weekly newsletter. To get the latest research, news, and analysis from the University of Michigan School Public Health, visit Public Publichealth.umich.edu/news/newsletter to sign up. You can also check out the show notes on our website, Population-healthy.com. For more resources on the topics discussed in this episode. We hope you can join us for our next edition, where we'll dig in further to Public Health topics that affect all of us at a population level.

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