The Flaw Behind Everything Wrong With US Healthcare

If I had to say what the problem with our healthcare system is, it’s that the patient is not the client. Whoever controls the flow of money at the moment of payment is the client. That’s the side everyone builds processes around. We’re simply not customers in most interactions.

1. How Much Should We Spend on Health?

Patrick O’Shaughnessy

This is interesting. I have a first question based on our last phone conversation, where you told me something that really amazed me. What percentage of GDP do you think healthcare should account for in 10 to 15 years?

I think it should be as high as possible. I see people always complaining that it’s too much. They’re looking at the trees and missing the forest. Healthcare is a sine qua non, an indispensable condition of life. It’s something you can’t do without. Without it, nothing exists.

It really depends on how optimistic you are about AI, and your audience is probably quite optimistic. If you imagine life in conditions of complete abundance and the Jevons paradox, then the only thing in our lives that has no diminishing marginal return is another healthy year. So in the future, in my opinion, society should spend every dollar on your health.

When we look at the U.S. and say, “We spend 18% of GDP. That’s a problem,” my question is: why? We’ve never considered absolute numbers like that a problem. The question is whether we get what we want for that money. That’s the whole point of the Jevons paradox: market volume increases when the cost of a unit of production decreases. The difficulty is that in the U.S. healthcare system, costs are high because the cost per unit of service has increased.

We probably spend 50% of our money on healthcare for 5% of people. The U.S. doesn’t refuse anyone in this regard. Many people look at the U.S. healthcare system as a major anomaly compared to others. I believe the U.S. system is actually a preview of what’s to come in many other countries. Look at Great Britain: the share of GDP spent on healthcare increased from 6% to 12%. Look at Germany: it increased from 9% to 12%. In the United States, it increased from 9% to 18%. The same applies to obesity levels.

Returning to the question: what could be more important for society to spend money on? I can’t imagine anything more important than our health. But the return on these costs should be significantly higher.

Patrick O’Shaughnessy

So, going back to today’s realities, I’m very interested in your view of the system as a whole. You can imagine a graph of obesity levels that, for the first time in a long time, has leveled off or even turned in the other direction. I believe GLP-1 is the main reason for this, and of course it has greatly stimulated your business. Tell us more than just about that. Give us your vision of the state of affairs. What is healthcare like in the U.S. today?

You could record a separate podcast about this. It’s interesting to think about where the money goes. Usually, if you want to understand an industry, you just follow the money. Let’s say 30% to 35% goes to hospital systems, 20% to 25% to doctors’ offices, another 9% to 10% to medicines and pharmaceuticals, and the rest is distributed among other categories.

Many people bring this up when they return to our question about the percentage of GDP. I would say the American healthcare system is really fantastic, better than people think, especially in terms of emergency care. It is more expensive, but we have higher cancer survival rates than, for example, the NHS. If you get cancer, it’s better to be treated in the U.S., right? If you have a heart attack or a stroke, you’ll want it to happen in the U.S. Our survival rates are higher on average than in other OECD countries.

At the same time, we don’t consume more healthcare services than other OECD countries. We have fewer hospitalizations and shorter hospital stays. We have a few more procedures and surgeries, which adds up to roughly the same number of services, but our prices are higher, and the administrative burden is significantly larger.

Many people talk about life expectancy in the U.S. It hasn’t grown over the last 10 to 15 years. In many ways, I don’t think that reflects the work of our healthcare system. There are 2 main reasons we die. The first is like a fast clock, and it reduces average life expectancy in the U.S. compared to other OECD countries. That fast clock is death from firearms, car accidents, overdoses, and other things that lower the average.

But that’s not the main reason why we die. Most of us die because of the slow clock: chronic diseases. That number has grown rapidly over the last few decades, as you mentioned—over the last 20, 30, or 40 years. These 2 things really shape how diseases arise in the U.S., how people die, and how money gets wasted.

2. The Patient Is Not the Customer

Patrick O’Shaughnessy

Thinking about the system as a whole, what surprised you most? What do you think people may not fully realize?

I would highlight 2 things. First, I really believe our healthcare system has at least 1 fundamental flaw from which all the others flow. Second, the entire healthcare system is based on time horizons that are almost irrelevant to an individual person.

When you enter the healthcare system, a fundamental misalignment of incentives arises. I think this is what’s surprising. If I had to say what the problem with our healthcare system is, it’s that the patient is not the client. This is the problem we’re trying to solve at Ro, and I think you can see that it works. But it’s a fundamental problem.

The reason is that whoever controls the flow of money at the time of purchase is the client. That’s the stakeholder everyone builds their activities around. Patients, individuals—we pay for our medical care. We’re just not the customers in most interactions, right? Our own expenses are a smaller portion of total expenses. We pay through taxes and lower wages.

So you look and ask: where is healthcare working? Where does it feel high quality? It feels high quality where payment is made in cash, and where the patient is the client. My favorite example is laser vision correction. The cost is decreasing, quality is improving, and convenience is increasing. Look at breast augmentation and cosmetic surgery: the cost is falling, quality is improving, and convenience is increasing.

Look at GLP-1s. They’re a great contrast with the entire healthcare system. Politicians and regulators have been trying to achieve transparent prices for 20 to 25 years. What happens? Pharmaceutical companies go directly to the consumer. What happens to prices? As my mother, a loving Jewish mom, would say, the difference between the price and the net price is the spread. There are drugs priced at $1,300 for which people actually pay $300 to $400.

What happens when they go straight to the consumer? The gap between the price and the net price disappears completely. When people blame insurance companies, PBMs, and pharma, not knowing who to blame, companies go direct. You completely eliminate the PBM and the insurance company. Usually, branded drugs systematically increase in price by 6% to 8% every year until the patent expires.

I hope you can see that the intermediaries who do nothing are eliminated from the process. The companies can receive the same, if not greater, gross profit while prices decrease. If you look at Eli Lilly’s profits, prices are falling, but sales volumes more than offset that, right?

For me, a PBM is like an appendix to the healthcare system. Once upon a time it might have had some benefit, but that was so long ago that no one remembers why. When you remove them from the equation, software does the same thing they did before. So even with GLP-1s, we see the PBM disappear and the insurance company mostly disappear.

People can argue about whether it’s worth doing, but with cash payment, PBMs and insurance companies disappear. Prices fall from $1,300 to $149, and drug manufacturers make more money. You can see that where it works, the patient controls the situation and is at the center.

Usually people criticize this by pointing to information asymmetry. To me, it’s a bit like the best form of government: democracy is the worst form of government, except for all the others. In my opinion, the patient is the worst person to make decisions about their own health, except for all the other options.

When you enter our healthcare system today, you’re told there’s information asymmetry. You’re forced to sign everything without even reading what’s written there. But imagine that you had a choice—the ability to vote with your feet.

Hypothetically, as a society, we sometimes introduce laws requiring hospital price transparency, and people thought it was incredible. It’s like putting lipstick on a pig. No industry would survive if its prices weren’t public. Any company that operated that way wouldn’t get any customers. Instead of praising it, we should see it as a symptom.

If you ask how much you spend on healthcare for your employees, let’s say it’s $20,000 to $25,000 per person per year. If I magically gave them a credit card that could only be used for medicine, with $20,000 in expenses that carried over to the next year, plus some amount for emergency care, that would be the ideal form of insurance, in my opinion.

Businesses do this to make money for the client. If they don’t make their prices public, they won’t get paid. And if they do their job poorly, they won’t get paid either. One reason trust in medicine is low is that there’s almost no transparency, and providers don’t do what they promised.

People feel confident in medicine only when they control payment in cash, or when their insurance is accepted 100%, covers all expenses, and gives them funds, choice, and predictability. Ro’s idea is that if we can pool patients’ costs, I think we can make the healthcare system work in patients’ interests.

3. Inside Ro's Business

I’d like to use Ro as a great example, since you know all the data like the back of your hand. Tell us about your product line now and what its distribution looks like. What percentage falls into each of the main categories?

With pleasure. We have four main categories. Ro is a leading supplier of GLP-1 drugs in the country. Cardiometabolic health is our number one category, followed by sexual health, dermatology, and reproductive health.

The fastest-growing part of our business is GLP-1. People often say, “That’s what happened, isn’t it? We’ve grown over the last four years, going from approximately $250 million in annual revenue to over $3 billion.” We did it with fewer employees than we had in 2021.

What people often say is, “Well, that’s just a weight-loss medicine.” This really fascinates me, because these drugs were first approved to treat diabetes, then obesity and overweight, then heart disease, sleep apnea, liver and kidney diseases. Now they’re being investigated for neurodegeneration, pain management, addiction, mental health, and cancer prevention. The leading part of our business is treating the leading causes of death for people on the planet today. That’s the “slow clock” we’ve been talking about. That used to annoy me, but now it’s like a badge of honor. This is definitely the fastest-growing and leading part of our business.

I’d like to spend a few minutes on each of the four leading categories, starting with GLP-1. Why are you so effective? What did you do to become a leader? Why don’t people just use the new direct-to-consumer services from pharmaceutical companies? What is it about Ro that made the company the best choice for getting these drugs?

That’s a great question, because people often ask about competition and differentiation. There are many different ways to talk about this. First of all, as you said, the results speak for themselves, don’t they? Ro is a leading supplier of GLP-1 in the country. We enroll probably 2, 3, 4, or 5 times more patients every day than our competitors, so clearly there’s some difference.

When you think about differentiation, people often want a specific answer, and I’d be happy if there were one. For example, we offer this feature, but someone else doesn’t. I could point out that Ro is the most affordable way to get started. Ro also has the best formulary. We’re integrated with both Novo and Lilly. Ro offers cash payment, and we help people check their insurance. We’ve already helped over 1% of the U.S. population check their insurance for free, entirely with the help of AI. You can order delivery straight to your door, or pick up the medicine in person.

We also work with our pharmaceutical partners to offer multi-month subscriptions, allowing patients to save $600 to $1,800 per year. That’s not available everywhere, is it? For many people, the membership pays for itself.

But the truth is, in my opinion—and I firmly believe this—the only source of differentiation is constant innovation. We have to keep looking for the next step and invent new ways to check. If the companies you love, like Apple, Amazon, or Google, stopped for 6 or 12 months, you’d see it. You see it in the AI race: every 4 weeks, a company appears that’s ahead of the others. If you stand still, it’s great for consumers.

That’s what I like about consumers: I love competition, especially in healthcare, because we have to fight every day to keep serving them. When we founded the company and built our technology, we built an electronic medical records system from scratch. We created our own CLIA-certified laboratory, accredited by CAP. We built our own pharmacies and pharmacy software. We created our own network of provider services. All of this is seamlessly integrated and built to be independent of any specific disease.

We built this incredible platform over 4–5 years before the advent of GLP-1 drugs. We’re very focused on this, but we were able to scale quickly. So when people think of us in the context of individual states, they should think of us as a world-class platform for providing medical care and treatment: fully vertically integrated, with software designed to help patients achieve their health goals.

Is there anything interesting to say about maintaining access to drugs like GLP-1, which are made by a few companies rather than 50? Is there anything interesting about that dynamic? With relatively few suppliers, you’d think they have some power and could take a larger share of the total margin earned by all the companies serving customers with GLP-1.

4. Pitch Me on a GLP-1

I think your assumption is correct. By the way, I think that’s how it should be. The developers of GLP-1 should earn more. They should get more margin than those who scale access to it. I think that’s mostly what we see, with some demand aggregators. Retail is a good example. It’s not ideal, but maybe Costco is another example, right? They can have 15% margins on the product itself. They get more of their gross profit from membership, but they have an incredibly sustainable and scalable business. In this case, there’s a lot of value for both suppliers and customers.

Is the demand aggregator Ben Thompson’s idea? Is that how you think about this business?

I think so. I’m sure he’d give a more academic answer about why we don’t do this, because service doesn’t come free to the next user. But I think pharmaceutical companies choose us because we put patients’ desires and needs first. You’ve seen how other companies set their priorities in this area. They put business above patient treatment outcomes, and they’re not as big.

Patients turn to us knowing that we’ll help them find the medicine they need and the right treatment and dosage, based on their priorities around cost, quality, and convenience. That’s exactly what consumers care about. I think that’s why we succeeded in integrating with both leading pharmaceutical companies: they know that we always want to compete in the market over who serves patients better in these areas. We contribute to this microcosm of the market.

5. The Future of GLP-1s

What do you think the impact of GLP-1 drugs will be in the future? A lot has been written about what they’ve done so far, about flattening the obesity curve. The data is very interesting. But when you think about the future, what percentage of Americans are taking these medications? People say somewhere between 10% and 15%.

What do you think the promising story for the GLP-1 drug class will be? I’m interested in both the broader impact and the generation of technologies that’s emerging. The new ones coming out soon seem very exciting. I’d be happy to hear your thoughts. What do you think this story will look like next?

There’s an impact on individual health, an impact on the healthcare system, and a social impact. We’ve already talked a little about the impact on individual health, but these drugs act on the causes that lead to the major fatal diseases, don’t they? They’re approved for diabetes, obesity, liver disease, kidney disease, sleep apnea, and heart disease.

They’re already approved for all of these conditions. Four years ago, they were only approved for diabetes. The impact is colossal.

There’s also an impact on the healthcare system. I think these drugs are fundamentally changing it. Industries get restructured when a large number of buyers worry about one thing for a long time. We saw how much of the healthcare system changed during COVID, when telemedicine suddenly became acceptable. One specific example: many states relaxed regulations, allowing medical professionals to treat people across state lines.

One of the problems with our healthcare system is a fundamental shortage of supply. We have too many people who need help and not enough people who can provide it. One of the things we’ve tried to do at Ro is turn a luxury into a commodity, turning a service into a product.

COVID is over, and we’ve suddenly returned to the idea that when the human body crosses a state line, everything changes dramatically. You’ll see how GLP-1s change the system. They’ve already started to change it. Ask why your employer decides what’s covered by your health insurance, when that decision has such a huge impact on your health.

Going back to the incentives problem we discussed earlier: your employer cares about you. You care about your employees. I’m sure of that. I care very much about our employees, but the employer cares about many employees for a shorter period than their lives. A person takes care of themselves, and perhaps their family, throughout their life. This mismatch in incentives naturally leads to suboptimal results.

What you’re seeing with GLP-1s is that they’re the most popular drug, or class of drugs, of our time. A growing share of spending on the most popular drugs is paid in cash. Patients can vote with their feet. What happens? All the things regulators have been hoping for a long time: prices become transparent and go down, competition increases. It’s all happening surprisingly quickly.

The third and last thing is the social impact outside the healthcare system. If I can digress a little about that: the reason we founded Ro is very personal to me. I deeply believe that when we help patients achieve their health goals, we help them realize their full potential. If we do that at a societal scale, we help realize humanity’s full potential.

I was very lucky. I grew up with a father who was a doctor, and he saved my life. I have a congenital heart defect. At 18, I had heart surgery, but my dad helped me achieve my health goals so I could pursue my life goals. He helped me get through that procedure. Immediately afterward, a main side effect of my heart medication was erectile dysfunction, which is obviously a horror for every 18-year-old college freshman who has to call his father. My dad helped me cope with that.

I’ve never said this publicly before, but when I was 12, I hadn’t had a growth spurt. I was already quite short, I was bullied, and my parents struggled with the healthcare system to get insurance coverage for growth hormones. So I injected myself in the leg every day for 6 years. When I went to high school, I was 142 to 145 centimeters tall. I graduated at 185 centimeters.

From my point of view, there was another possible scenario: at 18, I could have been 160 centimeters tall and had erectile dysfunction, which would not have been pleasant. Instead, I’m 185 centimeters tall and married to the most amazing person in the world. I believe that happened because my parents, and my dad, kept fighting the healthcare system. They put me on a completely different life trajectory.

Whenever we, as a society, fight the basic causes of death rather than the consequences, we see how radically the shape of society changes. From year 0 to 1800, average life expectancy was 30 years. Some people will say, “Yes, it was because of infant mortality.” Yes, there was infant mortality, maternal mortality, and infectious disease. Those were the 3 main factors.

What happens when we successfully fight infections, infant mortality, and maternal mortality? People no longer mourn the loss of children and wives every day. They invest in the children they have. Those children go to high school and college. Women enter the labor market. We get the Industrial Revolution. Forty percent of the population working in food production moves into other areas. Electrification of homes rises from 10% to 100%. I believe all this happened because health is a prerequisite for progress.

Today, if we consider the main causes of death I mentioned—chronic diseases—and we can fight them in their early stages, I believe we can change the trajectory of our society in beautiful ways that are impossible to predict. I can’t wait to see what happens next.

What do you think? If you had to predict the percentage of people who will use GLP-1 drugs in 10 years, what would you forecast? Could it be 10% to 15%, or over 50% of the population? Do you think this will become the norm, regardless of whether people have the acute forms of disease listed in the indications?

Yes, certainly. I’m curious about this: if you look at the raw numbers, 75% of the U.S. population is overweight or obese. On that basis alone, this group clinically meets the criteria. That’s the bottom-up approach. What about the top-down approach? What percentage of the U.S. population is metabolically healthy? Ten to 12%?

People may be interested in taking these drugs for prevention, perhaps for inflammation or as geroprotectors. Of course, there are people who shouldn’t take these medicines, or may not tolerate them. But as tolerability improves and we gain a better understanding of their mechanisms of action, I think we’ll see them fighting many of the environmental and genetic factors behind chronic diseases in modern society.

6. Jobs Over Lives

The huge question is accessibility. But in my opinion, most people will accept them. I think statins are a good comparison. They’re prescribed to around 40 to 50 million people, and these drugs are much more effective simply because of the breadth of their action.

Before concluding this section on the state of the industry and the system, I like the idea of “jobs versus lives” as a frame. Tell me what you think about it.

This is one of those topics that can cause controversy, but we can discuss it. There’s an ongoing discussion in healthcare. I think you see it in other industries, too, where people say medicine has to remain human. I think that’s the wrong question. It’s not that I don’t believe some parts will remain the same, but this obsession with methods instead of results means you’re not putting patients’ health above all else.

I believe tools like people, as well as new technologies, have to prove their effectiveness. The status quo shouldn’t get carte blanche just because it exists, right? I think driverless cars are a great example of how we’re having a rather strange discussion. Every year, about 40,000 people die in car accidents. That’s almost the same number of people who die from breast cancer every year. It’s madness.

Driverless cars have been shown to be 10 to 20 times safer than human drivers in certain situations. So we have cures for certain types of cancer, but the discussion isn’t about how to speed up their implementation. It’s mostly focused on job losses. I don’t want to belittle the problem of job losses. But we shouldn’t, and we can’t, put work above life.

We were talking about cancer cures, and someone said, “What about those who are currently treating cancer patients without these drugs? I don’t even know if they could…” That was the most absurd idea in the world.

There’s a story I heard from the CEO of a driverless car company. They spoke with a regulator, and when they told him about the reductions in mortality, the regulator asked, “What about organs?” The CEO was shocked. The regulator was referring to the bodies of people who die in car accidents and can save the lives of others. A beautiful thing. I don’t know if the CEO said this out loud, but at least he answered me, and I thought: I hope they remain in the body of the original owner.

Of course. As a society, especially in matters of protecting health, we should put the result above the process. The new approach has to prove its value. That doesn’t mean technology automatically gets carte blanche. It has to prove that it’s much better than the current state of affairs, not just 1% better. But we also can’t let the current state of affairs go unchallenged.

I think we’re seeing this now with driverless cars. This is a very painful conversation. I really believe that people who hinder the introduction of driverless cars where they’ve proven their safety have to bear responsibility for human casualties. I think we’ll look back on it that way.

One of my biggest concerns about healthcare is that we’ll continue to put process above results. There was a great chart a few days ago that compared total revenue from GLP-1s with income from AI.

And it is bigger. GLP-1 revenues are much higher. It’s just madness.

There are 2 interesting things here. First, not only is the revenue from GLP-1 larger, but twice as many people pay for GLP-1 as pay for AI.

Yes. From a consumer perspective, that seems to give you the answer. I think this is a problem with the current narrative around AI: insufficient impact on everyday consumption. I hope this gap between AI’s real impact and its impact in real time on tens or hundreds of millions of people will be overcome.

7. The Turnaround

I would like you to tell a story about this incredible turn in the development of your company. It’s been around for 9 years, and about 4 or 5 years ago, you went through a really exciting period. You mentioned this number casually before, but the company became 10 times larger than it was not long ago. Of course, GLP-1 plays a big role in that, and the company’s charts look almost like GLP-1 charts. That’s one explanatory factor, but there’s a fascinating story behind it that I’d like you to explain in detail.

When I heard it from you before, I thought it was a very cool and interesting example. I know you’re ready to be candid about the details of entrepreneurship. It’s easy to say, “Oh, cool, $3 billion, that’s great business,” but it’s been 9 years and so much sweat, blood, and tears to get here. Maybe tell me that story.

Yes. It’s cool in retrospect and quite painful in the process, but I agree with you. It all started when I realized we needed a reboot. We actually started the company anew in the summer of 2022, but we made the decision to reboot in December 2021. I was on a plane flying to my parents, looking at my laptop and analyzing the previous year’s metrics.

11 months earlier, in January, we had raised $500 million at a $5 billion valuation. We had made almost all the typical mistakes a company can make. We confused our long-term vision with our short-term strategy, so we decided to do everything, hire everyone, and try to do everything at once. It was a disaster.

People ask, “How did you not notice this while it was happening?” Sometimes, when you look at quarterly or annual results, or take a moment to reflect, it hits you like a thunderbolt. I was on that plane looking at the numbers, and we had grown by only 9% in 2021. We had hundreds of millions of dollars in our accounts, and we spent them. We were what I’d call a zombie company: you don’t grow fast enough to break free, but you don’t spend enough to go bankrupt. You just walk around like a zombie.

We also had debt that could crush an elephant. It was something like $800 million. I was sitting there, having worked 70 or 80 hours a week for years. Our team had worked so hard for our mission for 5 years, and we might not even be able to cover our debt. It was a difficult flight.

At that moment, our HR department sent a wonderful Christmas gift to every employee. This was 2021. We were trying to do everything right. It was a business from New York, run by women; they made macaroons, and they were beautifully packed in plastic. As I was flying home for Christmas, I saw a comment in a general Slack channel that sends messages to the whole company. Someone wrote, “People, next time we give gifts, can we do without an ocean of plastic?”

I was so angry. Steam was coming out of my ears. I wanted to reply, “To all: you are dismissed.” Thank God for the bad Wi-Fi on the plane, because I didn’t send that message. I just looked at it.

My first realization was bad, but the second was much worse. First, I was annoyed with this person. Second, I was even more annoyed with myself, because no one cares about packaging when the company is winning, right? We were, literally and figuratively, soft as pasta. We were such a “soft” company, and I was raised in a completely different way. This wasn’t what the company was for. This wasn’t our corporate culture. It was terrible.

That’s why I moved away from analyzing the financial results and wrote a 6-page note to my co-founders. The gist was that I deeply believed in our mission and vision. We had created an incredible technology platform, and we had amazing people. I believed in our foundation and that we could fulfill our mission, but things were going wrong.

The best way to fix it was to fully embrace a culture of strong attraction and strong rejection. With great people, a technology platform, and resources, I was sure we could change the world. If you disagree, we need to discuss it. If you agree, then in 2022 I’ll begin to act decisively. Fortunately, they agreed.

Then came January 2022. From January to May, we said goodbye to about 7 vice presidents. From May to June, we reduced the company’s staff by about 20%.

I have to say this because I feel obligated to: there’s a strange Silicon Valley fetish for layoffs. I think there are too many of them being encouraged, if you know what I mean. When this happens, people seem to applaud it. For me, it would be much more effective never to bring it up.

Secondly, this is the worst part of the job: depriving someone of their livelihood. And that doesn’t mean I don’t relate to these people. Third, I’ve already mentioned the vice presidents and the 20% of staff. But I firmly believe, returning to the idea of “strong attraction and strong rejection,” that it works. These aren’t just nice words; they’re an important component of cultural fit. It’s not only about whether someone is talented or smart.

While I was in college, I interned at Booz. There were 12 of us interns. 11 got jobs, and I was fired after 4 weeks. I didn’t even know you could fail a consulting internship, but it happened. After 4 weeks, I was consulting for a company like the Yellow Pages. I was fired, suspended from work, and given paperwork; after 7 weeks, I was asked to leave. I believe there can be talented people who simply end up in the wrong environment.

We said goodbye to 20% of the organization. Then my co-founder Rob—we were 3—passed the baton for the next stage of the race. It was just me and Saman left. I really respect Rob for that decision and for recognizing the situation. He’s still on the board of directors, by the way. We’re still close.

Then we founded the company anew, which involved several things, including relying on the best specialists. We brought everything under the Ro brand. We used to be Roman, but we had gone beyond men’s health. We removed the word “man” and brought all our brands together under one Ro brand.

We radically changed our approach to work, including introducing new principles. One of them was to say openly: work hard. When we presented this principle, people asked, “Do you mean ‘work with your soul’?” I answered, “That’s a separate principle.” I clearly mean work hard. It’s not ambiguous.

Then we said, “Here’s our new culture: strongly attract, strongly repel.” We were very frank. We said, “Look, we take full responsibility for not being clear, both about what we build and how we do it.” Of course, a culture of strongly attracting and strongly repelling is like the best products, music, fashion, or media: they either attract you strongly or repel you strongly. The very reasons you love something might be the reasons someone else hates it. That doesn’t make them better or worse people.

The best analogy for me is a restaurant. For example, a steakhouse. Don’t go to a steakhouse if you’re vegan, and don’t go to a vegetarian restaurant if you’re a carnivore. That doesn’t mean Ro doesn’t accept feedback. We love feedback. We simply draw a clear distinction: if you give me feedback at Ro, I’ll tell you whether it’s a feature or a bug.

Bugs are what we’re trying to eliminate. Features are what we develop. You shouldn’t go to a steakhouse and say, “Hey, replace this steak with mushrooms.” You should say it’s a feature, not a bug, that it serves meat. But if you say, “Hey, I ordered medium rare, and it’s well done,” that’s a bug. If someone tells me they lack context for their work, that’s a bug.

By fully embracing a culture of strong attraction and strong rejection, and making the menu of this “restaurant” very clear, we’re fighting for the right to work. Work is a gift. People spend most of their time there. It was important to me to create a culture of strong attraction and strong rejection, which means having extremely diverse experiences and expertise, but a consistent way of working.

At Ro, we work in one way. Our “what,” “why,” and “how” are very clear. We made that clear and offered people the choice to join or leave. Another 6% or 7% of people decided to leave.

It was September or October 2022, and we had grown by 100% every year for the previous 4 years. There were 600 of us when I was on that plane. Now there are a little over 400 of us, and we’ve grown the business 10 times. So we grew 10 times with 30% fewer people.

I’m curious what you associate that with. The company had become “soft” before that moment of rebuilding. As advice to others: don’t do that. It led us to problems.

The first 100 people we hired were people we already knew or had worked with before. Our culture was shaped by osmosis. If I had to describe our culture, it’s extremely high productivity and a big heart. They’re not just balanced.

They’re both at maximum. If you come with a big heart but aren’t performance- and metrics-oriented, you’ll think I’m a fool. If you’re extremely productive but don’t have a big heart, you’ll find our style sentimental and strange, and ask why we spend time on this. But both aspects are at their maximum. That rare duality is how I was raised.

That’s exactly what our culture was like at the beginning, but we didn’t talk about it directly. We were like a restaurant that simply says, “Come when you’re hungry.” We serve you the food and then give you the menu. The best advice I can give founders is that the best corporate cultures, in my opinion, strongly attract and strongly repel. The culture knows who it is and keeps trying to consolidate its advantages and eliminate its disadvantages.

But you must be clear in describing what it is, so that you understand it and everyone else understands it, and then be steadfast in defending it. My co-founders and I lost control, which frankly allowed other people to define too strongly what the company was like. Although we hired very good people, we owed them a much clearer explanation of the “menu” than we gave them. I take full responsibility for that. I think founders should do that.

The most important turning point for me was realizing that I would never give up. Once you, as a founder, understand that you’ll never give up, you have to make your company a place where you love to work. You and your co-founders are the only people who can really create that. That’s what I mean when I talk about protecting this force.

So, returning to the idea of growing tenfold with two-thirds of the staff: what proportion of that came from favorable conditions? What fraction came from people working more efficiently because of technology? You wouldn’t see that level of growth over this period without riding a huge wave, right?

There’s a reason we’re the leading supplier of GLP-1 drugs in the country by a noticeable margin. If you look at credit card data, we engage two or three times as many customers as the companies in second, third, fourth, or fifth place. We’re riding the same generational wave as the others, but we’re doing it better than everyone else.

I think it’s similar to how you compared GLP-1 with artificial intelligence: Novo and Lilly compared with OpenAI and Anthropic. There are many companies besides OpenAI and Anthropic that have those opportunities, but haven’t made the most of them. Anthropic is so young—I don’t even know how old they are. You really need to catch the wave. It’s like surfing, and you’ve probably realized I love analogies: you need to catch it. Catching a tsunami is really difficult. Other people let it pass beneath them or get swept under by it.

What other underrated ways have you used to do this?

First, I think you can build anything if you have the best talent. So we bet on our top performers. We constantly invest in the best people through compensation, promotions, coaching, and resources. Of the 400 people currently at Ro—we started with more than 600 and reduced the team—I’m deeply convinced that ours is the best team in the industry. That’s the most important thing, because an incredible team creates powerful attraction and culture.

8. Recreating His Dad in Software

Another thing is an insane level of focus. We focused on building things sequentially, not in parallel. Jony Ive talks about this, and Frank Slootman mentions it too. You can accomplish much more than you might think when you build everything sequentially instead of in parallel. There’s a pull to do everything in parallel because it seems like you’re making visible progress on each thing in a short period of time. So you have to be patient.

If you have a 90-day horizon and want to build five things, you can move each one forward a little and see progress on all five plans after 90 days. But if you focus on just one, it will have gone much further and made a much greater impact. It’s like working only on the first 10 years of the compound interest curve and never reaching year 30. It’s terrible; you lose all the benefits. But if you have an intense level of focus and do things sequentially, each one builds on the previous one. We were strongly inclined toward a sequential approach instead of a parallel one. That was one of those things: this crazy level of focus. Almost no one in the whole company was context-switching.

It all started because I felt we weren’t moving quickly enough, sometime in December 2022. Right after we launched our beta program, I introduced daily meetings at 8:15 a.m. with the entire leadership team. We met every day at 8:50 for two years straight. Could it have been 10 minutes? Could it have been 15 minutes, or 5 minutes? Could it have been an hour and a half, while we worked through everything we needed to do, got aligned, and made all the decisions that needed to be made? That’s what it ended up being.

It’s very difficult when we’re talking on Monday at 8:50 and you say, “Great, I’m responsible for the next step.” You can’t come in on Tuesday without moving it forward. You definitely can’t come in on Wednesday without making progress on it. But if we meet on Monday and don’t see each other again until the next Monday, so much else can happen: “Oh, I got distracted by this, and this is important. I didn’t know which thing was a higher priority.” You can’t do that within 24 hours. The organization’s speed and consistency of action were unparalleled. We’ll do this whenever we need to accelerate certain teams or initiatives.

Another thing I think we did was reject long-term roadmaps. That’s quite painful for people, and I tell them they think we’re crazy. I wouldn’t recommend this to every company. When people hear it, I ask them not to miss the main point because of the details. It doesn’t mean nothing in the organization is planned more than six months ahead, and it isn’t an excuse for a lack of rigor.

Actually, it’s because in an era like ours, when industries like GLP-1 and AI are changing so quickly, spending a lot of time on long-term roadmaps is like printing road maps instead of using Google Maps. It’s false precision and a huge waste of time. Any new detail that changes course can make steps three through 17 instantly irrelevant, and you’ve wasted a lot of time. You’ll understand steps three and four much better once you’ve completed steps one, two, and three.

So I think we’ve learned to live well with long-term uncertainty as an organization, while maintaining short-term precision and rigor. I think it’s similar to your concept of avoiding excessive goal orientation. Our long-term goals and visions are very general, simple, and unchanging: we help patients achieve their health goals. When we do that, we reveal the full human potential. We do it on a grand scale. We unlock humanity’s full potential.

In the short term, and day to day, we can react to the data we see. We can react to what patients tell us, to inventions of new treatments, to changes in regulation, or to the emergence of AI. It lets you be, as the cliché goes, unwavering in your vision but flexible in the details.

9. Where Healthcare Goes Next

Yes. Fantasize a little about where you think we’re headed as a healthcare system in the U.S. So many amazing companies are discovering medicines using AI. I’m sure the medications that help you fulfill your mission for customers will multiply at an incredible rate. Where do you think it all goes?

I think we’re at the beginning of this patient revolution. I really believe that, partly because of the systemic failure that’s happening. There are three tailwinds. There’s a tailwind for GLP-1, but I actually think there are three for our business.

The first is that human biology is becoming digital. That includes everything from symptoms reported by patients themselves to tests, genetics, and medical data. Your biology is becoming available online. That’s the first tailwind: biology becoming digital.

The second is that what used to require a specialist now requires only a prompt. When we first started, people would ask us, “Can I get a doctor online?” They significantly underestimated how imperfect the existing healthcare system was, how burned out and tired doctors were, and how much people needed an alternative way of life. We have highly qualified doctors who can work from home and see their children, just as we do. We see this in tech today. But it’s interesting to watch investors’ attitudes change: they pay $100,000 a year for a personal doctor, and $20 a month for Claude, which is much better. What used to require a specialist now requires just a prompt.

Third, there are now treatments that radically change the quality and duration of people’s lives. They’re just unevenly distributed, right? There’s a phrase about how the future has already arrived; it’s just unevenly distributed. Think about Ro as the largest GLP-1 supplier in the country. We’re starting to ask ourselves questions like: Why do men lose less weight than women when they’re not taking GLP-1? Why do people of Latin American descent lose less weight than white people? Why do some people lose 35% of their body weight and others only 5%? Why do some people experience side effects while others don’t? You add genetic data, wearable device data, continuous lab tests, and data provided by patients themselves.

You add all this up, and the question you constantly ask yourself in medicine based on trial and error is: Can you catch the weakest signs of illness? It’s like a barely audible whisper, isn’t it? If you can, you can change the trajectory of treatment.

These three driving forces—the development of biology, AI, where what used to require a specialist now requires a prompt, and existing and new treatments—allow you to transform personalized care into a service accessible to everyone, which could create a revolution for patients. And I think we can go even further: not just personalized care online, but a completely new form of health protection for the price of a Netflix subscription.

I think you’re on a GLP-1.

Yes, I am on a GLP-1.

What’s your suggestion for someone? Convince me. I’m not on a GLP-1. I guess I wasn’t usually the type of person who would use it. How would you present this technology to people who are interested in it?

I’m a big fan of a comprehensive approach: diet, exercise, sleep, medications, supplements, and community. Those are the basic things you can do for your health.

Returning to motivation structures: the time horizon over which I want to reduce my risks is radically different from how a typical health system assesses risk. They measure risk over 10- to 15-year time horizons. I’m pretty sure I’ll be fine at 45. I worry about 55, 65, and 75. Many chronic diseases are “area under the curve” problems. How long have you had elevated LDL levels? How long have you been living with metabolic dysfunction or insulin resistance? These are area-under-the-curve problems.

I wouldn’t say you must take a GLP-1 agonist. First, you should determine what your health goals are. Then you evaluate your family history to understand the risks and benefits, and whether you’re ready for them. Finally, ideally, you work with a specialist to understand what combination of treatment methods is right for you.

I’m not giving that answer as a “consult a doctor to find out what suits you” disclaimer. It’s because that’s how it’s supposed to work. My “health stack” has been built over the last 10 to 15 years with my father. We conducted A/B tests on various drugs, added and removed some, and measured blood counts and other metrics to adjust everything to my goals.

My father had his first heart attack and stroke when he was only 39 years old. He was forced to stop practicing medicine. It became a kind of blessing and burden at the same time: on the one hand, it took away what he loved most; on the other, he became a father who was home, and I was able to spend a lot of time with him.

In many ways—and I’m sure a psychotherapist would have a lot to say about this—I feel like I’m trying to replay it using software. I’m trying to give it my all and preserve his life forever in one form or another. As a result, I became very aggressive in fighting heart disease.

When I was about 30, my cholesterol was 230, my ApoB was over 100, and my LDL was 130 to 140. I watched my diet, played sports, and did everything within my power, but my genetics demanded additional support. So I started taking statins. Then I added Zetia, the brand name for ezetimibe. Later I added Repatha, which we talked about, and then a GLP-1.

My LDL went from 130 to 70 or 80, then down to 60 and 10. My score went from 90 to 62. When I get my ApoB results, there’s a “less than” sign. I’m very proud of this. I’m ready to be disproportionately aggressive on this issue compared with the average person.

For me, this is the conversation that should ideally be had: What matters to you? What are you trying to achieve? What risks do you face? Then you analyze the risks and benefits of every decision.

I’m very interested in LDL cholesterol and area under the curve. Fortunately, there’s no family history of heart disease, but I take Repatha because my LDL levels are very high. You and other people convinced me it was worthwhile, along with some wonderful doctors. Let’s focus on this example. You’re taking several medications to lower your LDL from 130 to 10. In your opinion, are there trade-offs involved? How do you assess what the benefit is? Perhaps it’s years or quality of life, but how much? And what costs or risks are associated with it?

Each of them has its own risks and benefits. I adjusted the dosages so I wouldn’t experience side effects from any of them.

When I started with statins, I experimented and first asked myself: Should I increase my statin dose? Is it worth adding Zetia? Should I add Repatha? I tried each of these drugs separately, stopping some and adding others to see the marginal impact and whether I could detect any side effects, whether they were dose-related, whether they were related to the drug, or whether they might come from a combination of treatments. Together with my doctor, I managed to find the right treatment regimen.

As in any case, the downsides are costs and side effects. I also think about the asymmetric risk of having a heart attack or stroke. For me, these medications are safe, the side-effect profile is very favorable, and they cost several hundred dollars per month. That’s worth it to reduce my risk of heart disease by whatever percentage they ultimately do.

Maybe this isn’t true for everyone, but I think Repatha is a great example of how I hope prices will come down. When it went direct-to-consumer, the price dropped from $600 to $200 a month, right? It fell by 60% to 70%, and hopefully it’ll go even lower.

A new oral drug is available: a PCSK9 inhibitor. In fact, it’s an oral peptide inhibitor of PCSK9. The way it was discovered is a great example of where AI can be extremely useful in health care.

AI is very good at what we all know: situations with a lot of structured data, a verifiable reward, and a very tight feedback loop. That’s where math and programming thrive. The problem with medicine is that it relies on trial and error. A lot of the data is unstructured, and the feedback loop—outcomes like death or heart disease—takes a long time.

PCSK9 is a great example of how we might do this more often and faster. There was the Dallas Heart Study in 2000. It had about 3,500 patients, half Black and half white. These patients underwent genetic testing and imaging and received constant care. In 2006, after six years, researchers realized there was a group of people in the study with a defective PCSK9 gene. Their LDL levels were 30 to 40, and their risk of heart disease was reduced by 85% to 90%, regardless of what they were doing. They could drink, smoke, eat cheeseburgers—whatever. They didn’t die of heart disease. They could have died from something else.

From 2006 to 2015, Amgen developed Repatha, an injection given twice a month. Now there are others administered monthly or once every six months. This year, Merck developed an oral peptide that received approval. It’s an oral PCSK9 drug.

From 2000 until 2026, almost a quarter of a century, it took to invent an oral version that imitates that “defective gene.” But if you take it early enough, it can largely prevent and eliminate the leading cause of death in the U.S. This is incredible, isn’t it?

But it took six years from genetic testing to detecting this defective gene. That’s 6% of a century; it took 26% of a century to release the drug. That’s too long, right, if you think about the number of lives that could be saved? I don’t want to sound too sentimental, but this is similar to your question about the kindest thing anyone has ever done for you.

When I heard your answer to that question, she was beautiful and strong. You said the reason you care so deeply about this is that these small acts of kindness can change the trajectory of someone’s life. The question is whether it’s possible to do the same with health, so that it takes only a small push at the very beginning of a disease. I think it’s possible. I think we can start doing it.

I think we’re on the verge of another change, like the period from 0 to 1800, when average life expectancy was 30 years. Over the past 70 years, we’ve gone from about 71 to 79, right? How do we get to the next big jump? I think we can achieve it.

I want to ask you for more details about your comment that you were trying to recreate your father in software. Tell me more about that.

He changed my life in many ways. It’s hard—I’ve never been asked clarifying questions about this. It’s difficult to put into words the impact he had on my life and how much he inspires me.

Deep down, I believe the best way to positively influence the world is to give people more healthy, happy years. If they succeed, they’ll be able to achieve their life goals. I grew up with a man—my father—who dedicated his whole life, every second of every day, to giving people extra years of healthy life. He believed in this so deeply, and I believe in it too. This is what he was born to do. I saw up close the impact he had on me and my loved ones.

I like the written word, and I love technology because it’s incredible leverage. I still read books written 2,000 years ago, and technology has scale: a small group of people can have a huge impact on the world. I saw my father’s influence on my loved ones and me, but he was limited in who he could talk to directly and whose hands he could hold. If I can reproduce what he did using software, operational processes, and technology, and give it to other people, then for me personally—I’m sure it’s different for others—it would be hard to imagine a life lived better than trying to do what he did for many, many people, for millions of people.

Can you tell me more about the idea of “what you were born for”? What have you noticed in people who seem to have found that thing? Why do you believe it exists, and what is it like to be in that state compared with periods of your life when you weren’t? Is there anything else you can share about this idea?

I think a lot of stories make sense only in retrospect, not while they’re unfolding. I’m not sure I felt, when I was young, that I was born to do what I do now. But looking back and analyzing my path, I see that everything makes perfect sense.

I think the same about my wife. She runs a YouTube channel called Huge If True. It’s one of the best and biggest channels. I’d even say she’s the best journalist on the internet. She’s very talented—very, very talented. She’s definitely my better half.

It’s incredible that when she explains why she does what she does, she says, “When people see a better future, they help build it.” People always ask her, “Why did you get into this? Do you like explaining things to people?” She realized only later that she must have been born to do what she does today.

She grew up in a family of lawyers. Her father was a corporate lawyer, but he also took on cases pro bono where people faced the death penalty. He discussed those cases over dinner with Cleo when she was little, from age 9 to 12. He was obsessed with opening and closing arguments, every little phrase. She saw that if you can explain something to a group of people—12 people who are your peers—in a way that helps them learn something new about the world, you can change the course of someone’s life. That’s why her father was so enthusiastic about his work.

She grew up in a home where they understood that education and the ability to teach people in a powerful, simple way can change the future. That’s why she still wakes up thinking she can try to do this on a global scale. As we said, because we’re both founders, looking back, you understand how you got to this point, but it was less conscious than feeling it was your destination.

Maybe you could say more about the benefits of finding that kind of work—about how it feels when you work on it.

Oh, it’s a real gift. You don’t feel like you’re working. It’s so inspiring. I fly to work every day like I’m on wings. My team knows that on Friday, you never have to say, “Have a nice weekend,” because I’ll answer, “I can’t wait for Monday.”

I don’t think there’s a greater gift than working with other people to positively impact the world. When you find it, of course there’s personal and professional life, but when you achieve harmony between them and don’t feel like you’re “working”—that’s a strange phrase to me. It’s what we spend most of our waking hours doing.

That’s why I believe talented people at Ro are a gift. We deserve this gift, and we take this responsibility very seriously. When you find a job that feels meant for you, you stop thinking of it as work. You just follow the call of your mind.

10. Marketing Into Stigma

One of the interesting things today is that not many wonderful, well-known consumer businesses emerge. They’re extremely difficult to build, but when you have consumer distribution, it’s one of the most powerful things in business. If I go back to that initial beachhead—Viagra or other drugs—let’s talk about all the aspects related to that first beachhead.

That’s a great question. In healthcare, there’s a startup graveyard where people focus only on needs, needs, and more needs. I think the main thing we’ve always believed at Ro is to start with what patients want and find common ground with what they need. It’s not about just giving them what they want while ignoring what they need. We find the intersection.

It’s important that we start with “I want” and find common ground with needs. If I went to your doctor and said, “Hey, Doctor Patrick, what does Patrick need?” Of course, they’d confidently tell you what you need. If I went to them and said, “Hey, what does Patrick want?” they’d say, “I don’t know. You have to ask him.” That naturally puts you in a patient-centered, selfless position, where you serve what the patient wants.

That’s how we attracted consumers in healthcare. We were prepared for the fact that we wouldn’t be understood. When we first started, The New York Times called us “medicine by restaurant menu,” as if that were something bad. I thought people get great experiences in restaurants. You come in, get a menu with prices, and choose what you want. We were comfortable not being understood, as long as treatment results and the patient remained at the center of everything we do.

People often ask us, “How do you assess the risks in the company?” I always answer, “Never at the cost of the patient’s health, but always for the patient’s sake.” As a company, we’ll take a risk if we’re fighting for improved patient treatment outcomes. New things, data, new models—they always have a higher burden of proof, and that’s right. So we provide data. We’ve published data about results and our response time to side effects.

Every time you send a message to Ro, a neural network processes it and analyzes the topic and issue. If you mention a side effect, we structure it, create a task, assign a medical specialist, set SLAs, and respond to side effects within 30 minutes, 24/7. This is a completely new form of health protection. If you want to shake up the system, you have to provide evidence.

Regarding marketing, I starred in commercials myself at the beginning. It wasn’t that I said, “Hey, I need to be a CEO who does self-promotion.” This is my first major podcast in 9 years. I acted in the commercials because marketing, as we understand it, has 2 components, and we still follow that approach today.

We often say that data is needed to influence the mind, and stories are needed to touch the heart. To influence a person, you need both. That was one component of our marketing: challenging people’s perceptions of who might have erectile dysfunction.

The second is that good marketing, especially in stigmatized areas like weight loss, reproductive health, mental health, ED—whatever it may be—tries to create permission structures for people who need a product or service. It does 2 things: it massively shifts the Overton window so that we’re at the extreme point and they never have to be, and it tells stories that resonate deeply with them.

Serena Williams is a great example. She’s a Ro Body ambassador for GLP-1 products. She’s unique as a person, the best tennis player of all time. But she’s one in a million when it comes to her health journey: she had 2 children, did everything right with diet and exercise, but the weight didn’t move, and she had health problems after the birth of her children.

I spoke to a patient this week who almost cried telling me what it meant to see Serena Williams. He felt calm and said, “If Serena needs it, then it’s fine if I need it, right?” You saw us do the same with Charles Barkley, Chrissy Metz, or Megan Fox and ED, right? Megan Fox could tell people of a certain generation to get a colonoscopy, and they’d be like, “Done.” The fact that she says, “Hey, sex is an important part of a relationship, and it’s okay if you need support,” matters.

This means you’re taking a step forward, and it really shows dedication to your partner. I like it. It creates a permission structure for someone who’s sitting there thinking, “Well, I don’t know what my partner will think.” I think all these things are trying to touch on each of those points.

Maybe you could tell me a little more about that. I’m intrigued by these methods. Is it possible to say that stigma is a signpost to hidden demand, like unmet demand? What did you learn about this idea?

There’s a lot of potential energy there. When there’s a lot of tension around a topic, that’s exactly what the founders of consumer brands can use. The way we used it was to always occupy what I’d call moral superiority. The more controversial you are, the louder you can be—as long as you can look back and say that, in time, history will be on our side.

For me, GLP-1s are one example. When we promoted them, we had what people called a “controversial” advertising campaign in the subway. We showed people who clinically met the criteria for the drug and added the words, “Weekly injection for weight loss.” It was literally an instruction. It caused a huge uproar. People were confused by the idea that someone would use injections for weight loss, and we knew that.

But people misunderstood the negative impact of excess weight on health. They thought of it as the easy way out. You can take social myths, like the myth that obesity is simply a lack of self-discipline or willpower, and try to disprove them. People say that only certain people need medication, or that only certain people should be treated for erectile dysfunction or something else.

Take another example related to GLP-1s. People often ask, “How do you stop taking them? When should you stop?” People should be able to stop taking medication whenever they want. They should be able to do so safely, without condemnation, if they want to try to achieve their health goals without medication.

But it’s a really interesting example of the stigma around weight-loss drugs. People talk about them as if they’re shocked, and they don’t want people to need these medications regularly, unlike any other medicine or treatment. What do people think will happen when someone stops taking cholesterol medication? Their cholesterol will rise again, right? What do they think will happen when someone stops taking birth control? That doesn’t surprise anyone.

And it’s the same with behavior. You can’t just squeeze once or eat one salad. Any medicine, any useful habit, needs to be sustained to keep getting results. What people find off-putting about weight-loss drugs reflects their attitude toward the issue. When tension arises where it shouldn’t—when it’s intellectually incorrect and socially charged—it creates an opportunity to engage with it from a social perspective.

What did you learn about conducting these campaigns? Megan Fox seems to have been the most recent one. What did you learn from the details, like choosing her over ten other people you could have chosen, or the visuals, the effects, the copy, or the release itself? Working with celebrities is a way to draw attention to the brand. Tell us about your experience.

There’s so much here. I’d be mistaken if I didn’t start by saying that this is my co-founder Simon’s superpower. I’m playing a role when I talk about it. He’s simply unsurpassed at it, and I think you can see it in Ro’s results and brand recognition.

If I try to imitate him and repeat his thoughts, choosing celebrities is again about creating permission, but it’s very, very powerful. Megan is a unique case, but if we remember Charles, Chrissy, Serena, Trisha Paytas, and the two or three more we’ll have soon, they all take this medication. It’s very important to him and to the patients that they share their experiences sincerely. That’s what he builds campaigns around.

If you look at the commercial with Charles Barkley, it’s just Charles. He’s improvising in front of the camera, joking and having fun, but he’s also telling his true story. It’s the same when Serena comes to a shoot. She’s completely focused. She’s going to become one of the top models in advertising of all time. Her phone is away, and she’s completely immersed in the process: the lighting, the director, the sound, everything. The positioning is impressive.

The coolest part about working with all these people is that you understand why they became who they are. Their professionalism becomes apparent within a few minutes of meeting them, so it’s just cool to watch. But with celebrities, the main thing is to find authentic stories that create space for trust.

They’re more useful now than five or ten years ago because the threshold for creating high-quality advertising is very low. Thanks to AI, what would have been a beautiful Instagram ad ten years ago, one that took a lot of time, now takes ten seconds or a few minutes, and costs nothing. So how do you cut through the noise when everyone is looking at pretty good content? You see Charles Barkley, Serena, or Megan Fox. You can’t recreate them in the AI era. I think it’s a powerful tool.

Returning to the idea of stigma, which stigmas are interesting to you today? The subway campaign seems completely normal now. The window of opportunity has shifted. Where else has it shifted? Where do you see a stigma that interests you?

Going back to your earlier question about people who use medication prophylactically, or at what’s considered an early stage, that fascinates me. On the way here, I probably passed 15 bars from my office. It’s literally exchanging poison for entertainment. You turn 21, and you can do it. Half of my TV commercials are about that.

Then you take a medication, which is probably the most studied thing people use. There are randomized controlled trials. There are clear risks and benefits. And, by the way, to get it, you should talk to an expert and interact with them. To keep getting it, you have to stay in touch with them. But advertising it on TV feels like, “Oh, no,” right? In contrast, poison is completely normal. Cheeseburgers are perfectly fine, and I love cheeseburgers. But there’s a difference when something is obviously negative for your health. We can have a conversation as a society about whether pleasure outweighs the downsides. At least with medication, there’s a probability equation: do the benefits significantly outweigh the risks? Someone interacts with an expert and continues doing so.

Sometimes when I tell people I take this medication, they’re shocked, while I see them literally drinking poison. That’s not a criticism at all. People should be able to do that, but the difference between the two things is quite surprising.

11. Zach's Hottest Take

Is there anything else? I guess the question could be: what are your boldest views? What do you disagree with your colleagues, the industry, or the world about? Where do you feel most alone in your beliefs?

I’m very lucky, but I think there’s an excessive obsession with the founder. I understand why, but maybe other founders don’t have this. I feel like I have an incredible support network, and in particular, I’d say that’s my wife. I don’t know if founders have very supportive wives. There’s a lot of talk about it, to be honest.

Cleo and I supported each other in turn. We met very young. I was 19 and she was 17, and we started dating a few years later. We’ve been together for 13 years. We grew up together in New York. We actually supported each other financially in turn.

When I first founded Ro, we lived together in a friend’s apartment. We had a smaller room, and he had the master bedroom. Her salary as a journalist bought us all breakfast, lunch, and dinner. I wouldn’t be the person I am today, and I couldn’t manage Ro, if we weren’t together.

There are a lot of people on this path, although success is usually attributed to just one person. I can say the same about our team. Our team is simply incredible. That’s probably one of the things I think about: a lot of founders have a lot of fanaticism. They believe they’re sinless, and that’s a little exhausting. So, yeah, that’s probably it.

12. The Kindest Thing Anyone Has Done for Zach

That’s it. That’s true. It seems like weakness, softness, but I think it’s the opposite. It’s been incredibly fun. It’s so cool to hear all the lessons you’ve learned, having done it twice, if I may say so—that you refounded the company halfway through. I really think those fair winds you told us about today are the most interesting in the world, and I really hope they continue to blow.

You know my traditional final question: What’s the kindest thing someone has ever done for you?

I was thinking about this because I keep hearing your podcast, and I think I was inspired by your answer. When I was 15 years old, I was at boarding school and missed home terribly. My parents came to visit me. They watched me play sports, and they took me to dinner. My way of expressing my love to them, because I was homesick, was somewhat rough.

And my parents knew it. They understood that this was just how I acted. When they were leaving, my father asked my mother to get behind the wheel. My mother has an autoimmune disease, so he usually drives.

Going back to what we were talking about before, sometimes you only understand things by looking back on the past. I didn’t realize then that something had changed, but I felt it subconsciously. I thought, “This is strange.” My father sat in the passenger seat, rolled down the window, and something in his voice had changed. He looked at me and said, “Tell me you love me.”

I instantly changed and replied, “Of course I love you. I love you very much.” He replied, “Okay, I love you too,” and they left. He looked at my mother—I found out later that he was watching her—and said, “Take me to the hospital. I’m having my fourth heart attack.”

I asked him about it later. Fortunately, he survived. He didn’t think he would. I said, “Hey, every second counts. What did you do?” He said, “First, it was only a few seconds, and I didn’t think I would survive. And secondly, I didn’t want your last words to me to be a quarrel. I wanted them to be ‘I love you.’”

That was one of the most selfless things he could have done, and it became a gift to me: never leave love for people unexpressed. To this day, when I finish a conversation with him or with friends, I say, “I love you.” Even with my co-founder, it took me 6 years to tell him “I love you” when we finished a Google Hangout video call. When I hang up the phone, I tell him, “I love you.” And I really do love him.

I think that, at such a young age, feeling that vulnerability—like putting your hand on a stove with silent love—and never wanting to do that again is something I’ll always appreciate.

Incredible story. Very unique. I’ve conducted many interviews like this, but I haven’t heard one like that yet. Thank you very much for your time.