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terating with customer feedback to me i just sucked in all of that knowledge because back in that day it was like a very refreshing concept at this point i think it is so mainstream so people default er yeah eb so back at the time it wasn t default the default was spending two years trying to perfect an application and doing a big launch and demo day or i mean techcrunch disrupt the goal was that in the first day of launch it was getting so much press it was getting a bunch of customers and some of those customers would be retained that used to be the playbook back in the day er yeah it s actually such a short time that this has changed that a lot of new founders can t believe it and so i m glad to get you on the record just as a testimonial about what it was like it was only 10 or 11 years ago that we re talking about eb exactly er yeah it s been a wild time eb and i think one of the things i m going to jump to carbon but i think since then actually the concepts have evolved quite a bit so we are now realizing it s not a single playbook but when we first studied carbon health so in healthcare space it s not easy to just build an application in seven days and launch it right er of course eb because we were trying to be a technology enabled primary care provider but to be a healthcare provider you have to get the license and you have to incorporate you have to have a physical location you have to be able to prescribe medication you have to be able to order labs medical imaging referrals insurance billing the bar is fairly high but we didn t launch the first version in seven days i think it took us 10 months to launch the first version but there is still some similarities when we launched the first version what we tried to prove at first was that patients would actually want this technology driven mobile app driven customer experience and to prove that we started accepting patients but we couldn t tell them that the service was going to be free so we literally did not have an actual billing infrastructure but we didn t tell people at first we sort of just acted like we were going to submit their claim to their insurance company we just never actually did it just so that we can prove some of the thesis earlier right er mm hmm eb it wasn t i guess that wasn t your typical let s launch an application and mold an iterate model but then even healthcare does it similar i think the concept has actually evolved the methodologies are just getting better like are changing based on the industry er yeah of course i mean i think that s one thing that people miss often is that leadership is a philosophy it s a set of principles it has to be translated into specific tactics and strategies that are very context sensitive and so yeah when you re in a highly regulated industry like healthcare or finance the playbook is going to look really different but the mindset is really what we re trying to cultivate so i actually think it s really an interesting example of you taking something that was learned in online education and online dating and then to take it into a much more if you forgive me for saying a much more serious problem domain of healthcare i m of course really honored to have played even the smallest part in that that was my aspiration in writing the book originally but i m curious why you made that choice to make that switch how did you tell us how carbon health came about why it s a much more difficult problem to tackle what inspired you to do it eb honestly i think from udemy to carbon in my perspective i had a very linear approach but i can totally see how it feels non linear so we started i was at speeddate left to start udemy in silicon valley again in 2010 and udemy became i would say widely successful we grew quite a bit in the first five years i was a founder and ceo and udemy s mission was really making online education more accessible but broadly i was fascinated with this idea that you can use technology to make something really essential accessible to more people and i was really thinking udemy was a great example of techno optimism i assume when you build the platform a lot of people who are not your typical ideally college professors can be teachers can make your living but also they can actually share their expertise with hundreds or thousands of other people and then i started thinking about what other industries need this type of transformation and healthcare was really top of the list for me and then while i was thinking about it my mom had this disease called neurosarcoidosis so she had this full body stroke which was completely unexplained she s back in turkey so i moved back to turkey for a couple of months my sister is a physician we were going from doctor to doctor and trying to understand what was happening and we were carrying thousands of pages of documents lab results dvds with mri ct scans and i think we kind of just jumped around thirteen really kind of specialized physicians and there s no sad story here so the physician number fourteen diagnosed it and the treatments worked fairly well but i just directly observed that the technology the tooling for doctors were really far from what they needed to operate at a high productivity level and i actually made a sketch back in 2013 i think so three years before i started a carbon and the story here is if you re going from doctor to doctor every doctor would look at these pages and they just go through hundreds of thousands of pages and write some things in their notebook and then they use the notebook to understand what might be happening and i asked my sister i said what are they writing on their notebooks and she said they re making a chronology of the case and my immediate naive reaction was why don t we give the whole content in the chronology format in the first place if that s how they are thinking about the problem and i made a sketch about it how i would design the physicians interface if i was building a new kind of healthcare software platform and i just left it sitting around when my mom recovered i came back to silicon valley and continued to be the ceo of udemy but that idea did kind of get stuck in my head that the largest the most expensive resource of any country was one of the worst utilized and i said somebody should really rethink how a doctor operates how they communicate with the patient how that whole concept of care delivery works and i and a couple friends we kind of sat down and started making some sketches and i realized that this was one of the thorny problems with a lot of regulatory challenges that most funders were not wanting to work at there were healthcare funders but they always wanted to take a slice of the problem and what i really wanted to do was just bring the strongest technology product physician kind of clinical operations people together to figure out whether we can use technology to make great healthcare accessible to more people so what really was disappointing for me was that the rare healthcare companies and technology were using technology but they were all exclusively focused on young affluent high income patients and i hadn t really seen even a single company who s trying to serve the average retail worker average teacher in this country that domain was almost completely unserved from the technology space and understanding how complex this problem was i thought somebody should spend 10 years of their lives just obsessing on this problem er so how did you get from somebody should really do something about this to you re going to do something about this eb i initially tried to look for funders to invest so i met bunch of funders i didn t realize the intersection of the funding team who s technical enough was product driven enough with intersection of the funders who are open to learning this new concept just not making any assumptions about how healthcare works we were willing to just come in and learn from some of the people in the industry as well and the intersections part of the intersection is people who are willing to work on a thorny problem right like mass market healthcare delivery i literally couldn t find anybody that i thought was doing it the way i thought it should be done and i decided that at that time udemy was already at the maturization phase i think we were a fairly sizable company and we had a strong executive team and i thought just hiring a ceo for udemy and then me taking on this new challenge sounded like the right thing to do er so what is the mission of carbon health eb it is very simple it s all about how you can provide really high quality healthcare to the entire population and especially focusing on the demographics which are not being served so really it s just combining this very software driven very technology driven approach with day to day healthcare but more tactically we decided that we have to start from the front door of the healthcare system because that s a consumer decision so things like primary care urgent care virtual care maybe even mental health these are decisions that consumers make so we theorized that if you provide an amazing experience without increasing the cost at all you could really dominate as that front door and if you can become a very sizable healthcare provider in the front of the healthcare system what happens is the rest of the healthcare system like specialists and hospitals and imaging centers things like that so those really rely on your patients to really i mean to feed their business if you become their primary customer acquisition channel you can now use your influence with the front door of the healthcare system to create a more democratized marketplace for the rest of the healthcare so that s really kind of the thing it s a little more complicated in reality but it s truly owning the primary care with high quality low cost very modern care and then really trying to pressure the rest of the healthcare system to have the highest best clinical outcomes at the lowest cost possible er so take me back in time to right before the pandemic the start of 2020 where was carbon health at that point how big had it gotten how many clinics did you open and just give us a sense of the stage of the company as you wound up facing the pandemic eb so we were in a very interesting phase because i started carbon health in 2016 so we were a four year old company and we had spent the first several years really nailing the unit economics the customer experience really this software operations finance and we had finally come to a place where the numbers were just undeniably working so we had managed to provide a really modern healthcare experience with very high nps score very high retention while still having a very strong provider experience and lastly innovate where we were seeing very good profitability with medicare reimbursement rates so essentially we had finally hit the benchmark which i considered as the benchmark to just start scaling the company like crazy it was several years of optimization and then we were actually scaled at that moment i think january of 2020 was when we said okay now we are going to just take this and scale it as fast as humanly possible and i think we had seven clinics just at that moment but we also had a pipeline of 20 clinics for 2020 and the pandemic hit us actually fairly early because we have the system that takes the details of the patient s problem and when we started seeing the news from china we put some additional questions to screen for covid risk and as early as january we started seeing patients who were coming from literally from wuhan china to california and they were coming to our clinics with respiratory symptoms so we caught this really early and then started really getting into this crisis management mode in january so by the time it was considered a pandemic in march we had decided that this is going to be our focus for the year for the foreseeable future er did i read correctly that the first case in california was found in a carbon health clinic eb so it was one of our patients which we couldn t get tested but then eventually because cdc well only cdc was providing testing at that point with that patient we were monitoring a lot of patients not just one patient we were monitoring thousands of patients remotely so we were asking them to stay at home we would actually check back with them daily and then if their symptoms get worse we would actually then suggest to go to other places so i think one of those patients went to er and then got tested by the cdc at a community hospital and was considered one of them i think it was considered the first community spread patient er talk a little bit about your mindset as this information was rolling in this was before the general public really had an awareness of this and obviously the american response and kind of our level of alertness to this crisis was very slow what was it like having that information how did you know what actions to take what did you view as your guiding light as you started to navigate those difficult waters eb so there was a lot of uncertainty i would say the cdc guidance honestly was very weak it didn t really tell us anything substantial about what we should be doing as a healthcare provider and there were some people who in the company even who said this is going to be a massive problem we have to just put all of our resources to fight this pandemic and then there were all sorts of people who thought this might be a three month kind of problem and it might be gone by the summer and i had to make the final call as the ceo and there was also just massive ppe shortage we were literally short of n 95 masks and i just discussed with our clinical leadership and we made the decision to just be on the front lines of this pandemic and offer testing as soon as possible essentially i and our clinical leadership said we just have to be in the solutions part of this problem because just going to put that at that time most healthcare providers some pretty much all of them were trying to shut down clinics who d use ours they were mostly trying to reduce their risk factors and they were hoping that the government the public health departments would actually take ownership of the response there so we decided to just go to the other direction and i remember talking to my wife about this because i felt really horrible i guess i mean the analogy i give my wife is i said i feel like i m a general sending soldiers to the front lines because we really did not know what the real risk factor is and for all we know we could have i don t know 10 of our staff getting infected and because in italy the news about healthcare providers were very i mean they were not good but our clinical leadership actually had a lot of experience in front of the original sars pandemic back in the day so they thought that if you have the right protection rights protocols we coul...
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