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Why US healthcare breaks: the patient isn’t treated as the customer
Zach Reitano opens with his core diagnosis of US healthcare: incentives revolve around whoever controls payment, not the patient. He argues that hidden pricing and opaque “list vs. net” dynamics would be intolerable in most other industries.
- •Zach says the central problem is that the patient is not the customer in most healthcare interactions
- •He argues that whoever controls money at the point of purchase becomes the real customer that the system serves
- •He points to extreme price opacity (e.g., large gaps between drug list prices and what gets paid behind the scenes)
- •He claims no industry could survive if its prices weren’t public
How much should society spend on health? Reframing the GDP debate
Patrick asks what percent of GDP healthcare could or should be in 10–15 years, and Zach responds provocatively: as high as possible. He frames health as the non-diminishing return good—another healthy year—and argues the real question is whether spending delivers outcomes, not whether the number is “too high.”
- •Zach argues healthcare is foundational and could justify very high GDP allocation in an “abundance” future
- •He references Jevons paradox to suggest markets can grow as unit costs fall
- •He says the US issue is rising cost per unit rather than sheer utilization
- •He argues the US doesn’t give up on expensive patients and suggests other countries may trend toward similar spending pressures
State of the union: where the money goes and why outcomes feel paradoxical
Zach breaks down where healthcare dollars flow (hospitals, doctors’ offices, pharmaceuticals, and the remainder) and contrasts US strengths in acute care with weaknesses elsewhere. He separates causes of death into a “fast clock” and “slow clock,” arguing chronic disease is the rising driver of long-term deterioration.
- •Zach outlines major spending buckets (hospital systems, doctors’ offices, drugs/pharma, and other categories)
- •He says US acute care outcomes can be strong, citing higher survival rates in certain emergencies and cancer comparisons
- •He claims the US doesn’t necessarily use more care than peers, but prices and administrative burden are much higher
- •He distinguishes fast-clock causes of death (e.g., accidents, overdoses) from slow-clock chronic disease, emphasizing the rise of chronic illness
The incentive mismatch: transparency, voting with your feet, and removing middlemen
Zach expands the thesis that patients lack power because they’re not the direct buyer. He contrasts cash-pay segments where prices fall and service improves with insured markets, and argues that direct-to-consumer drug distribution can compress the list-to-net gap and remove intermediaries like PBMs.
- •Zach says healthcare works best when the patient pays directly and has choice
- •He gives cash-pay examples like LASIK and cosmetic procedures as places where cost drops and quality/convenience rise
- •He describes GLP-1s as a “foil” that reveals dysfunction: direct models reduce list-to-net gaps and can bypass PBMs/insurers for cash-pay
- •He argues transparency laws are a symptom; true consumer power would force transparent pricing without mandates
- •He describes Ro’s aim as aggregating patient spend to “bend the healthcare system to the will of patients”
Inside Ro today: four categories and GLP-1s as ‘treating the slow clock’
Patrick asks for the current product lineup, and Zach describes Ro’s four main categories and the growth profile of the business. He pushes back on the idea that GLP-1s are “just weight loss drugs,” emphasizing expanding approvals and ongoing research directions he says broaden their relevance.
- •Zach lists Ro’s four categories: cardiometabolic health (including GLP-1s), sexual health, dermatology, and fertility
- •He says Ro has become the leading provider of GLP-1s in the country
- •He describes rapid scale from a much smaller run rate to over a multi-billion run rate, alongside fewer employees than earlier
- •He argues GLP-1s map to major chronic disease drivers and notes additional conditions they’re approved for and being studied for
Why Ro wins in GLP-1s: differentiation through constant innovation and vertical integration
Patrick presses on why people choose Ro versus other options, including pharma direct channels. Zach argues Ro’s edge isn’t one feature but a compounding set of innovations plus an integrated platform built before GLP-1 demand exploded.
- •Zach claims Ro signs up far more GLP-1 patients daily than competitors, implying meaningful differentiation
- •He lists practical advantages Ro emphasizes (affordability to start, integrations, delivery/pickup options, insurance checks)
- •He says Ro built core infrastructure in-house: EMR, lab, pharmacies, pharmacy software, and provider network
- •He argues sustained differentiation comes from continued innovation rather than a single static feature
- •He frames Ro as a condition-agnostic distribution and care platform built to serve patient health goals
The future of GLP-1s: individual health, system rewiring, and societal ripple effects
Zach lays out three layers of GLP-1 impact: individual outcomes, structural change in healthcare economics, and broader societal effects. He predicts very high long-term adoption and links chronic disease reduction to wider societal progress through a personal and historical lens.
- •Zach says GLP-1s are upstream of leading chronic disease drivers and describes their already-expanded set of approvals
- •He argues GLP-1 demand is rewiring healthcare by pushing direct-to-consumer cash pay, transparency, and competition
- •He critiques employer-controlled insurance incentives as misaligned with an individual’s lifetime health horizon
- •He shares a personal story about how healthcare access and advocacy changed his life trajectory
- •He predicts a majority of people could be on GLP-1s in the future and compares potential adoption to statins
‘Jobs over lives’: outcomes-first thinking and the danger of protecting the status quo
Prompted by Patrick, Zach argues that the wrong debate centers on whether healthcare must remain ‘human’ rather than whether outcomes improve. He uses driverless cars as an analogy for how society can delay life-saving technology due to concerns like job displacement.
- •Zach says focusing on “healthcare must remain human” prioritizes inputs over outcomes
- •He argues new tools (including technology) should earn their place by being substantially better than the status quo
- •He compares delayed adoption of safer driverless cars to the healthcare system’s resistance to change
- •He argues society shouldn’t prioritize job preservation over reducing preventable deaths
- •He notes consumer behavior signals priorities, mentioning high consumer uptake of GLP-1s relative to AI subscriptions
Ro’s painful reset: from hypergrowth mistakes to refounding the company
Zach tells the internal story behind Ro’s turnaround, starting with a personal moment of realization after weak growth despite massive fundraising. He describes leadership changes, layoffs, and a deliberate cultural overhaul as part of a “refounding.”
- •Zach recounts realizing the company had grown slowly despite a major prior financing and significant burn
- •He describes a cultural warning sign sparked by an internal reaction to a company gift, and what it revealed to him
- •He says Ro moved on from multiple senior leaders and reduced headcount significantly
- •He emphasizes layoffs were painful and rejects treating them as something to celebrate
- •He outlines the refounding steps: brand consolidation under Ro, new principles, and making culture explicit so people could opt in or out
Operating model after the turnaround: talent density, focus, daily cadence, and ditching long roadmaps
Patrick asks what enabled Ro to grow much larger with fewer people. Zach credits both a major market wave and execution choices: investing in top talent, sequential focus, unusually tight leadership cadence, and rejecting long roadmaps in fast-changing environments.
- •Zach says massive tailwinds mattered, but execution determined who captured the wave
- •He describes doubling down on top talent through compensation, coaching, and resourcing
- •He argues for sequential building over parallel work to reduce context switching and increase compounding progress
- •He describes a daily leadership “steer” meeting that forced rapid follow-through and alignment
- •He explains why Ro deemphasized long-term roadmaps, calling them false precision in rapidly shifting markets
‘Pitch me on a GLP-1’: goals, risk tolerance, and Zach’s own aggressive health stack
Patrick asks Zach to pitch GLP-1s to someone who doesn’t fit the stereotypical user profile. Zach reframes the pitch as a personalized goals-and-tradeoffs conversation, then shares his own medication approach shaped by family history and careful experimentation.
- •Zach says the right conversation starts with a person’s health goals, family history, and risk tolerance
- •He describes chronic disease risk as an “area under the curve” problem over decades rather than short horizons
- •He shares his personal history: a heart condition and a family history of early cardiovascular events
- •He explains he tested medications and doses iteratively with a doctor to isolate benefits and side effects
- •He details his own sequence of therapies (including cholesterol-related medications and a GLP-1) and why he’s comfortable being unusually aggressive
AI and drug discovery through a heart-disease example: shortening the loop from insight to treatment
Zach explains how long timelines in medicine slow progress and uses a PCSK9 story to illustrate the gap from genetic insight to widely accessible therapies. He frames AI as most effective when data is structured and feedback loops are tight, and argues medicine needs better ways to detect early “whispers” of disease.
- •Zach describes how trial-and-error medicine and long outcome timelines make progress slower than in software-like domains
- •He uses a genetic-study-to-therapy timeline example to argue innovation cycles in medicine take too long
- •He links earlier intervention to shifting disease trajectories rather than treating downstream consequences
- •He argues small early nudges in health could change life outcomes, paralleling Patrick’s reflections on kindness
- •He expresses optimism about reaching another major inflection in population health outcomes
Recreating his dad in software: purpose, leverage, and finding what you’re ‘born to do’
Patrick asks Zach to unpack the idea of recreating his father in software, and Zach ties Ro’s mission to scaling the kind of care his dad provided. The conversation broadens into how people discover their calling in retrospect and what it feels like to work in deep alignment with it.
- •Zach explains his motivation as giving people more healthy, happy years so they can pursue life goals
- •He describes technology and operations as leverage to scale the human impact he witnessed in his dad’s medical work
- •He and Patrick discuss the idea that life paths often feel clearer in retrospect than in the moment
- •Zach shares how his wife’s background shaped her work and how explanation/education can change trajectories
- •He describes the feeling of doing the work you’re meant to do as energizing and not experienced as “work”
Marketing into stigma: turning tension into permission structures and consumer pull
Patrick and Zach explore how Ro built consumer distribution by starting with what patients want and then finding overlap with need. Zach explains how stigma can signal latent demand, and how Ro uses stories—often through celebrities—to normalize sensitive health decisions.
- •Zach says many digital health startups focus on need alone, while Ro starts with what patients want and finds overlap with need
- •He describes using both data (to move the brain) and story (to move the heart) to move people
- •He explains “permission structures” and shifting the Overton window so customers don’t feel extreme or alone
- •He argues celebrity campaigns work best when grounded in authentic use and personal experience
- •He discusses why recognizable faces may matter more in an era when high-quality ads are cheap and abundant
Zach’s hottest take and closing story: crediting support systems and never leaving love unspoken
Near the end, Zach shares a contrarian view about founder worship, emphasizing the often-unseen support of teams and partners. He closes with a personal story about his father that shaped how he expresses love and gratitude.
- •Zach pushes back on founder-centric narratives and credits his support network, especially his spouse
- •He describes how he and his spouse took turns supporting each other early on
- •He suggests some founders over-attribute success to themselves, which he finds exhausting
- •In response to the closing question, Zach recounts a moment with his father during a medical crisis that taught him to say “I love you” explicitly
- •He explains how that lesson changed how he speaks to family, friends, and colleagues
Publisher timestamps
- 0:00Welcome to Invest Like the Best
- 0:34How Much Should We Spend on Health?
- 4:59The Patient Is Not the Customer
- 10:24Inside Ro's Business
- 18:28The Future of GLP-1s
- 25:46Jobs Over Lives
- 30:02The Turnaround
- 47:43Where Healthcare Goes Next
- 51:55Pitch Me on a GLP-1
- 1:00:27Recreating His Dad in Software
- 1:06:33Marketing Into Stigma
- 1:19:06Zach's Hottest Take
- 1:20:58The Kindest Thing Anyone Has Done for Zach
