The Quiet Operators · No. 014
The Founder Who Turns Down Projects
How Kevin Mackey built a decade of trust in medical software by saying no to the wrong revenue — and why the next move in functional medicine may already be underway in a quiet office above the Pacific coast of Costa Rica.
By the time most software founders hit year ten, they’ve signed away something — a piece of the company to venture capital, a piece of the mission to a growth target, a piece of their ethics to a deal that was just too big to pass on.
Kevin Mackey hasn’t.
The founder and CEO of FxMedSupport — a ten-year-old integration and development partner that sits as the operational nervous system around Cerbo, the leading EHR in functional and integrative medicine — has built one of the most quietly powerful platforms in independent medicine by doing the one thing most founders are afraid to do: turning down the wrong projects.
“If you are willing to create a product or an integration that is fundamentally against protecting the patient’s information, I don’t need you to be my client.”
“We’ve lost many clients throughout the years,” Mackey says without flinching. “Not because the product didn’t deliver — but because myself and the business owner didn’t see eye to eye, and I was not going to allow any part of our product to be utilized in a way I don’t think is ethical.”
He’s quick to clarify the scale. Out of hundreds of active clients, the unethical ones represent less than one half of one percent. But when they show up — usually with a development request that would compromise patient information, or a workflow that bends a fundamental rule “for the greater good” — Mackey doesn’t negotiate.
Sometimes the conversation ends with a refund — even after a client has already signed and onboarded. “We’ve straight up told somebody who just signed up: here’s a refund. We don’t need to do business with you. We don’t have the same ethical mindset. I have no problem turning away money.”
01
The Four-Prong Problem
What separates Mackey from most software founders is that he doesn’t actually think of himself as a software guy. He thinks of himself as someone who understands the architecture of a struggling medical practice — and software is just the tool he uses to fix it.
He describes the dysfunction as a four-prong problem.
The first prong is the provider. “The medical doctor who owns the practice — their inability to actually take off the doctor’s coat, put on the business person’s hat, and separate themselves truthfully. Because at the end of the day, the doctor will always martyr herself, himself, and the business for the patient.”
The second prong is economics. “Most medical practices can’t afford the support they truly need. That’s why they feel overwhelmed.”
The third prong is execution. “They’re not using virtual outsourcing or geographic arbitrage. They need to find the best person in the world to do the administrative tasks, and ensure the people that are in-person are doing the highest-level, most highly executable work.”
The fourth prong, Mackey adds — and the one he says most founders never even name — is software. “You have to make sure the software underneath the practice grows with you. Not the version of you that opened the doors. The version of you who exists three years from now.”
It’s a thesis he’s written about extensively in his own essays. A practice in year three is not the practice that opened in year one. The volume changes. The visit mix changes. The supplement catalog changes. The patient expectations change faster than any of it. And if the software underneath that practice is frozen in time, it stops being a tool and starts being a cage. That, Mackey argues, is exactly why he chose Cerbo as the foundation — and exactly why FxMedSupport exists as the layer that keeps Cerbo adaptive on behalf of every practice that runs on it.
It’s the kind of analysis that doesn’t come from a software roadmap meeting. It comes from a decade of sitting next to providers, watching them drown — and a decade of bending Cerbo into the shape each one of those practices actually needed.
02
Decisions Aren’t Guesses
Ask Mackey how he prioritizes what to build next, and his answer reveals something unusual about how he runs the company.
“There is not a thing in our company that’s a guess. Every single decision is evidence-based off of a deep proprietary simulated software we created years ago.”
“We know when we make an action that the simulation — which we’ve probably run hundreds, if not thousands of times — will most likely give us output X, Y, or Z,” he says.
The mental model he describes is closer to a chess grandmaster than a typical CEO. “My mind has the ability to see that every time a question is asked, I come into a fork in the road. I can see what happens if I take the left, and I can actually work down all of the pathways. And then I can look at the right path and see all of the right pathways.”
Sometimes the simulation tells him to take a short-term loss. “In the long strategic path to a general leading his troops around a multi-front campaign, sometimes you take a loss in order to capture greater territory later — and ultimately win the war.”
03
Earning Trust the Long Way
For the 99.5% of clients who aren’t ethical mismatches, Mackey runs a remarkably patient sales process. Fresh medical school graduates trying to launch their own practices arrive in his pipeline overwhelmed — pitched by every software vendor in the industry promising the dream.
His response is counterintuitive. “I tell them I don’t want their business right away. I tell them to go do research.”
He’s also unusually generous about the EHR he integrates with. “Yes, the EHR you’re looking at — Cerbo — is the most expensive. It is. But it’s the most expensive for a certain reason. It was the only EHR actually created for integrative, functional, non-insurance-based medicine. Others were created to copy it. This was created as the original.”
When prospects choose Cerbo but don’t sign up for FxMedSupport — which Mackey estimates happens with less than 5% of qualified leads — he asks why. Not in a sales follow-up. In genuine inquiry.
“I want to know that information so I can give it to my development team, throw it on the whiteboard, and fill the gap. So that the next time that client or a similar client is in this situation, the gap has been filled.”
It’s product development as anthropology. Rejection becomes intelligence. The whiteboard becomes the roadmap.
04
Community as Research Lab
Twice a week, Mackey hosts what he calls Community Connection — open sessions anyone interested in Cerbo or FxMedSupport can join. He’s transparent that the offering isn’t entirely altruistic.
“I do it for a selfish reason,” he says. “The more I connect with the community, the more I understand the pulse — the needs, the wants, the desires. There’s always a give and take. I offer my time, and in return, I get to understand more pain points. Then we get to go build more tools for them.”
Eighty-eight applications, integrations, and leverages have come out of that listening over ten years — every one of them living natively on top of Cerbo. None of them, Mackey notes, came from a roadmap meeting. Every single one came from a moment of paying attention — to a provider, to a Facebook group thread, to a friend’s practice on a holiday. The full catalog of those integrations is now documented inside Cerbo’s own knowledge base.
05
The Operating System of a Founder
Running a company on this kind of ethical clarity and architectural patience requires Mackey to protect his own time the way he tells doctors to protect theirs.
He starts at 4 a.m. Coffee. Meditation music. A walk with his dog to the beach to watch the sunrise. Then deep work. He pulls himself away mid-day to listen to the birds and the monkeys outside his window in Costa Rica, then back in. At 5 p.m., the same dog, the same beach, the same sun — watched setting now instead of rising.
The internal discipline is just as deliberate. “If we ever find that we do something more than five times the same way in a relatively recent amount of time, we build an optimization or automation for it. It’s just part of our routine.”
Customer service tickets, development proposals, status updates — Mackey calls it “the work work.” He doesn’t love it. So he builds a team to handle it, with tracked ratios of customer service agents to active clients, and dashboards on every developer’s actual hours.
“By the time we get to a certain date and time, we’re at the execution level — because the simulation we ran a hundred times, adjusting the variables, made sure we hit our end zone.”
06
The Advice He’d Give Himself
Asked what he’d tell the younger version of himself — the firefighter paramedic who left medicine after an injury and stumbled into software — Mackey doesn’t hesitate.
“Step into it more. Believe in yourself faster. The fact that you haven’t done it yet doesn’t mean you can’t do it.”
“The fact that there’s bigger applications out there only means they started before you — not that they’re better than you,” he continues.
It’s the kind of advice that, in hindsight, sounds obvious. But it’s the same lesson he’s now quietly applying at the scale of an entire company.
FxMedSupport is ten years in. Mackey is, by every visible measure, no longer the young man hesitating. He’s built the architecture, hired the team, run the simulations.
The only thing left, as he often writes in his own essays, is the decision to walk it.
If not now, when?