This week I sit down with Josh Miller, CEO and co-founder of Gradient Health, one of the fastest-growing companies in the Tweener portfolio and one most people in North Carolina have never heard of. It’s a mix of company story and founder lessons, with a healthy dose of philosophy along the way. Josh drops a lot of nuggets for builders, so grab a notebook.
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Who is Josh?
Josh Miller is the CEO and co-founder of Gradient Health, a Triangle-based company that sources, de-identifies, and standardizes medical data so AI developers can train models that make healthcare cheaper and better. Josh grew up in the Fort Lauderdale area and came to North Carolina for his undergrad at Duke, where he studied computer vision. Right out of school, he founded FarmShots, which used satellite imagery to spot disease and pests in farm fields so growers could spray only where needed. Josh estimates it cut global fertilizer and pesticide use by about 1%. FarmShots was acquired by Swiss agrochemical giant Syngenta in 2018. Josh swore he’d never do another startup. Two years later he started Gradient. He’s a second-time founder with a rare mix of technical chops and sales instinct, and he credits that combination with a lot of his success.
Highlights
The growth curve: Gradient grew from about $200K in revenue in year one to $1.2M, $3.5M, $7M, and roughly $40M this year, with $15–16M net of hospital payouts.
Capital efficient: Gradient has raised only about $9M total, including roughly $3M rounds in 2023 and 2025, with Tweener and Venture South among its local backers.
A million a head: Gradient just reached 40 employees, generating roughly $1M in revenue per employee. A typical SaaS company doing $40M in revenue might have around 400 employees.
The 87% problem: Gender, ZIP code, and date of birth alone can identify about 87% of Americans, which is why true de-identification requires much more than removing names.
Paying it back: Gradient expects to pay nearly $9M this year to partner hospital systems, helping ensure that the institutions caring for patients benefit from the data powering AI.
Weak labels vs. strong labels: Foundation models have shifted the value of data. Pre-training relies on massive volumes of weakly labeled data, while expert labeling is increasingly valuable in post-training.
Medicine is surprisingly subjective: Two experts can interpret the same tumor very differently. Small, carefully curated datasets reflecting expert judgment are becoming increasingly valuable.
Picks and shovels: Josh has considered building his own AI models but sees a strong business in supplying the data without absorbing the enormous cost of training models at scale.
Culture as the engine: “We talk about problems.” Josh credits a culture of openly confronting what’s not working, while staying committed to the larger vision, as a key driver of success.
The 100x engineer: AI tools have made good engineers 2–3x more productive and the best engineers 10x more productive. Josh believes the gap between the best and average engineers can now reach 100x. And yes, he gets a substantial Claude bill every month.
Founder color: Josh’s wife is a former wildlife biologist who worked in the Everglades, and the family has a ball python named Gilbert. His advice after a recent health scare: work hard, but prioritize your physical and mental health. Building a company over 7–10 years is a marathon.
Some companies grow quietly in your backyard until the numbers make everyone ask where they came from. Gradient is one of those, and Josh is generous with the lessons he picked up along the way. Enjoy the conversation.
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