USAF Medical Clinic Redesign

My mission, if I should choose to accept it: Design a new, medical clinic that will keep the airmen mission-ready for decades into the future. The medical group commander responsible for the project was a full Colonel that wanted the best for her troops but insisted on the optimum use of the designated funds for the project. The Lieutenant Colonel (Lt Col) that she assigned the work to wanted to do it the typical Air Force way. We began the work and quickly identified they could reduce the new clinic’s footprint by fifty percent. We were still meeting demand, working faster, and meeting the target of having no waiting rooms. The Lt Col didn’t believe it could be done.

As always, there was some pushback. The Lt Col became an active resistor to the new possibility. We pushed with data. Ultimately, it was a compromise between our capability and their comfort level with the approach. Although they ended up adding some space back for their peace of mind and comfort, it was a great result. The output thrilled the Colonel. I earned a commander’s coin for that work. That clinic now serves as a model for the Air Force. What happened with the Lt Col? He was unceremoniously pushed on to his next role.

I loved this project, not because we were achieving our mission to improve the accomplishment of their mission, but because it was a base with fighter jets. In junior high, I had dreams of becoming a fighter pilot. I wanted to fly the F-15 Eagle. It was the premier fighter jet during the ‘80s. I had models of it, drew pictures of it, and stood in awe at its performance at the annual air show. However, my dreams died when I got glasses to correct my nearsightedness. Although, the F-22 replaced the F-15 and the F-35 is replacing the F-22, there were still some F-15s around on this base.

During my training runs in the evening, there was a road next to the airstrip that the F-15s would use. One run allowed me to “race” an F-15 as it taxied down the runway. I shared my story with the Colonel and the next day I was standing in a hangar, climbing into the cockpit of my childhood dream. We didn’t go out for a flight, but I was sitting in the jet, looking at gauges and controls of this once-elite fighter. I loved it.

VA Cardiology Suite Redesign

The task seemed relatively easy to me: design a new cardiology, surgery suite that can provide world-class care while simultaneously keeping up with future demand for our veterans. This project was at a major, regional VA hospital. I had done similar work before, but not for a government agency. Apparently, it was a big deal. The local press was at the kick-off event for the work. I was partnered with a high-powered, architectural firm. Our goal was to develop and finalize the design to build.

We established a team of stakeholders and subject matter experts. They conducted interviews with patients, surgeons, nurses, and staff. We began the process and analyzed existed demand, procedures and available technology as well as budget. We discovered great information. The government building-requirements binder was as thick as I had ever seen but despite the significant number of rules and regulations and requirements for cardiac surgical suites, we made them work for us.

The team created an optimized layout for the entire department, with specific attention to where clinicians delivered the medical care, the surgical suite. We used a Lean tool known as Process Preparation (2P). For this, we made small-scale, “paper doll” cutouts for everything that might go into a surgical suite. Then we moved things around on an architectural blueprint until we found a good solution for the suite itself and the entire floor. Eventually, we mocked-up an actual suite with surgical tables, full-scale cardboard cutouts, and auxiliary equipment until we finalized a solution that would work for everyone at each stage of use: before, during and after surgery.

We had created the goal. From there, it was figuring out how to make it happen. A team took our work and delivered it. It was a great plan with great teamwork that yielded great results. Our veterans are receiving better care, at a lower cost, because of it.

Solving Children’s Food Insecurity with Innovation

The goal was to help feed the 50,000 children who don’t get meals on a regular basis. Not getting enough to eat is called food insecurity. Police, educators, public policy makers, industry, and nonprofit food pantries would have to partner together. Although I have worked with several federal agencies over the past several years, my first foray into the local public domain was in Indiana. They asked me to play the process expert and facilitator for a project that could have a significant local impact to urban residents. In setting up the team, we included execs from the police, public policy, food pantries, donors, healthcare and local media.

Secondary research indicated 20% or over 50,000 children in the identified area were food insecure. This number was a significant gap, and we needed to understand what, besides food, was necessary to fix the issue. Reporters conducted our primary research by interviewing dozens of food insecure families. The core team visited multiple food pantries. These combined efforts gave our team the necessary information to make informed decisions. After several months of preparation, the team spent a week together thinking about what solutions would be effective. Several great project ideas came out of our session: police delivered food, food pantries at every school, and an app for information. We named project leads for each idea, and the teams began their work.

It took a while to build some momentum. Sometimes, it looked like it was over before it started. There was a great dream but it faced some obstacles. Fortunately, months after the initial session, the effort is making serious progress. They are delivering meals to hungry children across the entire metropolis in new ways not previously imagined. It took a strong realization to get this effort started, continue it through some tough times and start to impact actual lives. The project is positively affecting people’s health and future.

Innovation Methodologies

Lean Startup, Agile, SAFe and Silicon Valley’s impact on development…

A headhunter contacted me in my twelfth year as a design engineer. At the time, I was designing for Honda. He asked me if I knew anything about Lean Product Development and its principles of set-based concurrent engineering, chief engineer, trade-off curves and more. I honestly had no idea what he was talking about and told him so. He wasn’t convinced so he sent me a book, TheToyota Product Development System by James Morgan and Jeffrey Liker. After quickly digesting the book, I realized it described what I did on a daily basis. I had not realized that academia had conducted research and coined terms for our style of development, Lean Product Development.

Design for Six Sigma (DfSS) was an attempt to drive six sigma  principles into the development arena. This methodology was accepted about as well as Lean was in design settings; in other words, not so much. There were, however, a couple of wins in both areas: Lean’s focus on flow and value creation and DfSS’ emphasis on the voice of the customer (VoC) and Design for X, where X could be anything other than technology that considered the impact on manufacturing, service, cost and more. That gave each of those practitioners a solid base from which they could build.

Agile wrote its Manifesto  years before but exploded on the scene after 2010. Everybody was scurrying to mimic the software world. Lean met Agile when Eric Reis’ book The Lean Startup gained notoriety for its emphasis on infinitely small design/test cycles. It doesn’t take into account prototype creation time. It assumes an instantaneous build. Outside of publicly distributed software, there simply aren’t industries that can do instant prototypes and the requisite testing. Approaches require a short “waterfall” approach before writing User Stories.

Scaling Agile isn’t easy. A scrum of scrums and SAFe are one person’s take on Agile’s answer to portfolio management. Proceed with caution as I have yet to see a successful implementation of SAFe.

Development teams don’t want structure

Creative teams don’t like process. They bristle under micro-management. They embrace Agile because scrum teams are nearly autonomous in what they work on, what order and by whom. Classic waterfall project management opponents outright reject large Gantt charts, critical paths, associated resources and precise prototypes stages today, and for a good reason, it’s bureaucratic and burdensome.

However, Agile has its limitations too. Because of the brand equity associated with Agile now, executives have little ammunition to dig in and debate the innovation methodology and process. Results seem eerily familiar: projects remain stuck in development, schedules aren’t maintained, and it stretches people beyond their limits.

Development teams must have constraints. You must define the innovation process, while keeping it dynamic. You must also closely monitor autonomy and holacracy. Teams often hide poor performance behind industry accepted development methodologies. Be aware of the advantages and disadvantages of each approach if you are going to implement them. If not, you may create a confused, frustrated team.

Nearsightedness Kills Innovation

This system became famous in its industry for its original implementation of lean in the early 2000’s. Following their heyday, the CEO went on to be quite famous and started a consulting firm helping implement lean in other healthcare organizations. However, they were still not achieving the breakthrough level of performance improvement they needed or wanted. They called me in when they were looking to redesign their care model for their high-risk patient population. By definition, we included the top five percent of these patients. It would require a new way of thinking about things.

Per my typical requirement, they named a leader and set-up a cross-functional team to successfully execute this massive project. We established stretch goals and began work. The team developed an in-house, risk stratification method to define the patient population for the new care model. This patient population was then studied to determine their barriers to care and better health. The insights were staggering. One patient traveled over 5,000 local miles annually to get to all of their appointments. Another patient had 66 physician interactions in one year; more than one per week!
Patients were interviewed, observed at home and brought into focus groups.

We studied their engagement with the healthcare system. Their needs and pain points became evident, and the brainstorming of solutions began. Soon, a new model of care began to coalesce. It was different than anything this healthcare network had done before. Every patient would have an interaction with a patient care team that acted as an extension of the primary care provider. The team included all critical elements determined during research: a pharmacist, a social worker coordinator, a behavioral health counselor and a triage nurse. The experiments began. The team saw multiple successes in medicinal accuracy, blood pressure control, blood sugar reduction, physical activity and patient engagement.

My involvement stopped when they were expanding the patient cohort. It was then the Operational Excellence team swooped in and almost destroyed the efforts. This company struggled the entire length of the project despite years of Lean implementation and associated subject matter expertise. Eventually, the COO disbanded the effort, even though the health outcomes were outperforming even the best physicians in their network. This organization struggled with many of the Becoming Endurance principles outlined in this book and the results have become obvious.

If you talk to the former CEO of this organization, he will say he wonders why they only came up with two “new” things during his tenure. My analysis and involvement made it clear that they were expecting the operational excellence tool kit to innovate. It is unable to do this; you need innovation techniques. Teams can’t innovate when you’re staring at the bottom line every month. Executives have to be 100 percent committed to the project once they decide to do it. The project should keep going until it’s time to stop it altogether. Why? Because nearsightedness kills innovation.

Priceless Gems

I was standing in a heavily secured room in the diamond district of Manhattan. In the palm of my hand was a large, pink diamond worth hundreds of thousands of dollars. I then held a smaller, yet more valuable, blue diamond worth millions of dollars. The value of those diamonds was legitimate, but their value wasn’t always known. A few decades ago, diamonds were worth whatever a salesperson could get for the diamond, often not even selling an actual one, but a knock-off gem. That doesn’t happen much anymore, or ever if the stone is certified. Why? In the early twentieth century, founders started a non-profit organization with the distinct purpose of protecting consumers from jewelry con artists.

The most, publicly famous output of this non-profit organization was the 4 Cs of a diamond: color, cut, carat, and clarity. Diamonds could now be valued based on criteria established by each of the Cs. This judgment is what determines how much a diamond is worth. Diamond owners can, for a small fee, have their gemstones assessed by expert graders, giving confidence to buyers and sellers about its quality. This organization created criteria not only for diamonds, but also all types of gems as they expanded their protection of consumers. They trusted me to hold the blue diamond in my hand, and they also trusted me to help them on their next part of the journey.

The biggest gap in the jewelry world then became the jewelry itself, not the jewel that goes in it. Most of us don’t think about it, but the shape of prongs has specific best practices that hold and display the stone forever and can be disastrous if done poorly. Cutting, polishing, soldering, casting and many more techniques can be done well or done poorly too.

Ring mold
Mold for platinum ring.

Under the leadership of their VP of Education, they hired a Director of Jewelry Design. He was responsible for growing and teaching tomorrow’s bench jewelers using world-leading, best-in-class techniques. This direction meant a complete overhaul of a specific certification program from the ground up. We recreated the entire program using innovation processes and visual management techniques. We interviewed instructors and students and identified pain points for each. Brainstorming began.

The team gutted the hands-on focused, outdated classrooms so students could easily interact with the instructors during praxis. We threw away the educational, paper-based study material and recreated in an electronic, interactive, tablet format for all classes. The response was overwhelming. Both students and instructors raved about the changes. Attendance grew, and the company was back on track to better protect and inform consumers in another area, jewelry design.

At the same time, I was able to successfully have my wife’s twentieth anniversary ring designed and built. I relied on contacts made while working there. With certified diamonds, the right precious metal, and a recommended bench jeweler, I was confident of what I was getting would last forever. It all came together, and I was able to present her with the ring during our anniversary trip to Alaska. She gets compliments all of the time, and I’m confident in what she wears everyday is worth what I paid.

anniversary ring
Ring I designed for my wife on our 20th anniversary.

Mandatory Steps for Basic Healthcare Reform

W After ten years of driving healthcare reform with healthcare systems, medical device OEMs, and thought leaders, I have an opinion on how we can get it done. I posted this on social media recently:  “There are 2 parts to driving #healthcarereform of reducing cost and improving outcomes: 1) Who gets care and 2) How care is delivered. Both need a radical overhaul.”

Someone replied, “Can you provide more detail around those points? How do you envision rationing who gets care? How would you go about innovating the delivery [for] that care?”

This article is meant to hit the highlights for each of those three questions. To keep it short, I’m not going to include all of the statistics so you will have to research them yourselves.

Who Gets Care

With the discussion of Obamacare and its repeal, the topic of “medically uninsured” is top of mind for many people. Some argue that healthcare is a right and that inequality and disparity of outcomes is unacceptable. Maybe it is, maybe it isn’t. I will leave that to the politicians and social reform.

There is much we can do regardless of where we stand on that topic. There’s a significant amount of healthcare spend and poor outcomes with births, untreated chronic diseases, and end of life.

Babies and their moms

Our babies need to come healthy into the world. Costs can be driven up for their entire life if someone has a poor start in life. Many infant mortalities and complications can be avoided with simple, prenatal care that is unavailable or unused for or by too many people.

The Chronic Diseased

With 45% of Americans having at least one chronic disease, healthcare reform must address this. We have to care for people with chronic diseases before exacerbations. Ultimately, we would like to drive down the rates of diabetes, hypertension, asthma, and others, but we can make a significant improvement in healthcare by offering easier treatment and education plans that are non-hospital, non-clinic based with minimal physician involvement.

Those Dying

We need to start talking about end-of-life sooner. When a loved one is in the hospital, it’s too late. I have seen far too many instances of family members trying to extend the life of their loved one for weeks days or even hours however possible. Not only is it uncomfortable for the person dying, it’s outrageously expensive and ultimately ends in death anyway. We should move to having 100% of advance directives in place prior to hospitalization. We should also talk about death with dignity in a non-hospital environment.

How Care is Delivered

Any industry is going to protect the status quo and tradition. It’s easier because it doesn’t require the players to change. Healthcare is no exception. Its employees are the most educated in the world. They have significant incomes and tremendous power. They accept change when legally mandated or when it could negatively impact revenue or personal income. Healthcare reform demands a change in how care is delivered.


Last week, two major academic institutions announced hospital projects. Total spend for two facilities is expected to be $8 billion! Both were claiming to advance medicine and offer the absolute highest level of care for patients. They used fancy words like artificial intelligence and precision medicine. With healthcare spend in the U.S. at nearly 20% of GDP, projects like this are fiscally irresponsible.

Hospitals should only be used for the highest acuity issues, academia should conduct research but everything else should be treated somewhere else. The smaller and more distributed treatment places are, the better. The centralized hospital model continues to drive unprecedented levels of inconvenience, cost, and societal impact. They increase traffic, have poor or expensive parking, require long patient commutes, have acquired infections and more. It also puts people in the worst healing environment: a hospital room.


We have overqualified medical professionals treating patients with simple issues. For many health issues, we don’t need to see an actual doctor. A nurse, nurse practitioner or physician’s assistant is more than sufficient. For other issues, our primary care physician isn’t the best and we should talk to a specialist. We can’t overutilize the high-priced experts, though.

We must use specialists, subspecialists, and super subspecialists only when necessary to return a patient’s health to “normal.”


We can’t continue to require a patient to schedule an appointment at a doctor’s office. It’s overkill. A significant number of appointments don’t require “hands-on” presence of a physician and they can be done via phone call, video conference, email or text. We must kill the office visit unless absolutely necessary.


Having open hours when the majority of dual-income families are working is ridiculous. Opening at 9 AM and closing at 4 PM doesn’t work. Non-acute healthcare, especially primary care, needs to be available before normal working hours and after normal working hours. Finally, we can no longer have providers that reject evidence-based medicine and instead rely solely on their own experience. Too many physicians and offices are clogging their schedules with appointments that are medically unnecessary. This includes everything from annual physicals to how often and how early a woman should get a mammogram.

Innovating Care Delivery

We have to innovate our patient care model to achieve healthcare reform. As much as I would like to think that an existing healthcare system can do this, there is little evidence that they can. There are very few systems that even have an innovation center in place and even fewer that focus on the patient care model. Most want to be a tech incubator for new ideas from the surgeons or physicians. While I applaud those efforts, we can have a significantly higher impact by investing equivalent time and resources into care model changes.

This requires a systematic approach with a dedicated team. A hospital or healthcare system must invest in the minimal number of resources required to develop new care models. It is a skill set not possessed, taught or practiced in any healthcare environment yet we must establish and expand this skill set, everywhere.

We can’t expect corporate mega-conglomerates to come up with the best way to care for patients. They are focused on selling technology and solutions at a high-profit margin. They rarely understand the customer, the entire healthcare process or the people delivering it. You must have an immersive, ethnographic process, such as design thinking, coupled with technology development and change management. It must be internal- healthcare systems know their patients and market best.

Create Healthcare Reform

Now, when I say it only takes two things to impact healthcare reform, they are big things. However, I have personally led and experienced organizations that are taking the right steps. There are companies like CVS which are redefining care delivery.

Reform will happen. Time will determine the winners and the losers. It can’t be the patients. Check out my article on Population Health for a deeper dive.

Value Proposition Sells, Not Technology

Here’s My Marketing Plan

I met with the marketing lead of a tech startup recently. He was developing his 2018 marketing plan and wanted my feedback. The company’s business model was B2B with a focus on “industry distributors” as the sales force to the end customer, employers. My first question was, “What is your value proposition?”

He had a great timeline that included the appropriate different campaigns, content, and targeting. He told me the areas he would be focusing on. It was all good stuff but with a limited budget, it would not maximize the results. He was highly underselling the value of their disruptive offering by promoting the wrong elements.

What Problems Does It Fix

The most important of all marketing dimensions is your actual value proposition. What is it that your product or service does better than anyone else? Why would someone want to buy what you have over what they are currently using? If you can answer those, without listing features, you have your value proposition. As innovation guru, Clayton Christianson would ask, “What job does it do?”

This should answer questions such as: Does it make my work easier? My life better? Is it cheaper? Can I expect higher performance levels using it? Particularly with B2B models, you are displacing an incumbent and must show a significant improvement to be worth the extra hassle of dealing with a new vendor.

Technology for technology’s sake is not good.

Although people may be wowed by it, your technology is not the value proposition, it simply enables it. Technology for technology’s sake is not good. It must solve a problem. The more widespread the problem, the higher the potential for success. The better it solves the problem the more people will be willing to spend.

If you can clearly articulate the one to three customer “pain points” solved by your solution, you can get a buyer and you can easily enable your salesforce. The harder it is to articulate a value proposition, the more difficult it will be to sell your product.

The Value Proposition Sells Itself

As you can see, your go-to-market strategy should be a natural extension of your product development. Even if your salespeople can sell ice to an Eskimo, it’s better to give them messaging that makes their job easier and you will sell much more. It can be as simple as a clever rewording of the information you uncovered during the early design thinking stage. You will have an excellent message.

With everything in development, it should be tested. It’s very easy to get early feedback by meeting face-to-face with the sales members and key customers. Do this at least once prior to campaign launch to ensure success.

Lead with what your solution can do, not what makes it do it. 

Passionate People Can’t Wait

“I just want to succeed in life.” Then you better be passionate about something.

There are few things that satisfy more than doing what you think you were built for. Without getting into life purpose and that challenging exercise, I just want to address passion. Those with it achieve far more than those without it.

I have a pretty high standard for those on my teams, especially for leaders. In addition to subject matter expertise, they must have creativity and be hardworking. Above all though, I favor the passionate. If there is alignment to values, they become unstoppable. It starts early in one’s career.

Don’t Be Boring

When I look at a new grad’s resume, I don’t care about the college portion: the school, the GPA, the classes. It’s easy enough to find people who check those boxes. I want to know what else they did in college. Where did they spend their free time? What projects did they work on? What are the interesting activities and why did they do them?

The same goes for an experienced professional’s resume. Positions and descriptions bore me. Show me the cool stuff they did. Was there something they almost got fired doing. What impossible project succeeded? What do they do outside of work? I want to see what really gets them going. The intersection of passion and talent is incredible.

A Burning Within

The passionate can’t help it. It’s a fire inside of them screaming to do something. The passionate have an unfair advantage. They possess an unrivaled internal engine. You don’t have to get the passionate started for what they believe they’re to do. They figure out a way and do it. They don’t wait for education, job training or permission. They do it because they’re curious and courageous. The passionate change their world.

Passion minimizes the negative by focusing on the possibilities. Obstacles get smaller. Problems are simply issues that have to be solved. Failures are lessons learned.

What do people care about? What do they enjoy doing? What would they do if they didn’t get paid to do it? That’s where the passionate become obvious. Everyone has something. If you don’t see it in someone, there is probably something deeper: it could be job misalignment, troubles in another area of life, current work assignment, competency frustration or depression.


If you’ve lost your passion, consider your career trajectory. Change it if you need to. I’m serious. If you don’t have a hobby, get one. Find something that makes you passionate and do that thing. Do it really well. Life will be better and you will feel like you are succeeding.

Population Health and What it Really Means

State of the Union

It’s hard to discuss population health or the topic of healthcare in the United States and not hear about how expensive it is. In the United States, we spend about $10,000 per person per year on healthcare. That amount is approaching 20% of our country’s gross domestic product. The Peterson Foundation tells us, that second place for highest per capita healthcare spending is Switzerland, at about $7000. Sweden and Germany spend about $5000. France is at $4500, while the UK, Australia, and Japan spend about $4000.1

Despite the high spend, both media and healthcare reform advocates point to the fact that the United States is behind many industrialized nations in quality of care. The current WHO ranking for the U.S. healthcare system is 37th.2 Many wonder how we spend so much and seem to have the best at everything, yet still have such a low health score. If you are an American, white male who is wealthy and educated, you have access to the best healthcare in the world, period. Change any of those variables, and your access to that “best healthcare“ is diminished. Period.

The factor of wealth alone lead to a thirteen-year difference in age of death.3 Some would say your zip code is the primary indicator of longevity. In greater Philadelphia there is a twenty-year difference in lifespan between the best and worst zip codes. Spend varies wildly too. In America, 20% of our population accounts for 90% of our spend.

There are multiple factors to our ranking but the biggest impact is the discrepancy between the people with the worst health in the U.S. and those with the best. It depends how you define health or what factors you consider lead to a healthy environment whether your country is ranked high or low. In fact, there were 100 indicators in use by WHO in 2015.4 For example, our alcohol usage, sexuality, suicide and obesity negatively impact our numbers compared to other nations although we rarely deal with other issues like tuberculosis or amount of spending on healthcare.

Population Health Panacea

Most medical literature today mentions population health. Healthcare systems are promoting it across the country. Universities are beginning to offer certification and advanced degrees in it. Hospitals and health systems are hiring executives to run it. A countless host of medical vendors are offering solutions that deliver it. What is it?

In 2003, Dr. David Kindig, Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin-Madison, proposed that population health was “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”5 Three terms should jump out: outcomes, group and distribution.


The World Health Organization defines an outcome as a “change in the health of an individual, group of people, or population that is attributable to an intervention or series of interventions.” It is the resulting change in health after a specific effort. WHO includes things like malaria and access to clean water in its world health ratings. We simply don’t worry much about those in the U.S. However, our culture of sexual freedom does care about the incidence of HIV and access to family planning, two other outcomes used by the WHO.

The problem with outcomes is the variation. They could be macro-measurements like national infant mortality rate or expected lifespan; or they could be very targeted measures such as uncontrolled diabetes in rural areas or hypertension of people living in economically depressed regions.

You have to determine what outcomes you are trying to move. They must be defined and measured. They must be tracked. It could be the percent of women over 50 with a biennial, breast cancer screening. It could be the blood pressure for all adults in a county. The combinations of outcomes are infinite. You must decide which are important and which aren’t. Once known, an action plan can be created and deployed. Outcomes should improve over time. This will define whether your interventions are working or not. You can’t use the same outcomes for different groups. Each group must use their own customized outcomes.


There is the “population” part of population health. Kindig calls it a “group of individuals.” What defines a group? Like outcomes, there are an infinite number of ways to define a group. Using the previous example, the group could be all women over 50. It could be the entire state of Ohio. Health systems, however, like to define populations by disease state or condition.

Several tech firms offer software to “identify all individuals” with a high-risk condition that will eventually lead to an exacerbation and hospitalization if left untreated. Popular ones include all patients with a blood pressure greater than 140 over 90 (hypertension) or all patients with a hemoglobin A1c over 7.0 (uncontrolled Type 2 diabetes).

For this reason, many healthcare systems have been forced by insurance companies to hire nursing care coordinators (CCs). These CCs specifically target rising-risk and high-risk patients to lower the cost of future care. Therefore, they define populations as the ones “on these lists.”

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. There population includes anyone approved for participation in the program.6

Medicaid is a state program (funded jointly by states and the federal government) that provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities.7  There are fifty different populations for Medicaid.

Depending on your interest, the population varies. Often people are overlooked until there is a known problem. There is very little interest in healthy or low-utilization groups of individuals.


The term “health inequities” is used when negatively defining distribution. The WHO defines health inequalities as “differences in health status or in the distribution of health determinants between different population groups.” 8 For instance, what are the individual BMIs for a group of people and why do they vary. Is it due to lack of access to healthy food or regular exercise or is it something else?

Some believe the distribution of outcomes should be equitable across the entire population. Zero variance is best. There shouldn’t be spikes, dips and huge variances. Your view on how equitable variation should be likely determines your political alignment and what the government should be doing for poor performers. Regardless, everyone is placed in the healthcare system. It is complex.

Healthcare Players

Healthcare providers, federal and state government, employers, and insurers are the major institutions in healthcare. Supporting these are a host of other entities such as medical device makers, pharmaceuticals, IT firms and more.

Healthcare Systems

According to Becker’s Hospital Review, just over 20% of United States hospitals are run as a for-profit business. That leaves almost 80% that are either not for profit or government funded. Provided they achieve annual profitability to continue operating, their primary focus is providing care.9 Healthcare systems provide the actual care for the patient in outpatient, inpatient or virtual settings. They own the physicians, clinical staff and administrators that run hospitals and clinics. They bill a third party for your services. This is the government or your insurance agency.


The government creates policy that impacts all players in the healthcare arena, including all of the aforementioned entities. It is their responsibility to look after the health of its citizens. Historically, government’s view on health changes based on which party controls it.

The U.S. government pays for about half of all medical expenses today. Medicare and Medicaid make up nearly forty percent of spend and other government programs are an additional twelve percent. (Private insurance is over forty percent and the balance of the total spend is out-of-pocket.) The government became a significant player in the healthcare market when most insurance was running through employers, leaving out the elderly and poor. The Medicare bill that included Medicaid was signed in 1965. This led to the formation of Centers for Medicare and Medicaid Services (CMS).10

Although there are nuances, the federal or state government sets the amount they are willing to pay healthcare providers for services provided to Medicare or Medicaid patients. Some suggest that the healthcare reform CMS is pushing is pop health. Initiatives like Accountable Care Organization (ACOs), Merit-based Incentive Payment System (MIPS) and other APMs (alternative payment methods) are mentioned in these discussions. I would call this hint-of-pop-health-flavored healthcare. It’s the government’s way of controlling costs and telling healthcare what they will and won’t pay for. It’s not population health.

Healthcare providers are stuck in between the patient and those paying for it, trying to figure out outcomes and populations and interventions. Eager, publicly-traded mega-corporations stand on the sideline, ready to fill the performance gap with solutions. The government defines the reimbursed amount clearly. The healthcare systems have to comply. The amount owed by non-CMS patients varies wildly. Primarily, insurance companies negotiate with health systems on behalf of employers’ health plans.

Insurance Companies

There is no altruism among healthcare insurance companies. They simply want profit. They want a greater share of the insurance dollar. Your health only helps their revenue. The more they collect (from you or your employer) and the less they pay out (for your visits and meds) the more money they make. Costs are controlled by increasing premiums and deductibles. Rates are negotiated with employers on an annual basis. They won’t lose money. That is why many are not on the exchange in many states.

Less than a century ago, there were no health insurance companies. Health insurance started when a Baptist hospital was looking to keep the bills paid. The hospital worked with a group of public school teachers in Texas. For fifty cents per teacher per month, the hospital would pick up any medical expenses for the teachers. This employer-based plan gained popularity during the Great Depression and eventually got a name: Blue Cross.11  When funneled through the employer, the benefit was tax-free. Eventually, if you were employed, your employer would cover a large portion of your health insurance. The unemployed had to find insurance elsewhere.


For the foreseeable future, employers continue to foot the bulk of the medical insurance spend. Most will send you a statement of benefits showing what you used the prior year. This is useful to decide during “open enrollment” for the following year. Costs are going up the cost of care increases and as the health of our nation decreases. At some point, we must fix the direction of both. This is accomplished by addressing health determinants.

Determinants of Health

You health is determined by five areas. These areas are called the determinants of health. They are biology and genetics, socio-economical, individual behavior, clinical care, and the environment. Each contribute to your overall health. Although 88% of our spend is on clinical care, only 14% of our health is impacted by it. The vast majority of our individual health (79%) is determined by our genetics (30%), socio-economics (28%) and behavior (21%). The remaining 7% is due to our environment.

These determinants impact our health. They create health inequities. They impact the distribution of health across a population. They determine who will get sick, from what, and why. Some we can control. Some we can’t. Some are easy. Some are difficult. Everyday, we make a voluntary or involuntary deposit to our future health. At some point, we will have to pay for a lack of health. 

It is the area of socio-economics that most pop health thought leaders want to target, hoping to improve the lives of those suffering from health inequalities. However, this means a greater invasion into our lives.

Healthcare’s Blurry Lines

Based on a 2015 research study with a client in eastern Massachusetts, a vast majority of patients do not want more interaction with healthcare, they want less. Healthcare is intrusive to their life, not complementary.

They consider health as the ability to do life. There chronic conditions and acute incidents are annoyances in the way of doing life. Their last resort is to enter the healthcare system with all of its cost, complexities, and inconveniences.

Population health advocates want more involvement in the lives of people. They want to push healthcare up the value chain and be even more proactive in people’s lives. They want it to include community meetings, school involvement and rigorous legislation. They want to expand it beyond clinical care. Maybe you agree. Maybe you don’t.

When there is a breakdown in our health, we want it fixed. There are two sides to fixing it: providing healthcare and paying for it. Anyone can find a doctor. Who should pay for it? Does age matter? Race? Level of wealth? There is currently no one responsible for the health of an individual over their entire life. Therefore, population health is a glimpse at a group of people’s health at a specific point in time, either good or bad. It is a snapshot that tells part of the story.

Our determinants impact our need for healthcare and thus our spend. Fairness means we should each pay for our personal predispositions and lifestyle choices along the full continuum of our life. If we are more prone to certain diseases, use tobacco products, eat poorly, fail to exercise or are sexually promiscuous, we should pay more for health. People must be personally responsible for their impact to lifetime healthcare costs.


In my humble opinion, we need a party that is vested in an individual’s full-longitudinal lifespan of health across the entire population. This could be solved with a universal insurer. Our base healthcare would be covered by this insurer and our premium would be accounted for by our top three determinants. Extras such as non-elective procedures would require an additional premium. We would have a full lifetime view and responsibility.

Is population health the future? Some say yes. Others disagree. Truly doing population health would require a massive overhaul that would make the Affordable Care Act seem insignificant. Is it right? Probably. I wrote another article that shares how we can fix health care without waiting for the government. As for me, I’ll keep working on my own health and its contribution to our country’s health.

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