Getting America’s Health “Left of Bang”

One major benefit of supporting Mission’s extraordinary Security team is that I’m exposed to books that wouldn’t normally hit my radar.  The most recent example (thanks Robert Whiteside) is Left of Bang by Van Horne and Riley.


In the book’s language “bang” is the explosion of an IED, an active shooter in a hospital, a suicide bomber in a cafe, and so on.  The challenge for soldiers and security leaders alike is to move from a “right of bang” operational mode, where the team reacts as best it can to an already bad outcome, and instead adopt techniques that support a “left of bang” preventative approach.

It’s a terrific read, and teaches fundamental skills that anyone charged with protecting anyone else (a family, a hospital, a country) can use to identify situations heading towards “bang” and intervene to prevent them.

As I’m reading (or more truthfully Audible-ing) the book though, I can’t help but think the same concept of “bang” is more broadly applicable to American healthcare.  For too long, healthcare in America has operated right of bang, to the point that most of medicine is centered around teaching practitioners to identify the relevant bang among a differential of many possible bangs and treat it as fast as possible.

If you’re having a heart attack, American hospitals seek to reopen your coronary arteries within 90 minutes of hitting the Emergency Department door.  If you contract Hepatitis C, there’s a $90,000 cure waiting for you in a handful of pills.  If you’re an obese smoker with diabetes, high blood pressure and high cholesterol, American medicine has more drugs and procedures that you can count to treat it all.

But this right of bang approach has led to a healthcare system that is structurally and fiscally aligned with reacting to disease instead of preventing it, and an outcomes curve whose slope is dwarfed by its ever-rising cost companion.  Much like the Wars in Iraq and Afghanistan forced the military to recognize it needed to shift from a reactive to a proactive mindset, its time that we really begin moving health in America left of bang… and here are three reasons I’m optimistic we can actually make it happen:

1. Technology is finally enabling it.  More then Hippocrates could ever have dreamed, healthcare is swimming in data that can open our eyes to the paths of clinical decline before they’re actually taken – both at the individual and at the population level.  With the past decade’s multibillion dollar investment in electronic medical records paying off in yottabytes worth of information, companies like IBM, SAS, GE and PeraHealth are all leveraging the power of analytics to crunch it.  Predictive algorithms can now support everything from hospital operations (moderately hard) to individual patient’s clinical experiences (very hard) to whole population health management (ridiculously hard).

But even that’s just the start – before my kids are old enough to drive, predictive will progressively flip to prescriptive, and when this happens physicians, nurses, and administrators alike will all need to get comfortable allowing the data not just to tell the story but to take independent action.  With Watson now processing 800 million pages of material each second, the hyperpotent combination of smart people/companies + oceans of data + incomprehensibly powerful computers will not only solve the challenge of exponentially expanding medical information but find new, cost-effective and highly efficient ways to drive our interventions left of bang.

2. Finance can finally support it.  In a fee-for-service world, moving left of bang has often been clinically wise but financially foolish.  As many leading systems have published (including most recently Intermountain in their 2016 HBR piece “The Case for Capitation”), preventing disease and its associated fee-for-service interventions reduces provider revenue when you’re only paid “by the widget.”  As America accelerates its move away from our fee-for-service past through the pay-for-value present and into a future where providers take on increasing amounts of risk, the fiscal rewards of moving left of bang begin to outweigh the penalties of losing fee-for-service revenue.

In the HBR piece above, James and Poulsen cite “23% to 29% of [a provider’s] payments” linked to capitation (global fees paid in a per-member-per-month manner instead of per visit, per surgery, per x-ray, etc) as the tipping point, where the ability to invest in left of bang strategies generates enough ROI to become sustainable.  And even in a potentially post-Obamacare era, MACRA is a clarion call that as of 1/1/17 began pushing providers towards greater risk and its 392-37 vote in the House suggest it isn’t going away soon.

3. The American people may finally accept it.  Americans believe perhaps more than any other people else on earth in the autonomy of the individual – so much so that “the pursuit of happiness” is one of the inalienable rights we declare to be endowed by our Creator, right after life and liberty.  While the interplay between independence and interdependence has always claimed a leading role in the story of America, today’s Americans are increasingly more likely to accept some interdependence, if not on each other than at least on technology, to improve their daily lives.  In an era when Siri tells me to take a detour to avoid traffic without me asking her, Google reminds me of my niece’s birthday in enough time to Amazon Prime her a present, and millions of people are sharing their step counts, exercise regimens, and continuous heart rate monitoring with Apple, Garmin, and Fitbit, we Americans have shown ourselves accepting of increasingly intimate intrusions when we believe they have real value.  And what could be both more intimate and more valuable than our health?

In order for the power of both the technology in #1 and the fiscal alignment in #2 to actually get health in America left of bang, Americans have to be willing participants in the kinds of interventions that can really make a difference.  Like accepting an Uber to get you to and from a doctors appointment when you don’t have transportation (see Ride Health) or allowing community paramedics into your home to help with medication adherence (see Mission’s Caramedics).  The Facebook generation has shown itself willing to make these and other tradeoffs, and they’re leading the way for their parents, grandparents, and even great-grandparents to do the same.

In the end, if we are going to transform health – not just healthcare, but actual health – in America, today must be the day.  With Americans’ life expectancy dropping for the first time in decades and the CDC adding new colors to its obesity map each year, we are truly standing on the precipice of a health disaster that only a left of bang shift can address.

In his book Sapiens, Yuval Harari says:

“We are standing on the thresh0ld of both heaven and hell, dancing nervously between the gates of one and the ante room of the other.”

If there’s ever an opportunity to deliver evidence-based, left of bang health interventions to America’s people and tilt the balance to the good, the time is now.


  1. Chris,

    This is a really great article on transforming healthcare *and* health!

    I’m glad that you enjoyed Left of Bang :).


  2. Reblogged this on Conflict Transformation & Ethical Guardianship and commented:
    Hi All,

    Please see this great post by Dr. Chris DeRienzo. He applied Left of Bang – a seminal book on staying safe, being preemptive with situational awareness, and proactively spotting threats – to the transformation of healthcare and health toward a model that is far more proactive. It’s an amazing post that takes the “left of bang” perspective and very effectively applies to a different discipline (one very important for us all).


  3. […] my last post I referenced “the pursuit of happiness.”  These words are from the most important […]

  4. Chris, I just stumbled across this. I’m pleased to see the concept of LoB applied across industries; and I completely agree that an ounce of prevention (in terms of health) is worth a pound (or thousands of pounds) of cure. Nice post. Thanks for referencing LoB. Jason (co-author of LoB).

    1. Thank-you Jason. Please feel free to share with your network – your book’s concepts carry far and wide!

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