Peeling The Healthcare Onion, By George Van Antwerp

George Van Antwerp is a Vice President at Silverlink Communications where he focuses on developing healthcare communication solutions across the industry with a focus on the pharmacy space. He and I have been conversing back and forth by email for a couple of years (since before he joined Silverlink who are—FD—sponsors of THCB & Health 2.0). He blogs regularly on both topics at Patient Centric Healthcare and today is his first post on THCB

I think an onion is the right analogy for healthcare for three reasons: (1) it can make you cry; (2) every time you pull off a layer you learn more; and (3) what you see from the outside is a lot different than what you see from the inside.

  • It can make you cry.

When you have the Congressional Budgeting Office projecting the healthcare costs will be 49% of GDP by 2082, you know things have to change. This is a front page topic almost everyday across the country. But, like an onion, if we don’t handle this right, it will make you cry out of frustration and pain. Change is not easy especially in a complex system that we have today. Finding the right mix of push and pull is going to be important.

Quality is still an issue across the system. Biting a bad onion or having a quality issue with your care can make you cry. Look at the USA Today article from yesterday about Too Many Prescriptions, Too Few Pharmacies or an entry on my blog about the Institute for Healthcare Improvement.

  • Every time you pull off a layer you learn more.

This applies so many ways to healthcare given our system, but I think of this from two perspectives – data / information and process. We have so much data in healthcare, but without the right model to make it into information, it just sits there. And, as we layer data (e.g., medical plus pharmacy plus lab) or integrate healthcare data with demographic data, we can learn so much more about our patients and how to care for them. This ranges from simple questions such as how to motivate behavior (e.g., cost savings versus loss avoidance) to how to deliver information based on their learning style.

Every question you ask (or layer you pull off) reveals a new set of data that can be transformed into information while at the same time creating new questions. Does the relationship you found in the data simply indicate correlation or is there actual causality there? I look at the data that CVS/Caremark presented around saving 30% of healthcare costs by driving compliance and adherence and wonder why people aren’t jumping up and down trying to capture this savings.

  • What you see from the outside is very different than what you see from the inside.

There is a concept in Six Sigma about designing the process from the outside-in. Imagine sitting in the middle of the onion…all you see is onion all around you. That is a common pitfall when solving problems in the industry that we work in. We are too close to the problem and the historical solution.  If all we see is the onion, those on the outside (our patients / members / employees) see the onion in relation to other food options. Their expectations for healthcare are produced by other companies that they interact with. They expect web solutions that work.  They expect excellent service. They expect to be valued as a customer and of course need the power to walk away and chose another option.

This is a common problem in healthcomm (healthcare communications). We present information in a channel that we believe is effective based on our experience and paradigm (i.e., written, verbal, kinetic). We use language that we think is helpful. A few of my favorite examples from my PBM days are:

(1) Telling patients that they need a renewal (prescription). They don’t know what that means.  It means they need a new refill since their original prescription refills have run out.

(2) Telling a physician to consider prescribing lisinopril and giving them sample bottles that say lisinopril. (Because, of course, they would know the chemical name for Zestril.)

But, this happens all the time. Telling a person that wants all the facts a lot of qualitative information will fall on deaf ears. Providing a person with lots of options when they’re looking for an expert opinion will frustrate them. One way to frame this is based on personality type.  (Of course, that information isn’t sitting in a database somewhere for us to tap into.)

The reality is that people are different. As you think about your healthcare process, try to be the patient. As one of my bosses used to say, give it to your grandmother and see what she thinks.  Can she understand it? Can she make sense of the process?

It’s not easy finding the right amount of onion to use in your recipe, but it is important to continue trying to improve.

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The Conversion of Our Protector The Food and Drug Administration originated in its primitive form at the time several decades ago to ensure the health and safety of the citizens of the United States. However, their focus seems to have changed, as they appear to have formed a pathological alliance with the pharmaceutical industry through the money the industry gives the FDA for various reasons, yet so large amounts of funds are issued to the FDA by the industry that it has resulted in possibly half of the FDA’s annual income. Results of this relationship, one could posit, have been… Read more »


It’s basically a mess. Here’s how to fix it: A New Wellness Paradigm How to Fix the United States Health Care System We Must Do It Ourselves “Problems cannot be solved at the same level of awareness that created them.” –Albert Einstein Identify the Components: Ones That Work and Ones That Don’t The first step to solving any seemingly daunting problems is to break it down into component parts, identify what works about the existing status; and what doesn’t. It’s crucial to learn from the past. As a physician and owner of a solo practice (small business) I’ve experienced the… Read more »


There is plenty of blame to go around:the providers, insurance carriers, tort reform etc. The realty is 82% of every health care dollar is a CLAIM dollar. Poor behavior=culture of no accountability=poor health=high claims. Want it to stop? Change the culture, disrupt behavior and stop rewarding it. Want the truth? Read ‘You Have an Ugly Baby’, this manifesto will rock your world as well as provide a way out.

Steve Kirk

The onion analogy is exactly the right one in this case, because it seems as if each “new” idea for quality improvement, cost savings or heaven forbid, improved patient access or outcomes looks exactly like the last. It is enough to make you cry and the frustration of nearly identical results “layer after layer” is beyond description. I agree whole heartedly with the suggestion that key healthcare planners, managers and insurance executives would have a totally different perspective and find real and renewed motivation for change if they were to spend several days and nights in our august health care… Read more »


In the current healthcare system, the welfare of patients and doctors are placed after politics, profits, and special interests. The consequences of this reality are sufficient to make all close observers cry. As a physician, I find it troubling to see opportunistic entities getting in the way of delivering appropriate care and driving up costs. Physicians should mobilize and be directly involved in the next wave of healthcare reform. Here’s an interesting campaign currently underway that can have a meaningful impact on raising public awareness about the reasons behind our broken healthcare system: http://blog.seankhozin.com/2008/02/12/test/


Onion metaphore’s aside, the issue of viewing healthcare from the patient’s perspective is critical. I’m convinced that many hospital administrators and many physicians in particular would benefit greatly from two nights in a hospital as a patient. So much of the way we treat patients in all phases of care are based on what is convenient for the “workers” and not for the patient. Plus I believe workers (including physicians) in healthcare are so weary that it affects the way care is provided.

Dierdre M.
Dierdre M.

Huh? Those who use the tiresome metaphor of “peeling the onion” have never actually peeled one, I’m convinced. If they had, they would notice that, after taking off the outer dry skin, each layer of the onion is alike. They would also notice that there is no core to the onion—it is entirely made up of these very similar layers, so there is nothing to find by peeling them away. The onion hides no essential mystery: its layers have nothing to reveal.
Gunther Grass has labored this metaphor to death. http://www.nybooks.com/articles/20490. Please, someone, provide the burial it, like all onions, deserves.