A huge, huge, cost driver in many of the applications is the fact that they have to integrate with the old systems in numerous ways.<p>A startup could probably build the basic version of many of these apps no problem, but that&#x27;s only the tip of the iceberg.  When you have to then import millions of customer records, which were not stored in any particular format (they&#x27;re idiosyncratic with each doctor&#x2F;office), and then integrate with the COBOL based system vendor 1 uses, and the IBM Mainframe that vendor 2 uses, oh, and those systems were never intended to interconnect with anything and the vendors are years behind schedule as well, and all while you have lawyers breathing down your neck with a 28 inch thick binder with all of the regulations you need to follow written in impenetrable legalese you can see how it can cost billions of dollars.<p>Your startup guys heads would explode if you asked them to write a formal specification for an interconnection system between their elegant web frameworks and a big blob binary COBOL based record system on an IBM 360 with only hardcopy documentation written by a vendor that went out of business in the 80s.  And yes, healthcare systems still run in environments like that for the reasons mentioned above:  making a new system is too hard&#x2F;expensive.<p>Oh, and the vendor that had the lowest bid for the contract is planning to outsource to some country that doesn&#x27;t speak English and is 12 hours offset from your local time.