Better health, patient experiences and lower costs can be achieved with the triple aim

Anthony M. DiGioia III, Editor

The United States is not receiving good value for its health care investment. We spend much more than other wealthy nations on health care, while many of our outcomes are worse. With few exceptions, the system is fragmented and uncoordinated. It financially rewards quantity of care, not quality of outcomes, leading to volume incentives for doctors and hospitals. As we face the increasing challenges across the United States, it is clear that some hospitals will cut costs in the traditional way, and others will partners with innovative surgeons and other physicians to build new designs. We are advocating for new models of care.

Encouragingly, we have seen many health care organizations make efforts to improve quality and eliminate defects within their walls. Some have achieved impressive results. But at the Institute for Healthcare Improvement (IHI), we believe that site-specific improvement is not enough. We need to fundamentally redesign systems of care in order to simultaneously pursue three goals: better health for the population, better patient experience of care and lower per capita costs. We call these three objectives the IHI Triple Aim.

Triple aim

The three components of the triple aim are inextricably linked, affecting one another in different ways; sometimes they conflict, sometimes they are synergistic. For example, better care can incur higher costs if the improvements entail expensive interventions and pharmaceuticals. By contrast, reducing the overuse or misuse of treatments and tests can both cut costs and improve outcomes. Preventive care will ultimately produce better health and lower costs, but these dividends could take years to materialize. As of now, isolated entities pursuing their own self-interest often do not have the incentive to strive for all three goals. The challenge is to change the system so that pursuit of the triple aim is the rational choice.

The triple aim is, at once, a concept and an initiative. The concept of the triple aim provides a useful framework for thinking about policy. It has been applied and adapted by a variety of systems and organizations around the world, including the Centers for Medicare & Medicaid Services, and it is implicit in novel payment strategies such as accountable care organizations and bundled payments.

Maureen Bisognano

Andrea Kabcenell

The triple aim initiative is also a specific program run by IHI. Starting in 2007, IHI has brought together about 100 organizations (60 in the United States and 40 abroad) in a learning community. A variety of entities, such as health plans, employers, public health departments and social service agencies, participate. Examples of triple aim members include Blue Cross Blue Shield of Michigan, Vanguard Health System of Tennessee, Common Ground of New York and the Veterans Administration. Each of the participants designs a portfolio of projects intended to achieve the triple aim for a defined population. For example, an employer could take all of its employees as the defined population, while a health insurance plan can focus on its members. It is crucial to choose a defined population, because another important part of the initiative is measuring the results. IHI’s role is to act as a convener, coach and connector.

There is no one right way to pursue the triple aim. Our members have devised a wide variety of creative approaches. That said, IHI has identified five design components that greatly facilitate the achievement of the triple aim:

• focus on individuals and families, designing care at the level of the individual and actively learning from individuals and families to inform designs for the population;
• definition of primary care that includes health-related social services, behavioral health care services and the broad spectrum of supports that help people attain and maintain health;
• prevention and health promotion through multi-sector partnerships including public health departments, the social sector and community-based resources, leading to better health and lower cost;
• per capita cost reduction to bring overall cost increases to a level not exceeding overall economic growth; and
• integration, social capital and capacity building to allow independent stakeholders to align around the needs of the population, to exercise good stewardship of resources, and to reduce health and health care inequalities.

Success stories

Numerous triple aim members have designed innovative programs and made remarkable headway. Some of these organizations have been operating under the basic principles of the triple aim for years, before IHI coined the term; now they are working with IHI to accelerate their progress. For other members, participation in the triple aim represents an initial foray in the effort to systematically improve health and health care and reduce costs.

One success story is Queens Health Network (QHN) in New York City, a regional health care system that is part of the New York City Health and Hospitals Corporation. QHN, whose clients are primarily low-income, has implemented an ambulatory redesign initiative, efforts to guide patients to appropriate levels of care and the use of electronic health information technology to support care. The defined population is adults served by QHN in its hospitals and ambulatory care. From 2006 to 2009, the cost per member per month fell by 5.7%, according to preliminary data. One program to avoid emergency department admissions offered home care services with 24 hours to 48 hours, as well as follow-up phone calls to patients until the first post-discharge appointment. From May 2008 to December 2010, QHN calculated that 1,774 emergency department visits were avoided, thereby saving an estimated $8,870,000.

Another exemplar triple aim member is the Wisconsin-based printing company Quad/Graphics. More than 20 years ago, the company created QuadMed. This employer-sponsored health plan provides the 22,000 Quad/Graphics employees and dependents with worksite primary care. The plan offers onsite appointments to support preventive care and wellness, as well as onsite labs and X-rays. The design produced an integrated, convenient system that spends less on hospitalization and drugs. Health care costs per employee are approximately one-third lower than other Wisconsin-based companies when adjusted for employee demographics, and patient satisfaction is high.

Implications for orthopedics

As the triple aim initiative continues to mature, recommended changes may emerge in use of orthopedic and other specialty services. For example, increased use of shared decision making between patients and families and their primary care providers could stimulate new ways to look at “pre-hab” and care-giver support. Community health support can create momentum to optimize the health care patients receive. Over the long-term, improvements in prevention and a focus on the health of the population should also elevate the demand for minimally invasive surgery and medicine.

Improvements in the experience of care and in clinical outcomes, like those achieved in the University of Pittsburgh Medical Center (UPMC) system, under the leadership of Antony M. DiGioia III, MD, help to reduce costs associated with care (e.g., shorter lengths of stay and fewer post-surgical complications), while simultaneously reducing the societal costs of injury and poor health. Healthier patients, ready to return to work earlier, are more productive members of society, and improvements in orthopedics can have a dramatic effect on this aspect of population health. We anticipate that more opportunities for improving health and patient experience, while reducing per capita costs will present themselves to orthopedics as well as other specialty services in the coming years, demanding both the skill and creativity of clinicians in all settings.

When IHI conceived the triple aim in 2006, it may have seemed like a quixotic idea. Today, it informs the official policy of several governments, and dozens of health care organizations around the world are committed to pursuing it. This initiative, and the broader concept, can help us move toward a health care system that is increasingly rational, efficient, affordable and humane.

References:

• Berwick D, Nolan T, Whittington J. The triple aim: Care, health, and cost. Health Affairs. 2008: 27(3); 759-769.
• The Commonwealth Fund. The Commonwealth Fund Commission on a high performance health system, why not the best? Results from the National Scorecard on U.S. Health System Performance, 2011. 2011.

• Anthony M. DiGioia III, MD, is the editor of Emerging Techonology & Innovation. He can be reached at Renaissance Orthopaedics, PC, and Pittsburgh, Pennsylvania Innovation Center, Magee-Women’s Hospital of UPMC, Pittsburgh; email: tony@pfcusa.org.
• Maureen Bisognano is president and chief executive officer for Institute for Healthcare Improvement.
• Andrea Kabcenell, RN, MPH, is vice president for Institute for Healthcare Improvement. Both can be reached at 20 University Road, 7th Floor, Cambridge, MA 02138; email: info@ihi.org.
• Disclosures: DiGioia, Bisognano and Kabcenell have no relevant conflicts of interest.