Is the “Triple Aim” a Part of the Problem?

If you care about transforming the delivery of medical care in the U.S., then you should should read a blog post from last week by Paul Levy, former CEO of Beth Israel Deaconess Hospital in Boston and conductor of “Not Running a Hospital.”  It’s titled: “The Triple Aimers Have Missed the Mark.”

For those who don’t know, the “Triple Aim” was the 2008 invention of Dr. Donald Berwick and colleagues from the Institute of Health Care Improvement (IHI) which Berwick triple-aim-graphic1-300x225created in the last 1980s when he also developed the now-essential medical care construct of “continuous quality improvement“.  As Berwick and colleagues articulated in a 2008 article in the journal Health Affairs:

“Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an “integrator”) that accepts responsibility for all three aims for that population.  The integrator’s role includes at least five components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.”

One can look at the Affordable Care Act and see the Triple Aim model at work in numerous places.  The key notion behind the Triple Aim is to ask: what are we trying to accomplish in the U.S. medical care system and where are we trying to go?  A quick Google search will give some indication of how far and wide the concept has traveled over the past 7 years, including well beyond U.S. borders.  It is a global phenomenon.

Now comes Paul Levy with a bucket of cold water:

“…the Triple Aim has been hijacked. It has been hijacked by powerful political and economic forces–often represented by the nation’s hospitals in general and by academic medical centers in particular–but also aided and abetted by federal action…”

“The clearest representation of the Triple Aim … is the creation of Accountable Care Organizations (ACOs.)  The idea is that a group of health care institutions and practices in a given geographic area will join forces as an ACO to provide management of care across the continuum of care. The argument goes further, that by shifting from a fee for service rate-making formula to one based more on an annual per capita (risk-adjusted) budget, the ACO should have an interest in the health of the population–resulting in an increase in wellness programs, preventative care, early intervention, and a decline in more expensive hospitalization and procedures.”

“An interesting policy hypothesis, but what happens when policy turns to practice?  First, we see that the dominant player in many an ACO is the community’s academic medical center (AMC) or tertiary hospital. It is not the local multi-specialty practice that has the long-term relationship with a person or family, and which might shop among the region’s hospitals for the best care patterns and cost efficiency. No, the area’s largest hospital is the one that sets up the ACO in most places and controls its governance and cash flow…”

“Look, there’s nothing wrong with the Triple Aim objectives.  What’s wrong is that its most prominent advocates–some of the most influential health care experts in the country–have focused so heavily on that ideological approach to health care policy that they have absented themselves from the real battles over power, money, customer choice, and cost.  They are losing ground every day.”

If you read Paul’s post, don’t ignore the 26 comments in all directions, mine included.  I hope this is the start of a fuller and overdue conversation.  I agree with Paul that we see well-meaning ideas get hijacked all the time, very much so in the health care space.  And so many of the cheerleaders are missing in action when it is  necessary to challenge entrenched and well-endowed powerful interests.  [I don’t think this charge can be leveled  at Berwick who was outspoken against the expansion of Partners Healthcare in Boston during his unsuccessful 2014 gubernatorial campaign.]

Still, I do believe that the Triple Aim has played a key role in shifting the health reform conversation in important directions — population health, patient centeredness, and lowering costs.  That we can see so many examples where our medical system is moving backwards on these goals is , in my view, not an indictment — it’s a recognition that this is never easy and it’s never over.  We all have an obligation to speak out more forcefully against those who take advantage of reform for their own self-interested purposes.

It’s also worth asking, what existed as the overarching goal for health system reformers prior to the Triple Aim?  To my recollection, not much at all.  That has been Berwick’s genius for many years now — to fill the vacuum at the right moment with the best message that captures the essential challenges and opportunities of the time.

As I travel outside the U.S., I am astonished by how often I hear health system leaders in other nations mention the Triple Aim — even countries where rates of health spending are far below ours (meaning everywhere!).  The 2008 creation of the Triple Aim was not a victory speech, but a call to arms.  The signing of the ACA in 2010 was not its victory lap, but the widening of its purpose, opportunity and potential.

Bully for Paul Levy for pointing our the weaknesses and inadequacies and distortions.  Bully to IHI and the Triple Aim innovators for keeping on keeping on.

Author: John McDonough

I offer insights and opinions on how to improve health care systems for everyone

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