As early as 2008, Berwick (President/CEO of the Institute for Healthcare Improvement) and co-authors introduced the Triple Aim Framework.1 In order to successfully optimize health system performance, the Triple Aim Framework demands that we: (1) improve the patient experience of care (including quality and satisfaction); (2) improve the health of populations; and (3) reduce the per capita cost of health care. Indeed, multiple hospitals and health systems have adopted these as their foundation for major provisions of the Patient Protection and Affordable Care Act. Along with the financial incentives built into the healthcare reform law, the hope is that progress made in these areas will generate meaningful changes in the way health care is delivered and foster a more functional system for providers and patients alike.2
Many of you may already be in the midst of this journey and struggling to make headway; indeed, it can be daunting to tackle changes within a complex and entrenched delivery model. There are real challenges to enacting this vision. One rather obvious barrier arises when the aims are not pursued simultaneously. Pursuing one goal at a time might seem more feasible and practical, however, they are interdependent; a lopsided quest for one may negatively affect the others. For example, if an organization focuses its efforts solely on decreasing costs without careful consideration of the effects on the patient experience or population health, they may successfully decrease costs but incur a negative impact on quality of care and health outcomes. This lesson was painfully learned during the cost-sharing explorations in the early 2000s.3,4
Another real, but less readily acknowledged barrier, is that the first two aims are not typically in the immediate self-interests of most healthcare organizations. The original authors of the framework acknowledge this issue:
“…the balanced pursuit of the Triple Aim is not congruent with the current business models of any but a tiny number of U.S. health care organizations ... For most, only one, or possibly two, of the dimensions is strategic, but not all three. Thus, we face a paradox with respect to pursuit of the Triple Aim. From the viewpoint of the United States as a whole, it is essential; yet from the viewpoint of individual actors responding to current market forces, pursuing the three aims at once is not in their immediate self-interest ... Rational common interests and rational individual interests are in conflict.”1
Tackling the Patient Experience First
By addressing the patient experience of care first, we can help mitigate both of the above challenges. As depicted in the figure above, the aims are not only interdependent, but flow in a progressive direction. By first pursuing the goal of improving the patient experience of care, organizations lay the foundation towards being successful in achieving the latter two goals. This is because a significant component of creating better patient satisfaction includes successful patient engagement which, in turn, results in empowering the patient to take charge of his/her own health. In doing so, the activated patient is more likely to make healthy lifestyle change, complete preventive screenings, adhere to their treatment plan, and have lower health care costs.5 To top this off, more involved patients are also the recipients of better quality of health care and report higher patient satisfaction with services.6
Investing in evidence-based strategies to build patient engagement and activation to enhance the patient experience is an effective way to both improve population health and reduce costs. The IHI summarizes this trickle-down approach by explaining that as the burden of illness decreases for individuals and populations,
“ … the stabilizing and reduction of the per capita cost of care for populations will give businesses the opportunity to be more competitive, lessen the pressure on publicly funded health care budgets, and provide communities with more flexibility to invest in activities, such as schools and the lived environment, that increase the vitality and economic wellbeing of their inhabitants.”7
Effecting systematic change is not easy but we suggest that a meaningful step comes in the form of empowering individuals and communities to engage in better self-management practices. In creating an environment that is conducive to a more positive healthcare experience, we achieve better clinical outcomes which, in turn, assists in other concerted efforts to implement cost-saving strategies and innovations.
1 Berwick, D. M., T. W. Nolan, and J. Whittington. "The Triple Aim: Care, Health, And Cost." Health Affairs 2008;27(3):759-69.
2 7 Years In, Triple Aim Transcends Jargon. Media HealthLeaders. June 22, 2015. Accessed at http://www.healthleadersmedia.com/health-plans/7-years-triple-aim-transc...
3 Premiums and Cost-Sharing in Medicaid: A Review of Research Findings. Kaiser Commission on Medicaid and the Uninsured, February 2013. Accessed October 18, 2016. Available at: http://www.kff.org/medicaid/8417.cfm
4 Lowsky D, Chari R, Hussey PS, Mulcahy et al. Flattening the Trajectory of Health Care Spending: Engage and Empower Consumers. The RAND Corporation. 2012. Accessed October 18, 2016. Available at: http://www.rand.org/content/dam/rand/pubs/research_briefs/2012/RAND_RB96....
5 Mosen DM, Schmittdiel J, Hibbard J, Sobel D, et al. Is Patient Activation Associated with Outcomes of Care for Adults with Chronic Conditions? J Ambulatory Care Manage 2007;30(1):21-29.
6 AARP. Chronic Care: A Call to Action for Health Reform. 2009. Accessed October 19, 2016. Available at: http://assets.aarp.org/rgcenter/health/beyond_50_hcr.pdf.
7 Institute for Healthcare Improvement. IHI Triple Aim Initiative. 2016. Accessed October 19, 2016. Available at: http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx