Last week’s letter ended with the introduction of the idea of an “integrator” and the insightful statement by Berwick, Nolan and Whittington in their paper in the May/June 2008 edition of Health Affairs, “The Triple Aim: Care, Health, And Costs” about the real barrier to the Triple Aim.
From experiments in the United States and from examples of other countries, it is now possible to describe feasible, evidence-based care system designs that achieve gains on all three aims at once: care, health, and cost. The remaining barriers are not technical; they are political. The superiority of the possible end state is no longer scientifically debatable. The pain of the transition state—the disruption of institutions, forms, habits, beliefs, and income streams in the status quo—is what denies us, so far, the enormous gains on components of the Triple Aim that integrated care could offer.
Following a brief review of some of the salient points from last week, this letter goes on to discuss the “integrator” and the “politics” of change.
My weekly request of you is that you check out strategyhealthcare.com. The new posting that you will find is a much condensed version of last week’s piece on the Triple Aim. If you did not read last week’s letter it may be a good starting place for this week’s reading. I am always hopeful that you will pass along an invitation to your friends to sign up for this weekly letter. The strategyhealthcare.com site is where they will find the sign up opportunity.
Leaping Barriers That Block The Path To the Triple Aim
Berwick, Nolan and Whittington were succinct when they said in their 2008 article on the Triple Aim:
We suggest that three inescapable design constraints underlie effective accomplishment of the Triple Aim: (1) recognition of a population as the unit of concern, (2) externally supplied policy constraints (such as a total budget limit or the requirement that all subgroups be treated equitably), and (3) existence of an “integrator” able to focus and coordinate services to help the population on all three dimensions at once.
They were so succinct that I fear that many of us did not really appreciate what they were saying. Great ideas often are presented in cryptic form, like E=MC2 . Watson and Crick’s paper in Nature describing the double helix as the secret of life was a one page paper! Lincoln’s Gettysburg Address was 272 words long! All of these cryptic statements of great ideas have generated millions of words of explanation and have taken us years to understand and begin to appreciate. With all of them the learning continues for decades before they are generally appreciated for the depth of insight and meaning they offer us. So it is with the Triple Aim.
Perhaps as difficult as it is to understand “recognition of a population as the unit of concern” or an abstract concept like “externally supplied policy constraints”, I think it is even harder to understand and implement existence of an “integrator” . My primary objective in the words that follow is to add meat to the explanation of what an integrator is, but before doing that I must clarify what the barrier is that we must leap if we are ever going to make progress toward the Triple Aim. The barrier is the status quo. It’s the world as we have known it. It is the mindset that says I must be careful or I will be hurt or experience a personal loss. It is the emotional angst associated with change that is the origin of the “political barrier” referred to by the authors when they say:
The remaining barriers are not technical; they are political...The pain of the transition state—the disruption of institutions, forms, habits, beliefs, and income streams in the status quo—is what denies us, so far, the enormous gains on components of the Triple Aim that integrated care could offer.
I have perhaps been simplistic when looking for an explanation for change. It seems to me that there are two reasons that explain why change does finally occur, loss and aspiration. Loss has two forms. First, there is what behavioral economists call “loss avoidance”. Loss avoidance is a rational path. People who change to avoid loss have usually made a decision to change after considering the alternative of staying with the status quo. They realize that they have reached the end of a road. For example, the doctor who realizes that it is impossible to succeed financially or serve patients well doing it alone in a FFS environment accepts change reluctantly and with some emotional pain, but is realistic and joins a group or decides to be a hospital employee. Change in this instance is to avoid a burning or exploding economic platform. The other form of loss as motivation is acceptance of change after the fact of a loss. After the predictions that the status quo will fail us and we do find we are surrounded by the rubble that is all that remains, then change is the only option. The platform of the status quo is gone. It did burn or it has exploded. The predictions did come true. Change is often a desperate strategy for recovery and repair in this instance.
I much prefer the second explanation for change, aspiration. Don Berwick and the many advocates for quality and safety are the examples in healthcare that I would present to you. These people change or advocate change as an avenue of aspiration. They reject the status quo because they realize it can never produce the results they desire. John Toussaint lead a Lean transformation at ThedaCare which was already recognized as having one of the highest, if not the highest levels of quality in Wisconsin because being the best was not good enough if they could be even better. That is change to achieve an aspiration.
For most of us change final occurs by some combination of loss, loss avoidance and aspiration. It is the fear of loss of current financial success and of what is known and understood that is the greatest barrier to the Triple Aim, even though the Triple Aim is the best path to the avoidance of loss and the most direct superhighway to the realization of our greatest aspirations. The Triple Aim is a vision of the sustainable achievement of a better world.
The authors acknowledge that these barriers are ultimately political and that overcoming them will require an emotional and social struggle. The pain of the transition state—the disruption of institutions, forms, habits, beliefs, and income streams in the status quo—is what denies us, so far, the enormous gains on components of the Triple Aim that integrated care could offer. If we were looking at their paper as a literary piece this would be what my favorite college professor taught me was the “thematic climax” of the story. I have already given you the classic denouement, or resolution, of this literary work of art:
We suggest that three inescapable design constraints underlie effective accomplishment of the Triple Aim: (1) recognition of a population as the unit of concern, (2) externally supplied policy constraints (such as a total budget limit or the requirement that all subgroups be treated equitably), and (3) existence of an “integrator” able to focus and coordinate services to help the population on all three dimensions at once.
If the “vision” is the Triple Aim, these are the three components of its strategic plan and within each there are tactics.
I sense that the greatest hurdle that faces most of us after we understand, accept and are motivated to work through all of the resistance of adaptive change, is how do we and our institutions discover or learn how to be a part of an effective “integrator”. The authors try to help us by expanding on the definition of an “integrator”.
An “integrator” is an entity that accepts responsibility for all three components of the Triple Aim for a specified population ...The simplest such form, such as Kaiser Permanente, has fully integrated financing and either full ownership of or exclusive relationships with delivery structures, and it is able to use those structures to good advantage. We believe, however, that other models can also take on a strong integrator role, even without unified financing or a single delivery system….In crafting care, an effective integrator, in one way or another, will link health care organizations ...whose missions overlap across the spectrum of delivery. It will be able to recognize and respond to patients’ individual care needs and preferences, to the health needs and opportunities of the population ..., and to the total costs of care.
Don Berwick had experienced being part of an integrator of care that was much like Kaiser, the Harvard Community Health Plan, which was the vision of Dr. Ebert as he searched for an effectively integrated operating model and finance system. I have had the good fortune of having the same experience. Most caregivers have not had the experience of working in an organization that accepted the responsibility of managing the total medical expense or the total cost of care.
It is the rare system that owns the whole “supply train” of care. Even Kaiser has suppliers of hospital resources in many of its smaller markets like its Southeast (Atlanta) and Mid Atlantic (Washington, D.C.) markets. The ACO in its various forms is the most likely generic “integrator” of the future but other forms of integration like the “CIN” (Clinically integrated network) and systems of care like the organization, Guthrie Health, on whose board I sit, are potential integrators. This is the picture that Berwick, Nolan and Whittington predicted in 2008 when they wrote:
We believe, however, that other models [organizations somewhat different than Kaiser] can also take on a strong integrator role, even without unified financing or a single delivery system….In crafting care, an effective integrator, in one way or another, will link health care organizations...whose missions overlap across the spectrum of delivery.
Berwick and his co authors were aware of the theoretical concept of the ACO because Fisher and McClellan had described it in 2006, even though none really existed in 2008. In 2008 when I became CEO of Atrius Health, I believed that we were the prototypical “integrator” and that we were an ACO. What was problematic for me was that most of my colleagues and indeed most healthcare organizations saw being an ACO as a potential finance mechanism for a part of their total patient population. It was the rare organization that embraced the idea of being an accountable organization for all of its patients no matter what the source of their their funding was.
Even to this day most practices and health systems will tell you that they have “x” number of patients and of that number a certain percentage are a part of this or that commercial ACO and another percent are part of a Pioneer, MSSP or NextGen ACO. It does not seem to be true that the concept is reversed and that they see themselves as one unified ACO, or “integrator”, that accepts payment from a variety of sources. My concept was the the whole practice is one ACO, accountable for the whole process of care, its quality and its total medical expense, for everyone of its patients.
Ideally in the pursuit of the Triple Aim, there must be one delivery system and it must function the same for everyone, no matter what the source of income that comes with each patient. I am delighted to see that this is the attitude that is behind the transition that is underway in Vermont. Vermont began with the idea of having all patients in a medical home. Medical homes are a key tactic in improving the care of individuals and they can facilitate the improvement of a population, but they generally operate in “silos”. An integrator is necessary to efficiently bridge “silos”. After considering a “single payer” system which would be a substantially greater exercise in adaptive change for everyone in the state, Vermont has evolved a concept of an “all payer” system where all of the citizens of the state will be in one ACO with all of the medical resources integrated under one board and funds coming “from all payers” into a statewide system from the private insurers plus the public funding sources. The statewide system will be their “integrator” and will launch in 2017.
The key to the operation of an integrator is not ownership of assets but the assembly of assets into a value stream that provides optimally for the needs of a population that has many subpopulations. For it to work the key mindset change of the practitioners as well as the institutions that participate is depicted in the image below and by the phrase “I to We”. If we accomplish the “I to We” shift, we are prepared for ACOs, Health Systems and CINs to become the integrators that lead the way to the Triple Aim. |
