| 19 February 2016
Dear Interested Readers,
“Commentary” on What’s Inside This Week’s Letter
This week’s letter concludes a four week examination of the Triple Aim. Back on January 29 I wrote:
...In the next few letters I hope to continue the use of memoir to demonstrate how the Triple Aim continues to offer us the the orienting benefit of a shared objective. I hope to reveal many layers of meaning within this simple statement. I have come to believe that just as you can suddenly see deeper meaning in an old song or a favorite scripture, thinking together about the Triple Aim can open new paths as sudden insights emerge from familiar words. It will be my contention that the Triple Aim subsumes all of the traditional values of medicine and more. It can be a guide for solving the new problems that arise every day. Before we are finished with the review it is my hope that I have convinced you that having a deeper understanding of the wisdom of the Triple Aim is essential to the outcomes patients individually desire and collective must have if we are to enjoy:
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
Re-reading that introduction, I realize that I have not achieved exactly what I set out to do. I have presented some of the history of the evolution of my own understanding of the Triple Aim and have connected that to my experience as a healthcare leader, but I have a lot to do in this letter if I am to convince you just why I thought the Triple Aim was so critical to the future of Atrius Health and why I am sure it is just as critical to the future of your organization or practice.
Stefani Daniels is an interested reader and quoted me:
Eliminating waste and being more efficient was consistent with our strategic plan but the motivation was for our survival. Lowering our operating costs was a good strategy to respond to the fear of falling reimbursement, as depicted in the image below. For most of the world in 2008, being concerned about the cost of care was not included in their understanding of quality.
And then she wrote:
These are your words from last week’s musings and I appreciate your honesty. And quite frankly, it’s the position execs have taken for decades…lower operating costs by any means.
Stefani went on to point out that as a consultant to hospitals on operations, the Triple Aim is still not imbedded in the thinking of most executives.
It typically translates into reducing FTEs, cut services, and, in one hospital I visited, convert to 1 ply tissue paper! Execs have had - and continue to have - a very myopic perspective about lowering costs. They never seem to see the costs associated with duplicate, excessive, wasteful and potentially harmful medical interventions or the delays in service delivery or the costs associated with warehousing patients over the weekends. Or, they may see it but prefer not to address it knowing that feathers will be ruffled. I can confirm that with some exceptions, lowering LOS and operating costs continues to be the focus of most C-suiters.
Around the same time (2008) you were focused on reducing operating costs, HealthLeaders published an article I wrote on the Myth of Length of Stay in which I point out that length of stay is a flawed metric on many levels. Nevertheless continued focus on LOS detracts from the real issues that constrain the adoption of a Triple Aim philosophy. From my position as a hospital consultant, I can tell you that Berwick etal hit the nail on the head when they cited that: 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. As I write in most of the care management assessment reports my firm prepares for hospital clients around the country, the executive team has the authority to make the kinds of changes they envision for a better future, but do they have the will? Unfortunately, most do not.
That is a pretty stinging testimony and I made sure that Stefani did not mind me sharing it with you. In this letter I will revisit some of the issues she raises.
Alan Gaynor who is another reader who gives me frequent feedback has responded by saying:
Dear Gene,
I have finally finished reading the last two week’s letters. I sense an important change in emphasis—from an emphasis on the leadership, values, structure, and processes of individual healthcare organizations to a strong recognition that whereas the goals described in the “Triple Aim” must be addressed organization-by-organization, the problem is broad and deeply political (see Brill on the politics of passing the ACA).
As I look back on the last three letters it is clear that although I did do some reflecting on my own experiences, what I have written may not have given you a deeper understanding and appreciation for the Triple Aim. I do think the exercise has increased my own appreciation of its beauty and potential. What I see in retrospect is that I have treated the 2008 article by Berwick, Nolan and Whittington as if it were scripture or one of the great classics of literature that can only be understood by a process of deconstructing and then personally reassembling its profound lessons to enable internalizing its message.
I tried to construct a commentary that provides you an opportunity to develop your own ideas. It was a natural response for me. It has long been the way I have learned to approach a complex idea. As the son of a minister I have sat through many hours of scripture study, and as an older adult have discovered that the complex ideas in theology are both an inspiration and fascination. I enjoyed literary criticism. In college I considered giving up the idea of becoming a physician to become a writer of fiction or a professor of literature. My final decision was based on loss avoidance and aspiration. I wanted to be a caregiver and was fascinated by the idea of practice. That was the “aspirational part of my decision”. The loss avoidance part was the practical reality that I had a family to support and being a liberal arts professor has always been economically risky!
What follows in this fourth essay after getting past the introductory material for reorientation is pretty much my opinion and my own analysis. I would be surprised if some of you do not have a different opinion. I hope that you do and will write me like Stefani and Alan have with your take on the future of the Triple Aim.
One fact that makes writing this letter hard is that we really do not have metrics that tell us where we stand with the Triple Aim. Not knowing where we are makes it hard to predict what will happen to this remarkable concept in the future. Because of those ambiguities, I hope that you will push back with your opinion.
If you would like to “catch up” with the conversation, I have summarized the core information of the last three letters in the last two posts on the strategyhealthcare.com website. If you know someone who would like to become an interested reader please tell them that strategyhealthcare.com is where they can sign up to receive these letters.
Looking Forward With The Triple Aim
I hope that I am wrong when I say that as important as the idea of the Triple Aim is to the future of healthcare in our country, we have no good metrics to measure where we stand in its pursuit. All we have are lagging numbers on what we are spending as a nation and debatable public health indicators of rather gross population metrics. We do not know how many healthcare organizations have incorporated the Triple Aim into their strategic plans. It is disappointing to accept that we do not know who has embraced the Triple Aim. Nor do we have any way of judging what they are accomplishing and no way of comparing their results to those who are still ignoring the philosophy. In 2008 Berwick, Nolan and Whittington were remarkably honest and blunt when they said:
For most [healthcare organizations], only one, or possibly two, of the dimensions [of the Triple Aim] 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.
Stefani’s experience as a consultant to hospitals suggests that little that changed. What are most healthcare organizations doing? Can we even say for sure what percentage of healthcare organizations are striving to incorporate the six domain definition of quality from Crossing the Quality Chasm (2001) into their culture? My guess is that the large majority are still focused on financial survival, resisting or only beginning to think about moving from volume to value and if it were not for the income opportunities of “P for P”, would not be as focused on quality and safety for the individual patient as a priority higher than their financial success. If that seems harsh, just let me say that “Stefani and I have been to the theater”.
I have tried and failed to get some objective measurement of just how many healthcare systems, hospitals, CINs, groups practices and other highly organized providers of care are now making effective progress in their pursuit of the Triple Aim. As an alternative I have tried to do some “back of the envelope" calculations based on numbers that can be obtained. As of April 2015 there were more than 500 ACOs in the country and there are surely more now. If all of them were aligned and making vigorous Triple Aim efforts it would still be a minority effort. That reasoning supports my impression that most organizations are still focused on finance and are “early on in their efforts” to make what has been called the transition from “Curve 1” to “Curve 2”. |
| | | “Curve 2” is consistent with the Triple Aim. The shift is necessary if we are to lower the cost of care but it is not the same as the Triple Aim. You can be on “Curve 2” and have successfully made the transition to value based reimbursement without embracing the responsibility of improving the health of the community or lowering the total cost of care to sustainable levels that do not detract for other social investments.
Organizations and communities that attain the Triple Aim will have healthier populations, in part because of new designs that better identify problems and solutions further upstream and outside of acute health care. Patients can expect less complex and much more coordinated care and the burden of illness will decrease. Importantly, stabilizing or reducing 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.
The bolding is my addition for emphasis. It answers the question, “Why is it important to reduce the cost of care?" Clearly stated are the collateral benefits of reducing the cost of care. Businesses will be more competitive, there will be less pressure on public budgets, and there will be more resources available for investments in the non medical aspects of society “that increase the vitality and economic wellbeing of their inhabitants”.
My concern is that there is an interdependence between assets in the community and the optimal health of the community that should require us to find the resources to make those investments now rather than after we have lowered the cost of care. We could hope that there would be a mutually positive interaction between better care by making social investments and the lowering of costs to accelerate the process. What we see in the real world is the opposite: as infrastructure further deteriorates, new medical concerns arise. Flint, Michigan is a gross example of deteriorating infrastructure adding to the cost of care. There are many causes for the current epidemic of opiate related deaths. Elements of the social determinants of health are part of the cause in the group that is economically stressed. The opioid epidemic is just one consequence of the lack of mental health resources, unemployment, poorly functioning educational systems and the lack of social services in distressed communities.
Here is an interesting thought. Is healthcare less expensive in the other advanced economies just because healthcare is an entitlement? Is it less expensive because they manage the delivery of care better with the result being less expensive care? Are their citizens/patients more engaged? Are their clinicians more parsimonious in their use of medical resources? Is their success related to the fact that they manage education, housing, employment, social services, and access to behavioral health resources better? Could it be that they have invested in their communities more effectively than we have and as a result do a better, albeit not perfect, job of managing the social determinants of health?
The diagram below was lifted from the IHI website and the article cited above. If you study the diagram you will see that concepts of quality as defined from the perspective of the individual is the starting point. |
| | | In one of the earlier essays I connected the Triple Aim to the quality and safety work described in To Err Is Human (1999) and Crossing the Quality Chasm (2001). Unfortunately it seems that this is where many of us are stuck. Improving the care of the individual is like motherhood and apple pie but recognizing that every individual is a part of a population has not become the conceptual framework of the majority of providers and healthcare organizations.
Marc Hafer, CEO of Simpler Consulting (I am a Senior Advisor to Simpler) has suggested to me that for most people in healthcare the concept of “population” is not fully understood or appreciated. I think that he is correct. Paradoxically recognizing the similarity of a patient to other similar patients facilitates the care of the patient as an individual. Processes of care that are efficient and effective for a defined population produce care that is more patient centric, safe, timely, efficient, effective and equitable for every individual. It is ironic that if the population of which the individual patient is a member is better managed, the care of the individual improves. Most clinicians with whom I have talked seem to see it the other way around. If they take very good care of the individual, the health of the population improves.
Berwick and his collaborators were very cryptic about what a population is and I find that many organizations freeze from uncertainty when they contemplate “population health” and what it means to their operations. Do you remember what Berwick, Nolan and Whittington said about populations?
A “population” need not be geographic. What best defines a population, as we use the term, is probably the concept of enrollment....A registry that tracks a defined group of people over time would create a “population” for the purposes of the Triple Aim. Other examples of populations are “all of the diabetics in Massachusetts,” “people in Maryland below 300 percent of poverty,” “members of Group Health Cooperative of Puget Sound,” “the citizens of a county,” or even “all of the people who say that Dr. Jones is their doctor.” Only when the population is specified does it become, in principle, possible to know about its experiences of care, its health status, and the per capita costs of caring for it.
In the upper left corner of the diagram we find “define quality from the perspective of an individual member of a population”. The next difficult concept seen in the diagram is the area in the blue oval. Health Care, Public Health, and Social Services look quite “happy” together. In the real world they are often three separate worlds that do not talk to one another. Within “Health care” the fragmentation is even greater. The many silos within “Health Care” add complexity to the gulfs between Health Care, Public Health, and Social Services and in this context the realities of the care of populations are quite compromised.
I like the focus on system level metrics but to achieve the level of integration, quality improvement and the management of patients that impacts the achievement of the Triple Aim for everyone will require metrics at the state and national levels. I was encouraged by the recent article by Porter and Lee in the NEJM that focuses on standardizing outcomes measurement. I can think of nothing that will facilitate the care of populations and the reduction of the total cost of care more than being able to compare systems on the basis of real outcomes measurements and processes of care and the associated costs necessary to get the best outcomes.
When you add up the steps that we must go through to get to a Triple Aim transformation that answers the three part problem that Berwick, Nolan, and Whittington described and that exists still today we must have real concerns. After eight years of Triple Aim effort what was true in 2008 is still true in 2016. - U.S. health care expenditures are far higher (at times double) than those of other developed countries, our results are no better.
- The United States ranks thirty-first among nations on life expectancy, thirty-sixth on infant mortality, twenty-eighth on male healthy life expectancy, and twenty-ninth on female healthy life expectancy.
- The United States is the only industrialized nation that does not guarantee universal health insurance to its citizens. We claim we cannot afford it.
The ACA has given millions access to care that they did not have in 2010. I would not diminish its accomplishments but with almost thirty million Americans still without care and tens of millions more who are “underinsured” in that they have continuing costs that distort their economic security, it is not unrealistic to say that we have a very tenuous hold on the first step to the Triple Aim. In Maine people are fond of say, “You can’t get there for here!” Can we get to the Triple Aim from where we are now?
The one biggest thing that would enable the achievement of the Triple Aim would be to make access to equitable healthcare an “entitlement”. Currently healthcare is a mandate. With a mandate you pay a fine if you do not acquire healthcare. With an entitlement you can petition the courts if your healthcare is inadequate. That is quite a difference.
National attention to the social determinants of health and to the resolution of “healthcare disparities” would be a major step in the right direction. Until we are willing to make adequate investments in education, housing, support of cultural opportunities, and full employment, we will continue to swim against a strong current in our quest for the Triple Aim. Continuing the movement toward better measurement of outcomes is a positive collective effort that supports the Triple Aim.
In their paper Berwick, Nolan and Whittington said:
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.
I have already discussed the issues related to recognition of a population. Perhaps externally supplied policy constraints deserves a thorough review as we look to the future. The movement toward payment mechanisms that are structured around the cost of caring for a population would qualify. Medicare’s refusal to pay for readmissions is another externally applied policy constraint. Regulations like the ones that exist in Massachusetts that require transparency and an annual review of statewide costs and quality data also represent important externally supplied policy constraints. There are other regulations that could be written at state and federal levels that could favor movement toward the Triple Aim and there was a time when I thought that surely they were coming. I think they are all on hold now in the midst of the political cacophony that exists in this election year. It is also true that the majority of physicians and their advocates and business associates would be outraged by further attempts to regulate a path toward the Triple Aim. It is not a surprise that those that resist further regulation and “government intervention” get real support from patients who have care, and are not that concerned about the cost because it is largely covered by a third party and they are sure that further change is not aligned with their own self interest.
Whenever we identify a problem it is good strategy to ask a simple question, “What part of the problem am I/are we?” Don Berwick has long advised us to think globally but act locally where we can make a difference. My own commitment to trying to lead an organization toward the Triple Aim and advocating that the Triple Aim was our strategic vision was clearly related to the fact that Don’s words and the work of the IHI have had an impact on my thinking.
At Atrius Health we realized that we could not change the world but we could advocate for change in our community and try to demonstrate that the Triple Aim was a viable pathway for us to follow in pursuit of our mission. Our efforts were not nearly as noteworthy as the efforts at Denver Health, Thedacare, Virginia Mason Medical Center, or Gundersen Health but we benefited from trying to mirror and learn from what we saw those organizations doing. Local efforts remain our greatest source of hope. These organizations and others, many of which have become ACOs are leading the way and are truly integrators. What part of the nation’s population gets their care from an “integrator” that is moving rapidly toward the Triple Aim? As I said earlier, it’s hard to know.
In 2012 I attended an event in Washington sponsored by the IHI. The Triple Aim and the ACA were hot topics in the aftermath of the President’s decisive reelection and the judgement from the Supreme Court supporting all of the ACA except the Medicare expansion. One panel that day included Tom Nolan. Nolan was realistic but hopeful about the future. What he said surprised and delighted me. He said that to improve healthcare in America three things were necessary. First, we must have widespread application of “continuous improvement”; second, we must become masters of collaboration and the “commons”; and finally, we must move from self interest to a new and more effective interest in what is best for our patients and our communities.
TS Eliot famously said in his poetic work, “The Four Quartets”:
“We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.”
We have been looking for an operating system and finance structure that would optimally provide for the health needs of the population for over fifty years. We have been sorting through our inventory of medical values and attitudes trying to decide which ones to retain, which one to modify and which ones to jettison. The desire is not new for
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
Along the way we have learned a lot and many things have been learned, forgotten and then painfully relearned. I think Nolan’s statement is consistent with Eliot’s poetry. We have had improvement science for a long time. The principles of its latest popular iteration, Lean, date back to the origins of the scientific method which is over four hundred years old. Our species learned the benefits of collaboration at least one hundred thousand years ago. We have been trying to manage self interest in balance with the interest of the collective as long as we have been living together.
As I look at the future and ask myself, “Will we ever get to the Triple Aim?” I want to answer, “Sure!”. But I am not sure. Earlier this year I wrote about the difference between optimism and hope. I am not optimistic about achieving the Triple Aim in the near future. There is just too much that still must change. Perhaps we are experiencing a “hockey stick evolution”. Are we going through a long period of preparing for change that will suddenly occur at a geometric rate? I doubt that from where we stand collectively at this moment, but I remain hopeful. I spent most of last week’s letter discussing what concerned Berwick, Nolan and Whittington and it is my opinion that those concerns still represents the biggest cloud on the horizon of the Triple Aim.
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.
My hope is sustained by the relatively small numerator of organizations and committed healthcare professionals like the ones you see at the IHI meetings or like I heard speak at the Vermont-New Hampshire HFMA meeting I attended a few weeks ago where all of the speakers focused on the Triple Aim. I have no idea of the size of the numerator but know these leaders still represent a very small percentage of the huge denominator that is all of healthcare. I am hopeful because I know that no matter what percent of healthcare these Triple Aim organizations are, they are working hard and with urgency. Their efforts may be moving us toward a tipping point, and that provides a basis for hope. I am hopeful because many of these organizations are trying to develop a Lean culture and learn how to use Lean tools so that they can manage “by process” across silos of self interest. I hear of innovations almost daily and some of these innovations may be a force of disintermediation that hastens the demise of the organizations that will never find the will or skill to survive. I realize that the future of many organizations is more tenuous than the slow progress of the Triple Aim. They are in great jeopardy.
The most concrete reason I see for hope for the future is the growing dissatisfaction with the status quo demonstrated by millennials. Our older clinicians and managers are just hoping to hang on a little longer. If you are in healthcare and under forty, you should want changes that facilitate the Triple Aim sooner rather than later. Living and working in the last hours of one order is not nearly as exciting as living at the dawn of a new era.
I do believe that the ideas and values of the Triple Aim will define the next era of healthcare. The alternative would be a dystopian reality that may sell movies and look exciting in video games but would be totally inconsistent with two thousand years of medical values that have always produced an urgency to look for better ways of providing care.
From The Land of 300 Gorgeous Days a Year
The picture in the header today is from San Diego. San Diego is a great walking city. I got to San Diego by way of Albuquerque where it was great to see my son who provides social services to some of the most disadvantaged and distressed children and families. There are many in Albuquerque who can’t wait for healthcare savings to produce surpluses that can be reinvested to improve the social determinants of health. As is true in many of our cities those investments are long overdue and we are reaping the sour rewards of a country where income inequality seems like an permanent reality.
About the time this letter comes to you, my wife and I will be heading to the coastal redwoods above Santa Cruz and just left of Silicon Valley to visit our grandson and his parents. In one week I will have been in New Hampshire, New Mexico, San Diego and Santa Cruz. They are all unique with different outdoor opportunities for exercise and different challenges for the Triple Aim!
As always I wish you a weekend of renewal. I hope that whatever you are doing you will find yourself asking what the special concerns are that deserve your attention if we all recognized the urgency of working together for
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time. |
| Be well, stay in touch and keep reaching, working and hoping for the good things that seem unlikely,
Gene
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