It’s Time to Redefine an Achievable Triple Aim

July 22, 2015 / By Norbert Goldfield, MD, Richard Fuller, MS

This blog offers further commentary on the excellent conversation that Paul Levy began in his column, “The Triple Aimers have Missed the Mark.” In his blog, he provides a succinct definition of the Triple Aim as “improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.”

Much has happened in health care since Don Berwick and many others first articulated this attractive call to arms. The healthcare landscape has irrevocably changed in the last ten years. In addition, as Paul critically highlights, the significant consolidation in health care has put the aim of reducing per capita costs in jeopardy. And, over the last decade, we’ve witnessed significant advances in health services research. While much can be written about the need and ability of reforms to constrain unit costs in health care (lowest cost service site, provider efficiency of production, constraint of market power and consumer activation to name a few) we believe that significant emphasis should be placed on the first two aims: i) improving the individual experience of care, and ii) improving the health of populations since both have ability to help constrain per capita costs.

In essence, we suggest that a more precise definition of these aims could help more effectively focus the conversation. We suggest that a redefined Triple Aim should consist of the following elements:

• Pay for risk-adjusted outcomes (move away from process measures). The call to improve population health is too generic and can be redefined at will.
• Increase consumer/patient engagement or activation. Patient experience is too general a term, and we know that patient activation is key to both better health and lower costs.
• Increase collaboration, including information sharing, between all healthcare consumers—providers, businesses, payers, and patients. To improve patient outcomes and increase consumer activation, all members at the healthcare dinner table need to have outcomes information that includes price, volume and setting for each type of healthcare encounter (ambulatory visits, hospital stays, year-long person-based episodes, and long-term care). Most importantly, this comparative information needs to be provided in a rational way so that credible comparisons can actually be made!

Put differently, our vision is that in our state, plan, medical group or country, we are committed to:

• Improving healthcare outcomes quality;
• Changing the way we pay all sectors of the healthcare economy;
• Connecting payment in all healthcare sectors to their ability to achieve better outcomes such as fewer complications and readmissions; and
• Making data available to consumers because an active, engaged and confident consumer is our best guarantee of better outcomes and lower costs. All consumers of health care want quality care, good outcomes and no complications. Consumers include individuals, businesses, and, in fact, anyone that has any stake in improving healthcare outcomes.

There is an emerging consensus that payment adjustments that rely heavily on adherence to care processes have not been effective. In his June 2014 testimony before the Ways & Means Health Subcommittee, Mark Miller, the Executive Director of MedPAC, stated “Current quality measures are overly process oriented and too numerous, they may not track well to health outcomes, and they create a significant burden for providers¹.” A Robert Wood Johnson Foundation Report on quality performance measures concluded that the focus of performance measures should “decisively move from measuring processes to outcomes².” The failure of process-based quality payment systems to effectively measure quality and control expenditures does not mean that process measures are not useful as internal management tools for individual providers. The issue remains that the exact operation and influence of processes implemented within an organization in return for payment, from entities like Medicare, are hard to specify. The result is a mixed bag of implementation by providers that may appear similar but, in fact, do not result in actual population health improvement. If we believe that the measure of a success for process implementation is achieving better outcomes, then why not focus upon outcomes and let the healthcare delivery system innovate to achieve them?

Our focus on outcomes recognizes that they can be divided into two groups – those that can be translated into dollars and those that cannot. Those that are amenable to direct translation into dollars constitute potentially preventable events (PPEs)³. We have identified and categorized the vast majority of those events which are potentially preventable and can be translated into dollars (potentially preventable complications, initial admissions, readmissions, ER visits, and outpatient services). PPEs are measurable, actionable, transparent, and can credibly be incorporated within pay for performance strategies. As importantly, they are risk-adjusted and have not been seen to disproportionately “hurt facilities that care for the poor” – while providing an incentive to improve care.

We believe that increased patient/consumer activation or empowerment is not only a good in and of itself but also an important tool for lowering potentially preventable events, and strengthening the patient experience with the health system. Both Judy Hibbard and John Wasson have documented the impact that increased patient engagement has on improving patient experience and lowering healthcare costs⁴.  This further demonstrates the importance of payers providing access to information and outcomes to all consumers at the healthcare dinner table. In a separate blog, we will discuss the issue of healthcare prices and provide concrete suggestions on what can be done. For sure though, payers need to provide access to information on outcomes, patient engagement and costs while encouraging collaboration among all healthcare consumers. Because this type of information is measurable and actionable, it can have a significant impact on bolstering patient engagement and experience and improving outcomes while controlling costs.

In short, we agree with Paul Levy. However, at the same time, we also suggest the elements of a new vision, most importantly a reframed Triple Aim, which takes advantage of the sea change occurring in our healthcare system. We strongly believe that implementation of our recommended key measurable and actionable elements of a new Triple Aim can lead the U.S. down a realistic path of improving outcomes while stabilizing healthcare costs.

Richard Fuller, MS, is an economist with 3M Clinical and Economic Research.

Norbert Goldfield, MD, is medical director for 3M Clinical and Economic Research.

¹ Miller, Mark E. Report to Congress: Medicare and the Health Care Delivery System. Presented to the Subcommittee on Health, Committee on Ways and Means, US House of Representatives. 2014 June 18: 3.

² Berenson, Pronovost, Krumholz, Achieving the Potential of Health Care Performance Measures, Robert Wood Johnson Foundation, Mat 2013.

³ Calikoglu, S, Murray, R, Feeney, D, “Hospital Pay–‐For–‐Performance Programs In Maryland Produced Strong Results, Including Reduced Hospital–‐Acquired Conditions,” Health Affairs, December 2012; 31(12):2649–‐2657. Minnesota Hospital Association RARE program website http://www.mnhospitals.org/patient-safety/collaboratives/reducing- avoidable-readmissions‐effectively-rare

⁴ Greene J, Hibbard JH, Sacks R, Overton V, Parrotta CD. When patient activation levels change, health outcomes and costs change, too. Health Aff (Millwood). 2015 Mar 1;34(3):431-7; Wasson JH A patient-reported spectrum of adverse health care experiences: harms, unnecessary care, medication illness, and low health confidence. J Ambul Care Manage. 2013 Jul-Sep;36(3):245-50 New metrics are helping hospitals improve care and reduce complications.  Read our latest case study to find out how.