Health Policy Case Study- The Triple Aim

Health Policy Case Study- The Triple Aim

Some would argue that the United States of America is the greatest country on the planet. While the US has many amazing attributes, it also has many shortcomings, one of which is healthcare. The United States has the world’s largest and most complex healthcare system, but it is also the most expensive and ineffective of any industrialized country. According to Bernstein (2014), the United States spends nearly 18% of its GDP on healthcare, more than any other country. The United States also has the most specialists in any country. However, the performance of the US healthcare system is severely lacking in terms of health outcomes and patient perspectives. According to Bernstein (2014), many of the United States’ problems stem from a variety of deficits, including a shortage of primary care physicians, a lack of access to care, particularly among low-income populations; a high proportion of residents who forego needed care and medications due to cost, resulting in an unjustified number of deaths from preventable conditions; extraordinary levels of infant mortality; and a lower life expectancy in people over the age of 60. For these reasons, the US healthcare system requires massive reform. The Triple Aim of Healthcare initiative is one effort to address this need. This paper will look at the Triple Aim, how it came about, and the challenges it faces in implementation. This paper will also discuss population health and look at case studies where the Triple Aim is changing healthcare.

What exactly is the Triple Aim?

The Institute for Healthcare Improvement created the Triple Aim Initiative to address the healthcare industry’s numerous problems. The program was launched in the fall of 2007 and was initially piloted by over 100 organizations worldwide. Following the passage of the ACA in 2010, the Triple Aim initiative was adopted industry-wide and is now part of the US national healthcare strategy (Institute for Healthcare Improvement, 2018). The program has three main components: measures to improve patient experience, including quality and satisfaction; measures to improve health outcomes for targeted populations; and measures to reduce the per capita cost of healthcare. To be successful, all three elements must be pursued at the same time. These are lofty goals, according to Whittington et al. (2015), and full implementation is regarded as the “Holy Grail” of healthcare. Organizations that are successful in implementing the Triple Aim must be able to combine a wide range of health factors, galvanize and embolden individuals and their families, expand the role and influence of primary care and other community and social services, and create a system that provides a seamless transition of care throughout an individual’s changing life stages (Institute for Healthcare Improvement, 2018).

Whittington et al. (2015) also describe three major principles that should guide organizations and communities working on the Triple Aim: laying the proper foundation for population management, managing population services at scale, and establishing a learning system to drive and sustain the work over time. It is critical to identify the target population for whom the Triple Aim would be most beneficial when laying the groundwork for population management. In most cases, the populations would be enrolled populations, which are groups of people who receive health care through a specific health system or whose care is covered by specific health insurance plans. Employees of a company, insurance plan beneficiaries, or members of integrated or managed care organizations are all examples of enrolled populations. A regional or community population is the other major type of population. These populations are made up of members of a community who may have common health needs or issues, such as complex chronic diseases or areas where mothers have low birth weights (Whittington, 2015).

After identifying the target population and laying the groundwork for population management, the organization implementing the Triple Aim would need to assess the target population’s needs and strengths. They would then apply that knowledge to a variety of projects, such as redesigning services to better meet the needs of the population and delivering those services to those in greatest need. To accomplish this, organizations must think outside the box when it comes to traditional services. They must broaden the scope of services to include not only healthcare but also social and community services that meet the needs of the population. Once the needed services have been identified and delivered to the target population, the organization must develop a learning system that tests, measures, and provides continuous feedback for the program’s ongoing improvement (Whittington, 2015). According to Livio (2014), in an interview with David Nash, a major proponent of Population Health Management, David discussed the importance of incorporating social services into the continuum of care. According to him, medical care only accounts for about 15% of a society’s resilience and well-being. The remaining 85 percent is made up of complex and sometimes messy social issues. Nash goes on to say that access to housing and food is often a better predictor of a family’s health than whether or not they receive medical care (Livio, 2014). The implementation of the Triple Aim would benefit and strengthen many areas of the US healthcare system, including innovations in payment reimbursement methods, reimagined primary care models such as the CPC+ program and ACOs, sanctions on providers to discourage avoidable occurrences, and the incorporation of health IT (Institute for Healthcare Improvement, 2018).

Difficulties in Putting the Triple Aim into Action

Organizations may face a number of challenges when attempting to implement the Triple Aim. There are numerous factors that can interfere with their ability to transform completely. One of the most difficult challenges is implementing the three main elements of the Triple Aim at the same time. According to McCarthy (2015), the three basic components of the Triple Aim are improving the patient healthcare experience (including quality of care and patient satisfaction), improving population health outcomes, and lowering or limiting the per capita cost of healthcare expenditures. A major stumbling block for organizations that focus on only one area at a time. This creates a situation in which one factor can have a negative impact on another. McCarthy and Klein (2010) use the example of organizations that focus solely on cost-cutting, which may unintentionally create patient dissatisfaction by eliminating popular services or amenities.

Another issue that organizations frequently face is how patients are managed. Many healthcare organizations make the mistake of focusing on the needs and health of individual patients rather than looking at the issues as a whole (Institute for Healthcare Improvement, 2018). To achieve the goal of improving population health outcomes, organizations must coordinate and integrate care across the continuum of healthcare services, including hospitals, outpatient practices, clinical staff such as doctors and nurses, and non-clinical staff such as care coordinators and other front-line workers (McCarthy & Klein, 2010).

The ability of organizations to conduct unbiased self-assessments while reviewing their processes and performance is a third challenge for organizations when implementing the Triple Aim. Organizations can evaluate their strengths while ignoring their weaknesses or opportunities for improvement by conducting an unbiased self-assessment. According to Weeks, Collins, and Lovett III (2014), by utilizing the Triple Aim framework, organizations can create a learning environment and create change at the system level by constantly testing and evaluating innovative clinical and administrative approaches.

Management of Population Health

Over the last 30 years, population health management has grown in popularity. According to Kindig (2015), there are several definitions of population health, and one may be more accurate than another, depending on the context. The most common definition of population health in the context of healthcare transformation is the “repetitive and ongoing process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement while also reducing costs” (Kindig, 2015). Focusing on population health management has numerous advantages for organizations, individuals, communities, and society as a whole. According to Rouse (2017), population health management has been shown to reduce the frequency of health crises, including the use of the most expensive services, such as hospitalizations and ED visits. It contributes to lower service costs by utilizing an integrated care delivery approach that encourages collaboration across the health services spectrum. Population health management has also increased access to care and improved the overall patient experience. Population health encourages patient and family engagement in their healthcare by allowing them to participate in decision-making.

One of the most important goals of population health is to collect, standardize, and analyze clinical data from the patient’s various care settings, which can then be used to identify areas of opportunity to improve health outcomes and lower costs. Population health management data can be analyzed to provide insight into which interventions and treatments work best for a specific population, assisting clinicians in identifying evidence-based care and support (Rouse, 2017). Population health management heavily relies on health information technology to collect and analyze data. This technology must be capable of supporting health data collection, governance, and analytics. It must also be capable of supporting required reporting capabilities, which are critical for ensuring compliance and provider incentives. The US healthcare system has shifted to alternative reimbursement methods in which providers are paid based on improved health outcomes, and they must be able to produce data demonstrating the success of their efforts (Rouse, 2017).

With the rise of population health and the availability of new data sets outlining evidence-based practices for specific populations, it is only natural that healthcare payers would prefer to reward providers based on outcomes rather than the traditional fee for service. This represents a shift from quantity to quality, and payers are already shifting toward value-based reimbursement. CMS and private insurers have been experimenting with innovative payment reimbursement pilot programs aimed at disease prevention and wellness promotion (Auerbach, 2015). These pilot programs include a shift toward value-based payments tied to clinical care measures. Providers who meet or exceed these benchmarks are compensated through capitation and/or performance incentive payments. They risk payment reduction or, in some cases, contract loss if they do not meet the outlined measures. The goal of this payment method is to reduce the use of expensive treatments and the use of hospitals and emergency departments for preventable conditions (Auerbach, 2015).

Shifting the Cost Curve

In different contexts, bending the cost curve means different things. It refers to a reduction in the expected rate of increase in healthcare spending per person. According to Holahan and McMorrow (2015), the United States currently spends $9,237 per person on healthcare. This is more than any other country on the planet. Trying to find ways to reduce this ever-increasing amount was a major focus of the 2010 Affordable Care Act (ACA). While the ACA has had a significant impact on healthcare, it is not without its detractors. With insurance premiums skyrocketing and per capita healthcare spending increasing, it’s easy to see why many people believe the ACA is failing to contain costs. What most people don’t realize is that these figures would have been even more dramatic in the absence of the ACA. Rates in 2016 were 20% lower than projected by the Congressional Budget Office in 2009, prior to the passage of the Affordable Care Act. The United States is on track to spend $2.6 trillion less on health care between 2014 and 2019, compared to initial projections made shortly after the Affordable Care Act was passed in 2010. (Holahan & McMorrow, 2015).

Even though some progress has been made, there is still a long way to go. Many supporters of the Triple Aim believe that the initiative will reduce costs and, in the long run, be able to accomplish the difficult task of bending the cost curve; however, others argue that the Triple Aim alone will never complete the job. According to Sullivan (2016), the Triple Aim must be modified because it will never achieve its goal of healthier populations and lower costs. The main issue, he claims, is that the Triple Aim encourages the system to focus solely on itself rather than putting more responsibility on patients to be more in control of their healthcare. He goes on to say that patient accountability relieves clinicians of some of their responsibilities, which can help to reduce burnout. To empower individuals, Sullivan (2016) advocates for more patient and family education. He also suggests ways to improve the Triple Aim model. One of his recommendations is to improve the technology on which the healthcare industry relies by achieving interoperability and agility in the IT infrastructure, more effectively utilizing data analytics capabilities, and developing self-management tools for patients to use when making healthcare decisions. Sullivan (2016) also advocates for increased transparency, a focus on do-it-yourself virtual healthcare, and the promotion of healthier lifestyles to prevent chronic conditions.

Organizations That Have Succeeded Using the Triple Aim

Despite Sullivan’s (2016) concerns, some organizations already see positive outcomes from implementing the Triple Aim. et al. (2010) discuss three such organizations, CareOregon, Genesys Health System, and QuadMed, that have been successful in implementing the Triple Aim in their article for the Commonwealth Fund. CareOregon is the managed care organization in charge of Oregon’s Medicaid funds. They focused on care management by implementing a patient-centered medical home model in several of their clinics. CareOregon was able to target high-risk/high-utilizer patients this way. They expanded their role beyond that of an insurance company to provide highly integrated care in local medical clinics for their members. They were able to reduce costs by $5000 per member in the first year by targeting the highest-risk patients and actively coordinating their care. They also discovered that clinics that used the PCMH model were able to save up to 9% on their medical costs when compared to clinics that did not use the PCMH model (McCarthy & Klein, 2010).

In Flint, Michigan, the Genesys Health System is a highly integrated health system. It is made up of community-based primary care providers who have joined forces with hospitals to provide care with a focus on care coordination, preventative health, and the efficient use of specialty care. Genesys also employs health navigators who serve as health coaches, assisting patients in adopting healthy lifestyles and providing education on disease prevention and management. They collaborated with a local health plan to increase access to care for low-income patients who previously did not have insurance. They discovered that by implementing the Triple Aim, one local employer spent 26% less on healthcare for employees who received care from Genesys physicians. They also used fewer hospitals and emergency departments than the state average for other physician groups. The use of health navigators was also very beneficial for their patient health outcomes, including a 53% increase in physical activity among previously inactive individuals, a 17% quit rate for smoking, and an 80-90% increase in self-management among diabetic patients who were previously unengaged (McCarthy & Klein, 2010).

QuadMed, a third organization, has also had success with the Triple Aim. QuadMed manages worksite health clinics staffed by primary care providers and wellness volunteers. These worksite clinics prioritize disease prevention and improved outcomes over the number of patients seen each day. They also implemented wellness programs for employees/patients to participate in at each worksite. The fruits of their labor are also bearing fruit. QuadMed reports that their patients’ A1Cs have decreased from 8.0 to 7.5. Having the clinic on-site has also increased employee job satisfaction and the sites have met or exceeded the national quality of care benchmarks. They have also succeeded in bending the curve by increasing employee healthcare costs at a slower rate than other employers in their area (McCarthy & Klein, 2010).

Health Partners Medical Group (HPMG), an integrated health system in Minnesota, is featured on the Institute for Healthcare Improvement (IHI) website. HPMG consists of hundreds of physicians, dozens of primary care clinics, and a variety of specialty and urgent care clinics. HPMG launched a new program called “BestCare” in 2004, with the goal of assisting the health system in achieving optimal practice by adhering to the four C’s: consistency, customization, convenience, and coordination. Consistency refers to having reliable processes in place that best meet the needs of patients, as well as having health IT to support those efforts. Individual needs and values are met through customized care. Patients will find it easier to schedule and attend appointments as access is expanded. The final C stands for coordination, and it refers to their medical home model, which encourages integration and coordination across the spectrum of healthcare services. HPMG has achieved excellent results by implementing BestCare. After using a case management program, they saw a 129% increase in diabetic patients and a 59% increase in cardiac patients receiving optimal care; a 250% decrease in wait time; a 39% reduction in ED visits; and a 20% reduction in inpatient behavioral health costs (Institute for Healthcare Improvement, 2018).

Replacing the Triple Goal

The Triple Aim can and should be applied to all aspects of healthcare. The initiative can help healthcare organizations improve their outcomes and overall performance. Organizations that want to implement the Triple Aim should look at other organizations that have already started the transformation and analyze what has made them so successful. While all healthcare organizations have different geographic, socioeconomic, and other population-based factors, the Triple Aim infrastructure can be implemented in some form or another in all of them. To achieve the desired results in the quality, cost, and effectiveness of healthcare services, it is critical that all local healthcare providers and community agencies be engaged and collaborate. These organizations must work together to bridge gaps and overcome potential barriers to program implementation. Finding funding for the initiative, ensuring adequate staff numbers to carry out the mission, overcoming any resistance to change within the organization, and gaining the necessary support from the community and leadership are all common issues that would need to be addressed in the beginning.

Conclusion

The Triple Aim initiative is a valuable approach to quality care because it provides a framework that organizations can use and model to transform their care delivery. The Triple Aim’s heart and soul are to reduce healthcare costs while improving patient experience and health outcomes. It is an integrated approach that involves the entire community in order to treat the entire population, resulting in healthier individuals. Many organizations have successfully implemented the Triple Aim, including HPMG, CareOregon, Genesys Health System, and QuadMed. Certain themes have emerged as a result of analyzing what has made them so successful. The findings show that integrated care and the use of care managers or health navigators are critical to population health management. As more organizations implement the Triple Aim, the healthcare industry will move closer to the holy grail of healthcare.

References

Auerbach, J. (2015). Creating Incentives to Move Upstream: Developing a Diversified Portfolio of Population Health Measures Within Payment and Health Care Reform. American Journal Of Public Health, 105(3), 427-431.

Bernstein, L. (2014, June 16). Once again, the U.S. has the most expensive, least effective healthcare system in the survey. Retrieved from https://www.washingtonpost.com/news/to-your- health/wp/2014/06/16/once-again-u-s-has-most-expensive-least-effective-health-care- system-in-survey/?utm_term=.c05c0236bd7e

Holahan, J., & McMorrow, S. (2015). The Widespread Slowdown in Health Spending Growth Implications for Future Spending Projections and the Cost of the Affordable Care Act. Retrieved from http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf429930

Institute for Healthcare Improvement (2018). Achieving the IHI Triple Aim: Summaries of Success. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/ImprovementStories.aspx

Institute for Healthcare Improvement (2018). IHI Triple Aim Initiative. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx

Kindig, D. (2015). What are we talking about when we talk about population health? Health Aff Blog. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20150406.046151/full/

Livio, S. (2014, May 29). Why ‘population health’ is so important in the age of Obamacare. Retrieved from http://www.nj.com/healthfit/index.ssf/2014/05/why.html

McCarthy, M. (2015). ACA and the Triple Aim: Musings of a Health Care Actuary. Benefits Quarterly, 31(1), 39-42.

McCarthy, D. & Klein, S. (2010) The Triple Aim Journey: Improving Population Health and Patients’ Experience of Care, While Reducing Costs. Commonwealth Fund Pub. 48(1). 1421.

Rouse, M. (2017, June 23). Population Health Management (PHM). Retrieved from http://searchhealthit.techtarget.com/definition/Population-health-management-PHM

Sullivan, T. (2016, September 13). Triple Aim alone will never bend the cost curve, experts say. Retrieved from http://www.healthcareitnews.com/news/triple-aim-alone-will-never-bend- cost-curve-experts-say

Weeks, W. B., Collins, C. D., & Lovett III, E. J. (2014). Scholarly activity as a strategic asset in an era of reform. Healthcare Financial Management, 68(12), 86-88.

Whittington, J. W., Nolan, K., Lewis, N., & Torres, T. (2015). Pursuing the triple aim: the first 7 years. The Milbank Quarterly, 93(2), 263-300.

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Post a total of 3 substantive responses over 2 separate days for full participation. This includes your initial post and 2 replies to classmates or your faculty member. All responses must be at least 175 words to be considered substantive.

Due Thursday

Respond to the following in at least 175 words:

• Think of a situation in which the Triple Aim framework could help you adapt to changes in the delivery of patient care. How could you use the framework to reduce the per capita cost of healthcare in your own work environment to better align the needs of your organization with 21st-century healthcare practice? Provide an example, either within your work environment or in society at large, of when an ethical or legal dilemma impacted your organization. Support your position by citing at least 2 references.

Due Monday

Post 2 replies of at least 175 words to classmates or your faculty member. Be constructive and professional. Support your position by citing at least 1 reference.