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7 Years In, Triple Aim Transcends Jargon

June 22, 2015

Fueled by the financial incentives built into the healthcare reform law, the Institute for Healthcare Improvement's concept is generating meaningful changes in the way healthcare is delivered, research finds.

The Triple Aim, an approach to health delivery that targets quality, cost and population health, could have been just another piece of healthcare jargon. Instead, hospitals and health systems large and small have adopted it as framework for major provisions of the Patient Protection and Affordable Care Act.  

In a recent assessment of the approach, the architects of the idea looked back over the past seven years and concluded that, "the Triple Aim became part of the US national strategy for tackling health care issues," especially in the implementation of the PPACA.

John Whittington, one of the authors of the Institute for Healthcare Improvement study, Pursuing the Triple Aim: The First Seven Years, put it this way last week: "We were very fortunate in the timing of this idea."

Others agree, noting that the Triple Aim, along with the financial incentives built into the healthcare reform law, is generating meaningful changes in the way health care is delivered.

At the same time, the IHI study suggests that one of the aims, cost reduction, is going to be more challenging than the other two. Published in the June issue of the Milbank Quarterly, the study notes that "Although several communities have made improvements for their populations for a particular health issue, few have been able to address the difficult challenge of obtaining the healthcare cooperation needed to improve per capita spending in a competitive health care environment in their community."

Still, even veterans of health reform efforts have been surprised by how fast the concept has spread and the changes it has enabled.

The Triple Aim offers a much-needed "soundbite" for those pushing health reforms, says Michael Millenson, a patient safety expert and author.

"The most important part of the Triple Aim is that it takes the ideas of improving safety and quality and puts them into a readily understandable context that resonates with clinicians and the general public, particularly with politicians," he says. "It puts the cost issue into a perspective that isn't radioactive politically."

That served Donald Berwick, MD, well when he left IHI in 2010 to run the Centers for Medicare & Medicaid Services. According to the IHI study, Berwick announced at an insurance industry conference that he was directing CMS "toward the Triple Aim as our highest-level goal." The authors also note that in 2011, the Agency for Healthcare Research and Quality incorporated the Triple Aim into its National Strategy for Quality Improvement in Health Care.

The Triple Aim's Effect on Population Health
What is working in Washington is working out well in some communities. Matt Guy is the managing director of the Pueblo Colorado Triple Aim Coalition, which includes two local hospitals, the public health department, community clinics, the chamber of commerce, the United Way, as well as the Kaiser Permanente of Southern Colorado.

"What made it attractive is the understanding that health needs to be improved through multisector work, "Guy said. "It can't just be the hospitals. It can't just be the public health department."

The coalition is working on lowering smoking, obesity, and teen pregnancy rates. The two local hospitals initiated the group's newest project, which will be a look at high emergency department use and readmission rates for patients with asthma and elderly patients injured in falls. The two hospitals came forward with data on claims and utilization, and a coalition commitment to identify factors bringing these patients back to the ED.

Guy says he's lucky to work with "two great hospital CEOs who understand that the world is shifting and changing. They are willing to come to the table and work with others in the community because they know in the long run it is going to benefit their bottom line and benefit the services they provide."

Hospitals have developed a competence in population health management in a way that was "not discernible at all prior to the PPACA," John McDonough, of the Harvard T. H. Chan School of Public Health, said in an email, "The Triple Aim has set the intellectual goal posts."

Still, McDonough, a long-time health reform advocate and former Massachusetts state representative, says some view the Triple Aim with rose-colored glasses: "Sometimes, in the desire to be upbeat and positive, we can overlook damaging and difficult things going on such as excessive provider concentration. We need to keep our eyes straight ahead and also to be fully aware of what's happening on both sides of the road."

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