Healthcare Policy Analysis and Development

Better health, better outcomes, and lower costs are what Triple Aim targets. The Institute for Healthcare Improvement (IHI) launched the Triple Aim initiative in 2007. It was designed to help healthcare organizations improve the health of a population and benefit patients’ experiences of care. This included quality, access, and reliability. Achieving all this, while still lowering the cost of care per capita, is no small feat (Berwick, Nolan, & Whittington, 2008). IHI and its colleagues determined that both individual and societal changes would be required for Triple Aim to be achieved. According to a 2014 national survey of hospital chief executive officers, financial challenges are their top concern, especially government reimbursement (Coyne, et al., 2014).

Since the early stages of IHI’s work on the Triple Aim, the integration of services has been an important component. Berwick, Nolan, and Whittington stressed the importance of a “system integrator” that would accept responsibility for achieving the Triple Aim for the population. This system integrator has the ability to pull together the resources to support the work. In the following, I will examine why Triple Aim is difficult to implement, and the reasons a focus on population health is key to its working. I will also explain how the Triple Aim attempts to bend the cost curve as it relates to the case study, as well as research an organization Lakeland Health System that is successfully implementing the Triple Aim in their community successfully.

Case Studies

 Case studies of three organizations were examined to show how they are partnering with providers, and organizing care to achieve Triple Aim. The organizations selected were CareOregon, a nonprofit-managed healthcare plan serving low-income Medicaid enrollees;

QuadMed, a Wisconsin-based subsidiary of printer Quad/Graphics, which develops and manages wellness programs and work-site health clinics; and Genesys Health System, a nonprofit integrated delivery system from Flint, Michigan (McCarthy & Klein, 2010). Each was selected to illustrate diverse approaches, and lessons from these organizations can guide us who wish to transform healthcare. They each serve different populations, and a focus on population health helps to achieve the Triple Aim.

These organizations demonstrated a commitment to bringing together different constituencies. This includes public health, nursing, specialty, and primary care. Now, CareOregon is transforming its role from a payer to an integrator of healthcare. CareOregon has partnered with safety-net clinics to optimize care for their low-income enrollees (McCarthy & Klein). Through QuadMed, Quad/Graphics has transformed its role from a purchaser of health insurance to an “investor” in employee health and productivity. QuadMed created work-site clinics for Quad/Graphics employees (and family members) that emphasize patient health and convenience.

Genesys Health System partnered with its affiliated physician-hospital organization, and a tax-supported county health plan for the uninsured. They developed a model of healthcare known as HealthWorks. HealthWorks has three key elements: Engage community-based primary care physicians, use health navigators who support patients in adopting healthy lifestyles to prevent and manage chronic disease, and partner with community organizations to extend the goals of the model to the entire local population (McCarthy & Klein).

By focusing on the health of their defined population, Genesys also encouraged their customers to eat healthier food, become more physically active, and provided incentives to quit smoking (Coyne, et al.). Fifty-three percent of the patients who did not previously eat adequate amounts of fruits and vegetables now do. Also, 53% who reported no regular physical activity now are physically active. Seventeen percent of smokers quit, and 85% of patients who were not taking their medications regularly now do thanks to HealthWorks (Coyne, et al.).

Population Health: Its Importance

 A population may be geographically isolated; or a population could be a group of disabled persons, prisoners, or Home Depot employees (Block, 2014). Being able to focus on the health of a specific population can greatly affect outcomes. David Kindig and Greg Stoddart defined population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group (2003).” Population health management requires an effective integrator to act as a fiduciary for the deployment of healthcare goods and services within the defined population based on health status and need. This facilitates the efficient and equitable allocation of resources (Block).

Effective organizations must engage to change the “more is better” culture through communication, transparency, systemic education, and shared decision-making. Primary care, as well as chronic care, must be improved. The establishment of patient-centered medical homes will provide innovative access and communication between the defined population of patients and the primary care team. An effective integrator works diligently at the macroscopic level to provide system integration, both administratively and clinically (Block). This encourages the latest medical knowledge; and standardized definitions of quality with safety, cost, and outcome data measured independently (Block).

Accountable Care Organizations (ACOs) are the most identified structures for measuring the health of a population. Determinants of health from medical care systems, the social environment, the physical environment, and genetics have a significant biological impact on individuals in a defined population. The ACO has to be transparent and meet the IOM’s national goals for individual quality (Block). According to Berwick and colleagues, externally supplied policy constraints are the next component as a precondition in the pursuit of the Triple Aim.

Politics, decision-making, and social contracting (relevant to the population at risk) shape the balance sought by the Triple Aim. The goal is the implementation of ACOs that can induce cooperative behavior among service suppliers to work as a team for the defined population’s best interests (Block).

Lakeland Health System

 Partnering with Great Lakes Health Connect, Lakeland Health System, based in St.Joseph, Michigan, is the first hospital organization in Michigan to query patient immunization records held within the Michigan Care Improvement Registry (MCIR) directly from their internal electronic medical record (Landi, 2017). I believe this is something that is replicable everywhere. All organizations can improve database operations, IT, and AI allowing easier access to patient and population information. However, an over-emphasis on new technology without meaningful ways to identify what is too expensive is yet another issue (Coyne, et al.). Great Lakes Health Connect (GLHC) has facilitated the electronic transport of immunization records to MCIR as a basic service to their participating providers for several years. GLHC has now given providers the ability to query a patient’s immunization records through their native electronic medical record environment.

A provider’s workflow functions more effectively when they are able to access the information they need from within their own system. Doctor Kenneth O’Neill, Lakeland’s vice president of clinical integration, said in a prepared statement, “Lakeland Health is highly focused on a ‘speed to value’ approach to achieving Triple Aim goals on behalf of our patients. While we don’t see ourselves as technology pioneers, given our long relationship with GLHC, combined with the promise of easier access to the state immunization registry, early adoption of this patient-centric technology made great sense to us (Landi).” By making health information easier to access, GLHC’s Immunization Query functionality allows more time and attention to be focused on patient care.

Dr. O’Neill offered this example to illustrate the value of better access to immunization records: “The Center for Disease Control recommends that adults over the age of 65 receive an annual vaccine to protect against Pneumonia. There are two competing vaccines in this class, but they cannot be administered within twelve months of each other (Landi).” Now with MCIR, it is easier to avoid the mistake of cross-immunization. Let’s examine other methods of determining Triple Aim success.

Achieving Triple Aim

 In order to achieve decreasing hospital admissions and the average length of stays for chronic disease, ACOs of all types must be established geographically around the country. This can be accomplished by focusing on promoting healthier defined populations (Block, 2014). Over the past several decades, all stakeholders of the U.S. healthcare delivery system have criticized the suppliers of goods and services for their inability to integrate their work over time, across varying sites. Senior leadership recognizes that volume and price contracting with payers is outdated.

Expenditures per capita continue to rise higher than in any other developed country, yet the U.S. healthcare delivery system consistently produces poorer quality, safety, and patient outcomes. According to a Kaiser Foundation analysis of the American population, 5% of individuals consume 50% percent of healthcare, averaging $43,000 annually (2012). Consumer-driven healthcare requires financial cost information in order to compare value. The ability to compare rival healthcare systems for similar goods and services is changing the goals and objectives of our health system. This ability is being enhanced every day through advancements in AI and IT. Stakeholders in healthcare are beginning to understand the need for a shift to cooperative, comprehensive, continuous healthcare for a defined population (Block).

To achieve the Triple Aim, organizations must broaden their focus to organize care to meet the needs of a defined population. Pursuing these three objectives simultaneously allows healthcare organizations to identify, isolate, and correct problems. Problems like poor coordination of care and overuse of medical services can be fixed (Block). It helps them focus and redirect resources to activities that have the greatest impact on health. The distinguishing factor was a population-based approach. This requires building a strong partnership between the health plans and systems, the care providers, and community organizations. Organizations must discover whether resources are being optimally deployed to meet the populations’ needs. It is through these decisions that defects and gross incentives can be addressed and removed (Block).

Patient Engagement

 We must re-imagine healthcare. Imagine a system with the right providers, delivering the right services, using the right processes, and tools at the right time, all the time. This is accomplished through care coordination that corrects the inherent flaws of the fee-for-service care models of the past. Patient data then becomes the currency of these new models of care (Williams, 2016). In the emerging value-based care environment, the success of accountable care organizations (ACOs) will depend on how effectively these organizations engage patients in their own care processes.

The first step in an ACO’s patient engagement strategy should be to identify the patient population on which to focus engagement efforts, based on the premise that the ultimate goal is to reduce costly healthcare utilization (Williams). The patient engagement strategy should fit within the ACO’s larger strategy to develop a patient-centric care model that promotes care coordination across the care continuum. With patient engagement as a cornerstone of its care strategy, an ACO can make significant strides toward achieving the Triple Aim of improving population health, enhancing the individual experience of care, and lowering per capita costs of care (Williams).

For an ACO, a patient engagement strategy should be understood as fitting squarely within the larger strategy of developing a patient care model that will ensure the organization’s success in the emerging value-based care environment. Personal health records provide improved communication between care recipients and caregivers (Gage & Albaroudi, 2015). The current focus is on the person and their health outcomes, not on the services they use. Providers, policymakers, and advocates nationwide have refocused the healthcare discussion, changing it from one about cost containment to value-based systems.

The Joint Commission, the National Committee for Quality Assurance, and other accrediting bodies develop minimum standards for organizations, the National Quality Forum (NQF) is moving quality measurement beyond the typical framework of structure, process, and outcomes to also focus on the voice of the patient (Williams). Quality measurement is a basic cornerstone of all health and social support programs. It allows monitored access to appropriate services, thus creating accountability. This is a key tenet in the new value-based payment systems under the Triple Aim.

Family Caregiving

 As state, federal, and commercial insurers, plus healthcare providers across the spectrum strive to build person-centered, population health programs, family caregivers are filling in more of the gaps to help loved ones remain safe and healthy in the community (Gage & Albaroudi).

The National Quality Strategy has prioritized the importance of engaging individual people and families as partners in care. Congress has underscored the importance of providing information to the family caregiver, and NQF’s work on developing person- and family-centered care measures is a great starting point for establishing scientific evidence showing how family caregivers’ contributions are essential to achieving the Triple Aim (Gage & Albaroudi).

The U.S. has experienced a major expansion of home and community-based services (HCBS) during the past 30 years, providing those of all ages with disabilities more choices regarding where and how to live. One indicator of the rise of HCBS is its increasing share of Medicaid long-term services and supports (LTSS) expenditures. It grew from 13% in 1989 to 46% in 2009 (Eiken, Burwell, & Sredl, 2013). In 2013, the Medicaid program announced that for the first time that the majority of long-term services and supports (LTSS) funds went to community-based services instead of higher-cost institutional services. This achievement follows many years of grant programs administered by the Centers for Medicare & Medicaid Services (CMS) and the Administration for Community Living to assist states in redesigning programs for those with chronic conditions or other LTSS needs (Eiken, et al.).

Woodwork Effect

 Although the use of HCBS has expanded, a common concern among LTSS policymakers is the so-called “woodwork effect.” It has two components: Publicly funded HCBS are more attractive, so more people will use publicly funded services (i.e., “come out of the woodwork”) if HCBS is expanded. It was hypothesized the increased number of HCBS beneficiaries would increase the overall rate of public LTSS expenditures growth (Eiken, et al.). However, evidence shows the shift in Medicaid funding toward HCBS did not significantly alter overall Medicaid LTSS spending.

Mental Model Challenges

 Given the magnitude of the challenge inherent to the Triple Aim, it has been argued on a conceptual level that new mental models need to be established. Mental models were first defined as a “psychological representation of some domain or situation that supports understanding, reasoning, and prediction (Storkholm, Mazzocato, Savage, & Savage, 2017).” Through contributions from cognitive psychology, pedagogy, and organizational science, our understanding of mental models has been expanded to recognize the role of past experiences.

The management of mental models is a central tenant to the development of learning organizations able to adapt to societal trends, pressures, and demands. The Triple Aim forces together goals that traditionally have appealed to two competing logics: Managerialism and professionalism. Change efforts have been obstructed by this conflict; the two logics can learn from each other. Staff and managers understood the change imperative inherent to the Triple Aim mainly as a political requirement to become more efficient and reduce costs (Storkholm, et al.).

Bending the Cost Curve

 Economists have emphasized information asymmetries and institutions that defer decisions to providers as one reason for high healthcare costs. A moral hazard is a tendency to overconsume when third-party insurance pays much of the cost. This is another oft-cited explanation (Coyne, et al.). Triple Aim attempts to control costs by assuring that payment and resource allocation support yearly initiatives to reduce waste, and rewarding providers for their contributions to better population health. The pursuit of this is still a challenge. Only 30% of cases have been able to improve quality, at the same time reducing costs (Hussey, Wertheimer, & Mehrotra, 2013).

There is policy consensus that both cost containment and quality improvement are critical; however, the association between cost and quality is poorly understood. Deming described in his “chain reaction” model that by investing in quality improvement costs can be reduced (1985). Many have argued Deming’s point. I tend to agree with him, but it takes a lot of work. With increasing costs, the quality benefits of additional resources may decline and eventually become negative (Hussey, et al.). However, economists agree there is evidence of a slowing in the rate of growth. Quietly over the last decade, large corporations have been on a slow and steady “buy-down” of benefits; this is benefit-consulting speak for “shift the financial burden to employees (Morrison, 2013).” Cost-sharing has been packaged as consumer empowerment, and delivered through the vehicle of consumer-directed health plans with health savings accounts.

In February of 2013, the Congressional Budget Office (CBO) announced that projected Medicare and Medicaid spending in 2020 would be some $200 billion, 15% less than the office had projected only three years ago. Also, generic pharmaceutical substitution rates are at an all-time high, which explains the amelioration in the drug-spending trend for chronic care medications in most healthcare plans (Morrison). ACOs are doing their part as well to curb costs. An ACO’s patient engagement strategy, focused on the patient population, has the greatest impact in reducing costly healthcare utilization (Williams). Much of the recent growth in healthcare costs has been in price, not volume. Private purchasers worried they will be asked to pay higher prices to compensate for the trend-bending activities of the government are concerned about massive consolidation in the delivery system (Morrison).

Future Challenges

 Healthcare organizations will encounter a variety of other problems beyond the cost curve. The issues include workforce, new healthcare designs, collaboration, population-level payment models, analysis of population data, and sustainable funding for community coalitions (Whittington, Nolan, Lewis, & Torres, 2015). The continuing work of organizations and communities pursuing the Triple Aim will help inform these issues.

Some community partners, for example, made less money when the population’s health improved. One healthcare leader (who asked to remain anonymous) described a health system CEO who encouraged his employees to participate in a coalition. This coalition’s aim was to slow down the improvement process. His reason was that the hospital would face financial risk if the Triple Aim succeeded. This anonymous example illustrates the potential political tensions at the community level that need to be considered when selecting populations of focus for the Triple Aim (Whittington, et al.).

There are three major principles that guided the organizations and communities working on the Triple Aim: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time (Whittington, et al.). Organizations often choose a population for which only two dimensions of the Triple Aim make sense, with the most likely weakness being per capita cost. Even though these organizations saw the value of improving health and care for the population, their payment model did not reward them for lower per capita costs.

In some cases, the payment model actually penalized them when they improved their health because it led to less need for health care and, consequently, less revenue. The initial conveners of the Triple Aim included healthcare executives, government officials, public health officers, social services executives, union leaders, business executives, insurance company executives, and other regional representatives (Whittington, et al.). An organization or community typically started with a small, core group of leaders who understood the needs of a population and were willing to use their personal influence to attract other leaders to initiate the process and grow.

The IHI team urged organizations and communities to choose a segment of the population on which to focus. Working with a group of individuals with complex needs, some organizations have used a blend of methods to segment that population even further. This includes talking directly to individual patients, reviewing past utilization and cost data, and working with front-line providers to gather qualitative information about high-risk patients (Whittington, et al.).

Next: Quadruple Aim

 Society expects more and more physicians and practices, particularly in primary care. Patients want their health to be better, to be seen in a timely fashion with empathy, and to enjoy a continuous relationship with a high-quality clinician whom they choose. Yet for primary care, society has not provided the resources to meet these lofty benchmarks. In a 2014 survey, 68% of family physicians and 73% of general internists would not choose the same specialty if they could start their careers over (Kane & Peckham, 2014).

The wide gap between societal expectations and professional reality has set the stage for 46% of US physicians to experience symptoms of burnout. It hurts physicians, and other members of the healthcare workforce. Thirty-four percent of hospital nurses and 37% of nursing home nurses report burnout, compared with 22% of nurses working in other settings (Russell, 2016). Dissatisfied physicians and nurses are linked to lower patient satisfaction. Physician and care team burnout can lead to the overuse of resources, and ballooning costs (Kushnir, et al., 2014). If we don’t take care of those that take care of us, the entire healthcare system will falter.

Conclusion

 Organizations all over the world are applying Triple Aim in many manners. Healthcare leaders must continue stepping forward with innovative solutions that can propel their organizations towards Triple Aim using value-based healthcare. Quality population healthcare management will lead to the efficient and equitable allocation of resources. We must design and implement well-conceived patient engagement strategies that effectively motivate high-risk patients to play a more active role in their own care. (Williams).

To be successful, patient engagement programs and technology should meet patients where they are, using technology that is familiar to them. The cost escalation has been slowed for the time being, but for it to last primary care, HCMS services must become more effective and accessible. The Triple Aim has paved a solid path forward for the future of the U.S. healthcare system, and systems everywhere.

References

 Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759-769. doi:10.1377/hlthaff.27.3.759

Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the patient requires the care of the provider. Annals of Family Medicine, 12(6), 573-576. doi:10.1370/afm.1713

Block, D. J. (2014). Revisiting the Triple Aim–Are we any closer to integrated health care?. Physician Executive, 40(1), 40-43.

Coyne, J. S., Hilsenrath, P. E., Arbuckle, B. S., Kureshy, F., Vaughan, D., Grayson, D., & Saygin, T. (2014). Triple Aim program: Assessing its effectiveness as a hospital management tool. Hospital Topics, 92(4), 88-95. doi:10.1080/00185868.2014.968488

Deming, W. E. (1985). Transformation of Western style of management. Interfaces, 15(3), 6-11.

Eiken, S., Burwell, B., & Sredl, K. (2013). An examination of the woodwork effect using national Medicaid long-term services and supports data. Journal of Aging & Social Policy, 25(2), 134. doi:10.1080/08959420.2013.766054

Gage, B., & Albaroudi, A. (2015). The Triple Aim and the movement toward quality measurement of family caregiving. Generations,39(4), 28-33.

Hussey, P. S., Wertheimer, S., & Mehrotra, A. (2013, January 01). The association between health care quality and cost: A systematic review. Retrieved February 27, 2017, from http://annals.org/aim/article/1487781/association-between-health-care-quality-cost-systematic-review

Kane, L., & Peckham, C. (2014). Medscape physician compensation report 2014. Retrieved March 04, 2017, from http://www.medscape.com/features/slideshow/compensation/2014/ public/overview#24

Kaiser Family Foundation. (2012, May 1). Health care costs: A primer. Retrieved February 27, 2017, from http://kff.org/health-costs/issue-brief/health-care-costs-a-primer/

Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380-383. doi:10.2105/ajph.93.3.380

Landi, H. (2017, February 13). Lakeland Health, GLHC partner to enable immunization record queries through EMR. Retrieved March 04, 2017, from http://www.healthcare- informatics.com/news-item/hie/lakeland-health-first-Michigan-hospital-query- immunization-records-directly-through

McCarthy, D., & Klein, S. (2010, July). The Triple Aim journey: Improving population health and patients’ experience of care, while reducing costs. Retrieved February 27, 2017, from http://www.commonwealthfund.org/~/media/files/publications/case-study/2010/jul/triple-aim-v2/1421_mccarthy_triple_aim_journey_overview.pdf

Morrison, I. (2013, May 7). The bending of the health care cost curve. Retrieved March 03, 2017, from http://www.hhnmag.com/articles/6364-the-bending-of-the-health-care-cost-curve

Russell, K. (2016). Perceptions of burnout, its prevention, and its effect on patient care as described by Oncology nurses in the hospital setting. Oncology Nursing Forum, 43(1), 103-109. doi:10.1188/16.ONF.103-109

Storkholm, M. H., Mazzocato, P., Savage, M., & Savage, C. (2017). Money’s (not) on my mind: A qualitative study of how staff and managers understand health care’s Triple Aim. BMC Health Services Research, 171-9. doi:10.1186/s12913-017-2052-3

Whittington, J. W., Nolan, K., Lewis, N., & Torres, T. (2015). Pursuing the Triple Aim: The first 7 years. Milbank Quarterly,93(2), 263-300. doi:10.1111/1468-0009.12122

Williams, R. (2016). Engaging patients to achieve the Triple Aim. Hfm (Healthcare Financial Management), 70(9), 72.

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How are healthcare systems providing relevant, efficient, affordable, and effective care?

Objectives:

· Identify the essential elements of the Institute of Healthcare Improvement’s Triple Aim.

o Improving the patient experience of care (including quality and satisfaction);

o Improving the health of populations; and

o Reducing the per capita cost of health care.

1. Correlate the impact of both funded and unfunded mandates in providing healthcare.

2. Compare the health care systems of the United States to other countries of the world.

Areas to think about with your responses include:

1. Policy/Management overview (who funds it/controls it?)

2. Health status/health indicators (avg life expectancy, maternal/infant mortality rankings, suicide rates, population demographics, density, etc.)

3. Providers

4. Access (how do people access care/maintain coverage?)

5. System Advantages

6. System Challenges

Readings: Use material from the Centers for Disease Control and Prevention, the World Health Organization (WHO), the Institute for Healthcare Improvement, the Library of Congress (http://thomas.govLinks to an external site.), and other reputable sites you discover.

• 600 words  APA      formatting is essential 2-references from WHO

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