\fPopulation Health Revisiting the Triple AimAre We Any Closer to Integrated Health Care? By Dale J. Block, MD, CPE In this article... Are we, as a nation, any closer to integrated health care? Have the preconditions for the pursuit of the Triple Aim been achieved? Can the U.S. health care delivery system pass the \"Triple Aim Test?\" Over the past several decades, all stakeholders of the U.S. health care delivery system have criticized the suppliers of goods and services for their inabilities to integrate their work over time and across sites of care. Expenditures per capita continue to rise higher than in any other developed country, yet the U.S. health care delivery system consistently produces poorer quality, safety and patient outcomes.1 Many efforts to improve the quality of health care in the past decade have focused on individual patient clinical care efforts promoted by the Institute of Medicine's (2001) six dimensions of quality: safety, efficiency, effectiveness, equity, timeliness and patient-centeredness. 2 The IOM argued that the current American system of care failed to provide Americans with a high-quality health care system they need, want and deserve. In 2008, Donald Berwick and others wrote a landmark article, \"The Triple Aim: Care, Health and Cost.\" In a highly organized and thorough discourse, the authors noted that the United States would not achieve high-value health care unless national initiatives pursue a broader system of linked goals called the Triple Aim: 1. Improving the individual experience of care 2. Improving the health of populations 3. Reducing per capita costs of care for populations3 40 PEJ JANUARYFEBRUARY/2014 Around the time that the Triple Aim concept was published in Health Affairs, Barack Obama was elected President. Campaigning for a complete overhaul of the U.S. health care delivery system, the Affordable Care Act was conceived. Americans would soon be embroiled in a health care debate of legendary proportions. Today, several questions remain about the U.S. health care delivery system: Are we, as a nation, any closer to integrated health care? Have the preconditions for the pursuit of the Triple Aim been achieved? Can the U.S. health care delivery system pass the \"Triple Aim Test?\" Pursuit of Triple Aim To begin adopting the idea of delivering integrated health care in the pursuit of the Triple Aim, a clear and concise definition of population health is required. David Kindig and Greg Stoddart define population health as \"the health outcomes of a group of individuals, including the distribution of such outcomes within the group.\"4 The population may be geographically isolated but may also be a group of employees, disabled persons or prisoners. Determinants of health such as medical care systems, the social environment, the physical environment and genetics have a significant biological impact on individuals in a defined population. The structure most identified today with managing defined population's health is the Accountable Care Organization (ACO). This entity, with its different forms and stakeholders, becomes responsible for a defined group of individuals' health care services using performancebased standards. The ACO is ultimately responsible for the defined population's clinical quality, safety and outcomes, and the costs associated with delivering the entire continuum of care for all of the patients. The ACO must be transparent and meet the IOM's national goals for individual quality previously reviewed. According to Berwick, externally supplied policy constraints are the next component as a precondition in the pursuit of the Triple Aim. Decisionmaking, politics and social contracting relevant to the population at risk shape the balance sought among the three aims. For example, payers' including evidence-based preventive health screening for the population requires careful consideration. Whether a screening test results in a true or false positive, it will require further testing and apply additional resource constraints on the availability of other health care resources for that same population. Without careful dissemination of evidence-based clinical guidelines, providers may not follow updated algorithms for preventive services. This results in a potential overuse of resources resulting from higher-thanacceptable false positive rates with subsequent increases in per capita cost while chasing the elusive and nonexistent disease. The final precondition in the pursuit of the Triple Aim, according to Berwick and his coauthors, requires the development of an \"integrator\" able to focus and coordinate services to help everyone in the defined population on all three aims at once. Traditional health care organizations (i.e., health systems, hospitals, physician groups) become the integrators and are required to link with public health and social service organizations. This enlarged integrator is responsible for providing for health care goods and services across the continuum of care for individuals of the population (including the population in the geography as a whole) with a focus on the total costs of care taken together. The overarching goal is the implementation of the ACO that can induce cooperative, meaningful behavior among health service suppliers to work as a system for the defined population's best interests. Critical to the success of the ACO is identifying the many functions of Many are admitting for the first time that the primary focus operationally for the health system should be on preventing chronic disease. an effective integrator. First, the effective integrator must work to change the \"more is better\" culture through transparency, systemic education, communication and shared decisionmaking with their defined population. Restricting access to care, shifting costs and administrative roadblocks are minimized while informing individuals about the determinants of their own health and the benefits of evidence-based clinical care. Second, the effective integrator must strengthen primary care services. The design and implementation of the patient-centered medical home (PCMH) includes: Establishing long-term relationships with patients and the entire primary care team Coordinating clinical care along the continuum of services and venues Providing innovative access and communication between the defined population of patients and the primary care team Third, population health management requires the effective integrator to act as a health care fiduciary for the deployment of health care goods and services within the defined population based on health status and need. This would facilitate the efficient and equitable allocation of health care resources. With limited health care resources available for chronic disease, the population would then be required to begin a metamorphosis toward preventive care focusing on lifestyle behavioral changes. Fourth, the effective integrator would insist on financial transparency and accountability by demonstrating a per capita cost of care for his defined population. This allows ACPE.ORG 41 for a cooperative environment shared by all stakeholders to become more value-driven through costefficient delivery of health care services. Reducing waste by eliminating unnecessary testing based on clinical guidelines and evidence-based medicine would reduce false positive preventive testing and begin matching supply to the underlying needs within the defined population. Finally, the effective integrator works diligently at the macroscopic level to provide system integration, both administratively and clinically, to encourage real-time and up-todate medical knowledge, and standardized definitions of quality with safety and cost and outcomes data measured independently and reported to all the stakeholders. This is the value proposition required to ensure achieving Triple Aim. Integrated delivery Meeting the preconditions of the Triple Aim is a critical component for establishing integrated health care delivery. Understanding the integration of health care delivery requires the systematic merging of identifiable health care processes leading to a complete program design, development and implementation for analysis and positive change of behavior at the individual or population level providing value to all stakeholders in the defined population. Health care quality, safety and outcomes achieved by the most costefficient evidence-based processes leads to the positive value-based proposition of health care currently desired by all in the United States. The Institute of Medicine defined quality of care as the \"degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.\"5 Reasonable goals and objectives for integrated health care delivery include: 42 PEJ JANUARYFEBRUARY/2014 Making our care patient-centered, focusing on the patient experience Knowing what is and what is not appropriate heath care for our patients Identifying and closing gaps between current clinical practice and optimal practice Changes in payment such that the financial gains from reduction of per capita costs are shared among those who pay for care and those who can and should invest in further improvements Diminishing clinical uncertainty Changes in professional education accreditation to ensure that clinicians are capable of changing and improving processes of care. Continuously improving the care we deliver The Triple Aim test Considering quality and cost outcomes (value) along with other organizational considerations6 Achieving value-based care requires congruency with established business practices. In the U.S. health care delivery system's current form, this congruency is not achievable in the balanced pursuit of the Triple Aim. Other barriers to integrated health care delivery include supplydriven demand, physician-centric care, limited foreign competition to create domestic change, and a general lack of understanding among clinicians for a system wide approach to care.3 Progressing toward integrated health care delivery, according to Berwick, requires a keen memory of the past (e.g., failures of health maintenance organizations) and a willingness to challenge the status quo in the future. A paradigm shift in health care financing and competitive dynamics requires the following to take place: Global budget caps on total health care spending for designated populations Measurement of and fixed accountability for the health status and health care needs of designated populations Improved standardized measures of care and per capita costs across sites and through time that are transparent Berwick and his co-authors wanted to know whether caring for defined populations is actually making progress toward achieving the Triple Aim. To do this, they proposed an intellectual exercise focused on three items. First, hospitals approaching the Triple Aim would realize a reduction in admissions for conditions that would be preventable if patients are engaged in preventive health. Second, the dynamics of supplydriven care are weakening as demonstrated by patients pulling health care resources with consumer-driven care. Finally, patients would believe their health care providers were actively engaged in their health and well-being by demonstrating mindfulness for their needs, wants and opportunities to lead healthier lifestyles focused on health prevention and promotion. So where do we stand? As of 2013, I believe that the U.S. health care delivery system is beginning to approach the Triple Aim. Successful ACO demonstration projects have been expanded with the sole purpose of caring for many other defined populations around the country. I have recently attended medical staff meetings at the hospital where I am on staff and meetings of the health system of which I am employed. Presentations are still focusing on monthly hospital census trends with average lengths of stay and readmission rates. Encouragingly, the discussion changes to presentations of statistics on meeting quality, safety and outcomes goals defined by national measures. Most amazingly, in my recent discussions with others on the senior leadership team in our health system, many are admitting for the first time that the primary focus operationally for the health system should be on preventing chronic disease. In fact, the senior leadership team wants to know how to do this first with our own employees in order to get ready to manage other defined populations for the future. Recognizing the importance of transparency and accountability is critical for our health system to prepare for transitioning to payfor-performance. Accepting that consumer-driven health care requires financial cost information as a means of comparing value between rival health care systems for similar goods and services is changing the goals and objectives of our health system for future managed care contracting. Senior leadership recognizes that volume and price contracting with payers is outdated. It should be obvious by now to all stakeholders that the current U.S. health care delivery system is working hard at establishing the preconditions for pursuing the Triple Aim. Population health management is being discussed and promoted at all levels of health care delivery. Evidence-based medicine and clinical guidelines are now the norm as evidenced by health system and hospital performance-based goals and objectives. All of the health care stakeholders are beginning to understand the need for a shift to cooperative, continuous and comprehensive care for all in defined populations. Quality, safety and outcomes discussions capture the majority of the attention in all operational meetings of health care systems and hospitals. Value-based health care, ACO development and patient-centered medical home adoption dominates the agendas of local, state and national health care meetings calling for changes to the current system of health care delivery. It is this author's opinion that many health care systems are closer than ever to passing the Triple Aim test. The final piece is to achieve decreasing hospital admissions and average length of stays for chronic disease and implementing ACOs of all types geographically around the country focusing on promoting healthier defined populations for generations to come. References 1. Cantor, JC, and others. Aiming Higher: Results from a state scorecard on health system performance. New York: Commonwealth Fund, June 2007. 2. Institute of Medicine. Crossing the Quality Chasm: A new health system for the Twentyfirst century. Washington, DC: National Academy Press, 2001. 3. Berwick, DM, Nolan, TW, Whittington, J. The Triple Aim: Care, Health and Cost. Health Affairs 27(3): 759-69, May-June 2008. 4. Kindig, D, Stoddart, G. What is Population Health? Am J Public Health 93(3): 380-83, Maaaar 2003. 5. Lohr, KN. Ed. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press, 1990. 6. Strite, S, Stuart, M. What is an EvidenceBased, Value-Based Health Care system? (Part 1). The Physician Executive 2005 31(1): 50-4, Jan-Feb 2005. Dale J. Block, MD, CPE, is a full-time practicing family physician with Premier Family Care of Mason in Mason, OH. djblock5@gmail.com. ACPE.ORG 43 Copyright of Physician Executive is the property of American College of Physician Executives and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use