In 2008, Dr. Don Berwick of the Institute for Healthcare Improvement authored a paper in Health Affairs that introduced the concept of the ‘Triple Aim’1. The Triple Aim is a simple approach to improving healthcare: improving health and experience while reducing the per capita cost. The Institute for Healthcare Improvement created the graphic in Figure 1 to visualize the Triple Aim idea. The concept is a straightforward way to tackle improvement opportunities for maximum impact: look for opportunities that provide a balance among the health of the populations cared for, the experience of patients or members, and the overall cost of healthcare.
Figure 1: The Triple Aim
Some examples of how the Triple Aim could applied in healthcare delivery include:
- Preventing unnecessary hospitalizations: improves health by keeping patients out of the hospital where they are at risk for infections; improves experience because patients are at home, where they would rather be; and reduces costs of unnecessary hospital stays.
- Care coordination through disease and case management models: improves health by more frequent monitoring and support; improves experience through a personalized connection between caregiver and member; lowers cost by avoiding unnecessary visits to specialists.
- Protocols for high-tech diagnostic imaging built into electronic health records: improves health by reducing unnecessary exposure to radiation; the patient’s experience is improved by skipping time-consuming and sometimes intimidating tests; and lowers cost by using evidence-based guidelines to determine when imaging is appropriate.
The combination of analytics and the framework of the Triple Aim is a powerful approach to prioritizing opportunities. For example:
- Cost: Utilize analytic tools to identify areas of variation, or compare administrative operational costs against national benchmarks to focus on inefficiencies.
- Quality/Health: Prioritize quality improvement efforts, using metrics like HEDIS.
- Experience: Listen to the voice of the customer: use patient experience tools like CAHPS (The Consumer Assessment of Healthcare Providers and Systems) for health plans, CG-CAHPS (Clinician Group Consumer Assessment of Healthcare Providers and Systems) for ambulatory care groups, or HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) for hospitals. These surveys are AHRQ tools that health plans, providers, and hospitals can use to have members and patients provide feedback where they want improvement.
- Bring the Triple Aim together: Map cost opportunities back to quality and customer experience metrics, and determine where the greatest return on improvement is obtained.
Care for patients with diabetes is an impactful example of how to apply the Triple Aim. Start with data: what percentage of your patients or members have a diabetes diagnosis, and how many are receiving hemoglobin A1c screenings on a regular basis? Benchmark the results against other plans or providers in your area and nationally, and look for variation. The findings will help identify cases where patients with diabetes are receiving the best evidence based care, and situations where there is room for improvement. Next, study the systems, providers or geographic care delivery regions that are beating benchmarks, and then spread learnings. This analysis has significant impact for the Triple Aim; for cost, a Milliman analysis published in the Journal of Managed Care & Specialty Pharmacy2 showed that the cost savings from reduced complications across patients with diabetes ranged from $67 to 105 PPPM in the commercial population to $59 to $106 in the Medicare population. Patients with diabetes who are receiving regular hemoglobin A1c screenings avoid common complications from diabetes like lower-limb amputations, blindness, kidney failure, stroke and heart disease, which impacts the ‘health’ part of the Triple Aim. Finally, patients with diabetes that is under control spend less time in the hospital (more time at home), miss less work, spend less time in the doctor’s office, and have less complications that can impair quality of life, improving experience. A well-crafted analysis of data can help organizations impact the Triple Aim of improved population heath, better patient and member experience, and lower per capita costs.
1Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs 2008; 27(3):759-69.
2Fitch K, Pyenson BS, Iwasaki K. Medical Claim Cost Impact of Improved Diabetes Control for Medicare and Commercially Insured Patients with Type 2 Diabetes. J Managed Care Pharm 2013; 19(8):609-20.
Graphic: Institute for Healthcare Improvement, available at https://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx