The Triple Aim is vital to our collective health

In 2008, a couple of years before the Affordable Care Act became the law of the land, Donald M. Berwick, MD, and his colleagues at the Institute for Healthcare Improvement (IHI) introduced the Triple Aim concept and set to work on ways to (1) improve population health, (2) increase patient satisfaction and (3) reduce per capita healthcare costs.

In pursuit of these goals, IHI encouraged the exploration of a variety of population health interventions — primary care promotion, enhanced communications between physicians and patients through e-mail correspondence, and targeted education initiatives to promote self-management of chronic conditions to name just a few. But, until recently, the term “population health” prompted questions even among my colleagues at Thomas Jefferson University.

Since “Obamacare” took effect in 2010, fans and foes alike have been struck by how fast we are moving toward the fulfillment of the Triple Aim and the true practice of population-based healthcare.

This movement is prompted, in no small measure, by the law’s call for broader health insurance coverage (i.e., health insurance exchanges), greater connectivity and population-based analytics, improved care coordination, and increased patient engagement.

There is ample evidence that the population health movement has begun to spread beyond the usual cited organizations, incluidng the Kaiser Foundation, the Mayo Clinic, and Geisinger Health System.

Electronic health record (EHR) companies, for instance, are inventing new strategies to facilitate the move to population health management by integrating patient data from disparate health information systems, organizing it for easy clinical access, and delivering it to clinicians at the point of care.

Example: Allscripts has begun to leverage aggregated EHR data, analytics, and patient portal technology to develop tools for clinical decision making and patient self-management.

The company sponsors a Population Health Forum where caregivers from around the country share examples of how population health management is enabling them to improve upon their clinical protocols while dramatically reducing costs.

Retail pharmacy chains are taking more active roles in population health management by applying clinical analytics and predictive modeling to their rich pharmaceutical data.

Example: Recently, Walgreens developed a stratified approach to identify subpopulations of patients who are at risk for “triple fail events” — (1) suboptimal health outcomes that are (2) overly expensive and (3) result in patient dissatisfaction — who could benefit from preventive measures.

In this way, the pharmacy can better determine which subsets of patients are at high risk – for events such as unplanned hospital readmissions within 30 days, untimely nursing home admission, or over-medicalization at the end of life – and direct information and other appropriate resources to patients, their physicians, and their caregivers preventively.

Health care consulting companies are entering the population health arena in new and potentially beneficial ways.

Example: Aegis Health Group recently launched a password-protected online population health portal designed to help employees identify and address their health risks proactively, and to provide employers with aggregate data and analytics for making decisions regarding employee wellness programs and incentives for completing programs.

I am energized by the growing number of organizations that recognize the Triple Aim as vital to our collective health — and I look forward to seeing fewer puzzled expressions when I say that I am the dean of a school of population health.

David B. Nash is founding dean, Jefferson School of Population Health, Thomas Jefferson University and blogs at Nash on Health Policy and Focus on Health Policy.

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  • Guest

    David why do you do this to us!!

  • PoliticallyIncorrectMD

    Triple Aim is only vital to your own agenda, it has nothing to do with our collective health. You should not be calling yourself a physician!

  • southerndoc1

    I love it when someone tells us that for-profit corporations are dedicated to reducing health care spending.

  • Anoop Kumar

    Dr. Nash,

    To me, population health represents an opportunity in that it actually focuses on the health of a population, as opposed to our current system which focuses on disease. Secondarily, our disease-based health system is inefficient in many ways. Unless we acknowledge that disease-based care should only be a fraction of our health system, there is no point in doing analytics and hiring consulting companies to tell us that trying to foster health with a disease-based system isn’t working. We can keep trying to fit a square peg into a round hole to keep busy, all the while spending more on consultants who tell us to push the square peg harder or shave the sides. What we do best in our system of care is treat acute illness, because it fits our disease-focused paradigm. Shifting to a health focus is not possible unless we change how and what we teach in medical school, and/or incorporate different types of medical care beyond conventional medicine into our system. These are the policy changes that will make the real difference in population health and I hope your school will focus on them.


    • Margalit Gur-Arie

      You can focus on the health of an individual just as easily as you can focus on the health of a population, and you can focus on individuals with disease or on population diseases. I believe Dr. Nash is advocating the latter choice for both.
      I think it’s time to drop the Berwickese “patient-centered” terminology and call it what it is….

      • Anoop Kumar

        At the individual level, some people working in healthcare are indeed providing patient-centered care, but as a system healthcare is certainly profit-centered.

        • Margalit Gur-Arie

          Barbara Starfield made a distinction between “primary health care” (the system) and “primary care” (clinical level). Lots of stuff can be explained if we look at it that way…. including profiteering.

      • Anoop Kumar

        Sure – it seems Dr. Nash is focusing on the health and disease of populations as whole, with particular importance to the use of data and analytics. If we’re truly interested in improving the health of populations, we don’t need much more analysis or interpretation to know that engaging health as a lifelong process founded on basics such as nutrition, mobility and rest is what we need. I think generally there is a reluctance to do that and money is aligned against that at a systemic level, which is the primary issue. As long as the big players in healthcare don’t agree with those basics and continue to put money in finding and managing disease (where the money is), all the data collection and analysis won’t matter. So it seems to me that, ideally, a school of population health would recognize this work toward changing that structure. Perhaps they are doing so.

        • Margalit Gur-Arie

          Right. In which case what is the difference between a school of population health and a school of public health? (as an aside, it may be worth noting that when HHS needed some extra cash for ACA marketing, they raided precisely public health funds – ironic to say the least). Health can and should be promoted and facilitated at a population level, but perhaps disease when it inevitably occurs is best treated at an individual level… Just a thought….

    • Andrew_M_Garland

      “Shifting to a health focus is not possible unless we change how and what
      we teach in medical school, and/or incorporate different types of
      medical care beyond conventional medicine into our system.

      I don’t understand. A few examples would help. What changes do you want, and what “different types” of medical care are you referring to? What is “beyond conventional medicine”; accupuncture, yoga?

      • Anoop Kumar

        By “beyond conventional medicine” I simply mean being open to an integrative approach, where therapies such as the ones you mentioned (acupuncture, yoga, as well as many others) go hand in hand with antibiotics and surgery. This is already happening but we need to open the doors even more. And medical schools need to teach that there is more than one way of doing things, simply leaving the door open for other therapies while recognizing the strengths and weaknesses of allopathic medicine. Many of these so-called alternative therapies engage people before they become “sick” and enter the allopathic care system, meaning they engage more at the level of lifestyle. Lifestyle changes are the best and seemingly most difficult way to shift away from disease and toward health. We need to stop looking at people as sick or not sick (black and white) and just look at health as an ongoing process from life to death where continuous engagement is the best medicine.

        • Andrew_M_Garland

          I think I understand. Yoga and accupuncture among other treatments, for the sick and the well and anyone in between, from birth to death, all supported (i suppose) by mandatory insurance and nudges provided by monetary penalties. How else would one change people’s lifestyles, if it isn’t enough to provide them information on healthy living?

          • Anoop Kumar

            We may beable to make it easier to adopt a particular lifestyle if there are better and more varied options on the healthier side of the health-disease spectrum. Different strokes for different folks.

            One problem with healthcare is that we are so disease-focused. A second is that even in delivering disease-focused care we are inefficient. So, yes, weneed to open up the market beyond allopathic care, which is happening anyway to some extent. Your point is well taken – we still need a good system to deliver this care.

  • Steven Reznick

    Improving the health of populations involves educating the population at a young age as to what works and what doesnt work. It involves changing ethnic cultural practices in a manner that encourages better choice of foods, food preparations, daily activities, lifestyle choices etc. Much of this used to be done in the home and in the public schools and public health units across the country. Budget cuts in the name of ” smaller government” have decimated many of the programs that taught students basic life skills. Am I to believe that now outsourcing these tasks to highly paid private consulting groups is the answer?
    The AllScripts example is particularly galling since they are buying up their competitors EMR businesses, shutting them down and not supporting their software while we hear Deans of Medical Schools with unclear titles and unobjectives compliment their actions?
    Medical school curriculums have changed dramatically across the USA in the last 40 years and continue to change. With current proposals to shorten medical school to 3 years and shorten residency training programs what exactly does Dean Nash propose to eliminate to allow the teaching of population based healthcare?

    • Mandy Miller

      “Budget cuts in the name of “smaller government” have decimated many of the programs that taught students basic life skills.”


      Budget cuts did that?

      Gosh, it was my parents and grandparents who taught and modeled those skills for me and my 6 siblings.

      Yes, believe it or not, at one point in the not-so-distant past, it was not the State’s job to “teach basic life skills”, but the nuclear family’s job. And it didn’t cost ANYTHING.

      • Steven Reznick

        You are fortunate to have grown up with a nuclear family who taught you life skills.We were taught life skills in my home but were also required to take courses in the NYC Public schools on hygiene, health , nutrition etc. Cub Scouts and Boy Scouts provided some of these skills as well. With over 50% of America’s kids borne into single parent homes the level of family education and support you grew up with may not even exist in most places?

  • ErnieG

    I have you question what you do. At times it sounds like you are legitimizing large corporate and government intrusions in medical care, and not really interested in the “triple aim” you claim to improve population health. If you were, you’d be looking at ways to reduce obesity in this country, which will do all three- improve population health, reduce per capita cost, and improve satisfaction and which is probably
    the single biggest health care problem in this country, but is very unlikely to be medically addressed. Much like clean water, food, and housing do a lot to improve the health of a nation, and which have little to do with medical care, so is obesity.

    Furthermore: 1) Medical care, as disease management, is not
    Health management 2) reducing per capita cost, on a macroscopic scale, almost always involves large butchered government and insurance rationing, rather that finessed scalpel incision with nuanced slices and 3) satisfaction, as an end point for medical care is as we all know it to be B.S.

    This “Medical care as Population management” is making
    physicians employees of insurances, corporations, and government, rather than healers of individuals. This is the
    large shift many physicians, and patient advocates fear—the idea that medical care is managing statistics, with physicians as data entry personnel, and large third parties as analyzers, who then coerce physicians into treating conditions
    and not individuals. If more physicians and patient advocates wake up and realize it is the large, disproportionate growth,
    role and power that third parties (insurance, government, and pharma) take in the management of patients and their diseases, then there would be a better debate on how to better redistribute wealth (i.e insurance gov’t money to pay
    for medical care) in a way that promotes a strong patient-physician relationship, strengthens the generalist’s roles and that aligns interests. Obamacare is just more of the same, with large players vying for the cash. I think you probably have not treated patients in a long time.

  • LeoHolmMD

    “Since “Obamacare” took effect in 2010, fans and foes alike have been struck by how fast we are moving toward the fulfillment of the Triple Aim and the true practice of population-based healthcare.”
    Is this a joke?
    1)The population is sicker and more dependent on healthcare than ever.
    2)Patients are frankly scared about the way the system in general is headed…beyond unsatisfied.
    3)Healthcare costs continue to rise despite a recession and all these great ideas to reduce healthcare costs.
    But I’m sure computers, Walgreens and some business majors will pull us out of it. The look you are seeing is not “puzzled”.

  • PoliticallyIncorrectMD

    Mr. Nash,

    How about this great idea for achieving triple aim goals. Why don’t we stop providing any medical care at all. This way, those who are older and sicker (with lower satisfaction scores) would eventually vanish and we’ll be left with healthier and happier population. Also, It will cost absolutely nothing.

    While greatly exaggerated, this example demonstrates the danger of the “population approach”, which is, while fashionable, ignores such basic core principles of good medicine as individual approach and forming a relationship between the patient and the physician.

    • Mandy Miller

      There was an episode of the UK political satire/comedy “Yes, Minister” that featured the perfect NHS hospital … one with no patients.

  • Mandy Miller

    “Since when are employers an appropriate nanny to their employees?”

    Good point.

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