In “The Triple Aim: Care, Health, And Costs” Berwick, Nolan and Whittington describe American healthcare as the most fragmented, most expensive and least effective care delivery system among all of the advanced economies of the world, and they identify the barriers to improvement. Their assertion remains a triple surprise for me. First, it was a true statement. Second, it did not disturb more people. Third, it is still true.
The authors diagnosed why the system was flawed, frequently failed its customers and was so expensive. They offered us a solution and a vision. Their solution was an extension of the recommendations that had emanated from Crossing the Quality Chasm (2001) where quality healthcare was defined in terms of a user experience that was patient centered, safe, timely, efficient, effective, and most of all equitable. Less noticed, but of equal or more importance was a template that offered vast system variation as long as certain systems properties were present.
1) Care based on continuous healing relationships.
2) Customized care based on patient’s needs and values.
3) The patient as the source of control.
4) Shared knowledge and the free flow of information.
5) Evidence-based decision making.
6) Safety as a system property.
7) Transparency as a system property.
8) Anticipation of need.
9) Continuous decrease in waste.
10) Cooperation among clinicians. [from “I” to “we”]
The solution offered was elegant. [The boldface emphasis is mine]
…the United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals. In the aggregate, we call those goals the “Triple Aim”: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.
They outlined necessary strategic considerations:
We suggest that three inescapable design constraints underlie effective accomplishment of the Triple Aim: (1) recognition of a population as the unit of concern, (2) externally supplied policy constraints (such as a total budget limit or the requirement that all subgroups be treated equitably), and (3) existence of an “integrator” able to focus and coordinate services to help the population on all three dimensions at once.
They asserted that it was rare to find organizations that were attempting to improve all three legs of the objective and related this to the conflict between the rational interests of individual institutions and the overall system of care in terms that were reminiscent of Garrett Harden’s concept of the “tragedy of the commons”.
For most [organizations], only one, or possibly two, of the dimensions is strategic, but not all three. Thus, we face a paradox with respect to pursuit of the Triple Aim. From the viewpoint of the United States as a whole, it is essential; yet from the viewpoint of individual actors responding to current market forces, pursuing the three aims at once is not in their immediate self-interest…. Rational common interests and rational individual interests are in conflict.
From this understanding it was possible for them to describe the barriers that existed in 2008 and that persist today, almost eight years later.
The remaining barriers are not technical; they are political. The superiority of the possible end state is no longer scientifically debatable. The pain of the transition state—the disruption of institutions, forms, habits, beliefs, and income streams in the status quo—is what denies us, so far, the enormous gains on components of the Triple Aim that integrated care could offer.
I want to explore the most important part of that last quote, “The remaining barriers are not technical; they are political”. The political barrier is the tension and angst between a comfortable status quo for individual patients, providers, and institutions and the promise that the Triple Aim offers as benefit for the collective. The barriers are self interest at every level and the status quo. It’s the world as we have known it. It is the mindset that says I must be careful or I will be hurt or experience a personal loss. It is the emotional angst associated with change that is the origin of the “political barriers” referred to by the authors when they say:
The remaining barriers are not technical; they are political.
Two factors explain why change finally occurs: loss and aspiration. Loss has two forms. First is a variation of what behavioral economists call “loss avoidance”. People who change to avoid loss have made a decision to change after considering the alternative of staying with the status quo. Change occurs in this instance to avoid a burning or exploding platform that is usually economic. The other form of loss as motivation is acceptance of change after the fact of a loss. After the prediction that the status quo will fail us has come true and we find that we are surrounded by the rubble that remains, then change is the only option. This attempt at change is a desperate strategy for recovery and repair and, as Collins points out in How The Mighty Fall, it often comes too late.
I prefer the second explanation for change, aspiration. Don Berwick and advocates for quality and safety are the examples in healthcare that I would present to you. They advocate change as an avenue of aspiration. They reject the status quo because it can never produce the results they desire. Change finally comes by some combination of loss, loss avoidance and aspiration. The fear of loss of current financial success and of what is known and understood is the greatest barrier to the Triple Aim, even though the Triple Aim is the best path to the avoidance of loss and the superhighway to the realization of our aspirations.
The authors acknowledge that these barriers are political. Overcoming them will require “adaptive change” experienced as an emotional and social struggle. The pain of the transition state—the disruption of institutions, forms, habits, beliefs, and income streams in the status quo—is what denies us, so far, the enormous gains on components of the Triple Aim that integrated care could offer. This would be what my favorite college professor called the “thematic climax” of the story.
Many dream of equality in healthcare. That is the vision in Vermont. Vermont began its journey with the idea of having all patients in a medical home. Medical homes are a key tactic in improving the care of individuals and can facilitate the improvement of a population, but generally operate in “silos”. As Berwick and his collaborators indicate, an “integrator” is necessary to efficiently bridge “silos”.
The key to the operation of an integrator is not ownership of assets but the assembly of assets into a value stream that provides optimally for the needs of a population that has many subpopulations. Many Vermonters believe that one single system of care would be best or if not one system, one payer. After realizing that there were too many barriers at this time for a “single payer” system, Vermont has “flipped the dilemma” and has proposed moving to equitable care by another route, an “all payer” system, where all of the citizens of the state will be in one ACO that treats all patients equitably. All medical resources will be integrated under one board and funds will come “from all payers” into a statewide system from the private insurers plus the public funding sources. The statewide system will be their “integrator” and will launch in 2017.
The Vermont experiment is dependent on a key mindset change of its practitioners and its institutions. Collaboration will be required. The focus must change from “I to We”. “I to We” moves the status quo from a focus on the individual to a focus on equity and the Triple Aim. If Vermonters can make that move then they will be ready to make the real changes that we espouse but have not yet accomplished in the majority of our systems of care.
Achieving the changes in mindset and focus that feel so hard at this time will facilitate the improvement of the health of the community and will move us closer to a system that is economically sustainable. The concerns of individuals will be aligned with the needs of the community. Patients will understand what has always been true and that is that their best protection as an individual is to be part of a population that is collectively assured of protection. The “I to We” evolution is as necessary within the population of those who receive care as it is among those who provide care. As healthcare professionals we cannot ask our patients to accept changes that we do not lead by our own example.
We struggle with the process of adapting to inevitable change. There will be losses and we do have aspirations. We need leaders who understand the problems, the history and the complexity of the system, and the hope that the Triple Aim offers. There may be barriers beyond the barrier of political will, like mountains beyond mountains. But the lessons learned moving out of the grip of the status quo will create a momentum that will enable us to climb those mountains and overcome them as barriers to our progress. If we can just get over the barrier of the status quo which is rooted in a very short sighted interpretation of our individual best interests and embrace the possibilities created by collaborating to improve the care of the whole population there will be no barrier to:
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
