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Achieving the Triple Aim


Achieving the Triple Aim: The Simultaneous Pursuit of Population Health Enhanced Individual Care Controlled Costs David Labby MD PhD Medical Director – PowerPoint PPT presentation

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Title: Achieving the Triple Aim

Achieving the Triple Aim
  • The Simultaneous Pursuit of
  • Population Health
  • Enhanced Individual Care
  • Controlled Costs

David Labby MD PhD Medical Director CareOregon Or
egon Health Policy Board Presentation May, 2010
The Institute for Healthcare Improvement (IHI)
  • Independent not-for-profit organization helping
    to lead the improvement of health care throughout
    the world.
  • Founded in 1991 and based in Cambridge,
    Massachusetts, IHI works to accelerate
    improvement by building the will for change,
    cultivating promising concepts for improving
    patient care, and helping health care systems put
    those ideas into action.
  • First Decade identification and spread of best
  • The Breakthrough Series Collaborative model. Work
    was organized around reducing defects and errors
    in microsystems such as the ED or the ICU. 
  • Second Decade focus on innovation, RD,
  • Broad-scale Idealized Design projects, such as
    the Office Practice and the Medication System
  • Pursuing Perfection initiative in 2002 with the
    Robert Wood Johnson Foundation, working with
    ambitious organizations seeking total
    transformation of all major care processes. 
  • 100,000 Lives Campaign and 5 Million Lives
    Campaign, in which IHI spread best practice
    changes to thousands of hospitals through the
    United States, and created a national network for
    improvement focused on reducing needless deaths
    and preventing harm from care.
  • IHI is currently engaged in improvement
    initiatives in England, Scotland, Ghana, Malawi,
    and South Africa.
Triple Aim
  • Proposed by Berwick and Nolan in 2007 to
    re-vision healthcare around 3 core values
  • What would it look like if health care were
    aligned to
  • The Triple Aim requires the simultaneous pursuit
  • Improved health
  • Enhanced experience of care
  • Reduced cost per capita

Potential Triple Aim Outcome Measures 11/09
Health Adjusted Life Expectancy(HALE)
  • HALE Product of average life expectancy and
  • rating their health status good or higher
  • Average Life Expectancy Average number of
    years a
  • baby born in a particular year is expected to
    live if
  • current age-specific mortality trends continue to
  • Self-rated Health Status Response to the
  • How is your general health? on a 5 pt. scale
    from poor
  • to excellent
  • Kindig, D. Purchasing Population Health, 1997

Triple Aim Initiative
  • Initial Prototyping (Sept 07 April 08)
  • 15 Organizations recruited to a Learning
  • Integrated Delivery Systems, Health Plans, Safety
    Net Organizations, Self Insured Employers,
    State Agencies
  • What can you do to accomplish these goals?
  • Define a target population that you can impact
  • What are you trying to accomplish for all three
  • What population oriented intervention are you
    going to implement?
  • How will you measure impact?
  • Rapid growth to an international collaborative
    learning system of countries with technically
    advanced medical systems
  • National, International Collaborative Meetings
  • Biweekly conference calls
  • Focused workgroups

2007-10 Triple Aim Workgroups
  • No New Money Regional Health Improvement
    Initiatives Regional Information Technology
    (IT) Socially Complex Testing
  • Applying the Triple Aim to a Region Children
    and Families Population Delivering within a 15
    Cost Savings Employed Population Individuals
    65 Population Measurement MEDICAL HOME/PRIMARY
    MODELING Prevention Health Promotion,
    including Social Marketing R D - Population
    Health Measurement Reducing Clinical Variation

Institute for Healthcare Improvement technical
brief 90-Day Project   Predictive Modeling
January 31, 2008   I. Research and Development
North American Triple Aim Sites
  • Health Plans
  • Blue Cross Blue Shield of Michigan (MI)
  • Capital Health Plan (FL)
  • CareOregon (OR)
  • Essence Healthcare (MO)
  • UPMC Health Plan (PA)
  • Independent Health (NY)
  • Integrated Delivery Systems (w/ Health Plans)
  • Caromont Health System (NC)
  • HealthPartners (MN)
  • Kaiser Permanente, Mid-Atlantic Region (MD)
  • Martins Point Health Care (ME)
  • Presbyterian Healthcare (NM)
  • Southcentral Foundation and Alaska Native
    Medical Center (AK)
  • Vanguard Health System
  • Veterans Health System
  • VISN 10Cincinnati VAMC (OH)
  • VISN 20Portland VAMC (OR)
  • VISN 23Nebraska, Western Iowa VAMC (NE)
  • Integrated Delivery Systems (w/o Health Plans)
  • Allegiance Health (MI)
  • Bellin Health (WI)
  • Bon Secours - St. Francis Health System (SC)
  • Cape Fear Valley (NC)
  • Cascade Healthcare Community, Inc. (OR)
  • Cincinnati Childrens Hospital Medical Center
  • Erlanger Health System (TN)
  • Fort Healthcare (WI)
  • Genesys Health (MI) (Ascension)
  • Safety Net
  • Colorado Access (CO)
  • Contra Costa Health Services (CA)
  • Health Improvement Partnership of Santa Cruz
  • County (CA)
  • Nassau Health Care Corporation (NY)
  • North Colorado Health Alliance (CO)
  • Primary Care Coalition Montgomery County (MD)
  • Queens Health Network (NY)

Last Updated 12/1/09
International Triple Aim Sites
  • Jonkoping (Sweden)
  • NHS Blackburn With Darwen PCT (NW England)
  • NHS Bolton PCT (NW England)
  • NHS Bournemouth and Poole (SW England)
  • NHS East Lancashire Teaching PCT (NW England)
  • NHS Eastern and Coastal Kent PCT (South East
    Coast England)
  • NHS Forth Valley (Scotland)
  • NHS Heywood, Middleton and Rochdale PCT (NW
  • NHS North Lancashire Teaching PCT (NW England)
  • NHS Medway (South East Coast England)
  • NHS Oldham PCT (NW England)
  • NHS Salford PCT (NW England)
  • NHS Somerset PCT (SW England)
  • NHS Swindon PCT (SW England)
  • NHS Tayside (Scotland)
  • NHS Torbay Care Trust (SW England)
  • NHS Blackpool PCT (NW England)
  • NHS Bury PCT (NW England)
  • NHS Central Lancashire PCT (NW England)
  • NHS Sefton PCT (NW England)
  • NHS Warrington PCT (NW England)
  • NHS Western Cheshire PCT (NW England)
  • NHS Wirral PCT (NW England)
  • State of South Australia, Ministry of Health
  • Western Health and Social Care Trust (Northern

Last Updated 10/5/09
Drivers of a Low-Value Health System
Low Value
High Cost
Low Quality
Supply- Driven Demand
No mechanism to control cost at the population
New Drugs and Tech ? Outcomes
Over- Reliance On Doctors
Under- valuing system design
Insignificant role for individuals and families
Key Issues
  • Social Determinants of Health
  • Fragmentation of Health Services
  • Misalignment of Incentives

Determinants of Health and Their Contribution to
Premature Death
Proportional Contribution to Premature Death
Adapted from McGinnis JM, Williams-Russo P,
Knickman JR. The case for more active policy
attention to health promotion. Health
Aff (Millwood) 200221(2)78-93.
Where We Are Today Whats Wrong With This
  • Dis - Integration

Needed The Integrator
  • It may or may not be a new structure or
  • It pulls together the resources to support a
    defined population.
  • It builds alliances and coalitions.
  • It optimizes the Triple Aim for the sake of a
    defined population.
  • It works with and helps to improve micro-systems
    to support individuals.

Initial Triple Aim Macro-Integrators
  • Hospital-Based Systems
  • Cincinnati Childrens Hospital Medical Center
  • Bellin Health (WI)
  • Genesys Health (MI) (Ascension)
  • Integrated Health Systems
  • Group Health (WA)
  • HealthPartners (MN)
  • Health Plans
  • CareOregon (OR)
  • New York-Presbyterian System SelectHealth, LLC
  • State Initiative
  • Vermont Blueprint for Health (VT)
  • Safety Net
  • CareSouth Carolina (SC)
  • Contra Costa Health Services (CA)
  • North Colorado Health Alliance (CO)
  • Primary Care Coalition Montgomery County (MD)
  • Queens Health Network (NY)
  • International
  • Jönköping (Sweden)
  • Bolton Primary Care Trust (England)

Early Triple Aim Examples
  • Vermont Blue Print for Health All Payer
    Community Health Teams
  • Jonkoping County Council Health System School
    System Collaboration to reduce childhood obesity
  • Common Ground Proactive outreach to high risk
    homeless population
  • Health Partners Integrated Medical System/
    health plan focused on high quality, cost
    effective care

Triple Aim Model Micro integratorsCan We Begin
with the Individual and Scale Up?
  • Act with the Individual and Family
  • Learn for the Population

Design and Coordination of Care
Individual Experience
CareOregon Starting with the Costliest Members
Bus Pass 23 versus ED 1400
  • Member was seen in the ED 21 times in Dec.
  • History of heroin use, transportation barriers
    to receiving Methadone treatment and from seeing
    her PCP on a regular basis.
  • We bought a bus pass.
  • No ED visits for two months and she is much more
    engaged in CD treatment and her PCP relationship.

Evaluating Cost per Capita
PMPM Total for CareSupport
Enrolled Members
Average cost for CareSupport Enrolled Members
(N1991) during the time period of Jan. 1, 2007
and May 31, 2008. Pre-CS claims paid for 12
months prior to enrollment in CareSupport and
Post-CS claims paid for 12 months following
enrollment in CareSupport.
  • 400/member/mo
  • 5000/member/yr
  • 7 Million Program Total
  • Return on Cost 41

Hospital PMPM
Total PMPM

Starting a Triple Aim Concept in Norrbotten,
- Life expectancy, mortality- Healthy life
expectancy (years gained, including
economic assessment)- Health outcomes and
behaviours, self reported health, summary of
disease burden
to develop
Population Health
Per Capita Cost
  • Economic assessment of healthy years gained
  • Other cost measurementse.g. cost per patient,
    health expenditure per inhabitant

- Population surveys, patient questionnaires,
health status e.g. EQ5D
Concept Goal and Target Groups
  • Goal Lower disease burden caused by overweight
    and obesity
  • Target groups- Children through childrens
    primary care, dentists and schools- Families
    through the children- Risk patients through
    primary care and screening at age 30, together
    with specialist care- General public through
    local alliances

Parts of the Concept to Be Developed
  • Patients and families- see the whole context,
    especially for the cronically ill and complex
    patients- jointly planned care based on patients
    needs- information and knowledge about
    treatment, including over time- enable
    patients to manage their own health- learn from
    the patient and family (to improve)
  • Definition of primary care- including
    integration with social care- responsibility for
    a defined population (economic incentives)-
    accessability (via e.g teambased care)-
    coordination with specialist care- health
    screening at age 30
  • Integration- coordination with specialist care
    - treatment agreements, care plans
  • Per capita cost- lower total health costs-
    economic incentives to promote a healthy
  • Prevention and health promotion- alliances
    within and between organizations- private and
    public sector, NGOs- use project model and
    PDSA-cycles- work on local level- focus on
    doing and measuring!

to develop
  • Use Triple Aim as lever! - Coordinate with and
    enhance work already in progresse.g. strategy
    for obesity patients, public health management,
    the County Political Strategy for Population
  • Build project structure with coordinator from the
    county council together with coordinator for the
    municipalities for the local alliances
  • Select two pilot municipalities/primary care
    centres to act as PDSA-cycles before county-wide

Largest private printer 11,600 employed 1.8
Billion sales
  • Created in 1990 as a subsidiary of Quad/Graphics
    to provide affordable, high-quality healthcare
    for the 11,000 employees while controlling
    escalating health care costs
  • Today employs its own medical staff, operates its
    own laboratory, pharmacy, fitness and
    rehabilitation centers, and contracts with local
    hospitals for specialized and advanced care.
  • Employees more actively participate in preventive
    healthcare and spend fewer days in the hospital,
    at a cost 30 less than the average Wisconsin

Mercer Consulting Study
  • Quad/Graphics healthcare costs are consistently
    below the benchmark, when adjusted for
    demographics and benefit design
  • 18 below in 1998
  • 19 below in 2000
  • 17 below in 2002
  • 26 below in 2004
  • 32 below in 2006

TA Model and QuadMed
  • Applying Lean principles to primary care to
    improve provider and patient experience
  • Leveraging benefit design to improve engagement
    and population health
  • Enhancing data and outreach using a disease
  • Achieving accreditation (AAAHC), including as
    medical home
  • Integrating specialty care

LeanYou! 2008 Marrying Wellness and Benefits
  • LeanYou! Healthcare Premium Reduction (Employee
  • 2 / week reduction
  • Sign up for LeanYou! program
  • Biennial on-line HRA (Hows Your Health?)
  • Commit to having a LeanYou! health evaluation
    during the year
  • 8 / week additional reduction
  • Sign tobacco-free attestation
  • LeanYou! Achievement Award (Employee and Spouse)
  • Increased cash rewards 400, 175, 50

Patient Experience of Care Hows Your Health?
Care is Perfect
Exactly the Care Needed
QuadMed Wellness Results
Wellness program employee-repeaters experienced
a 2 increase in group health costs vs. a 31
increase among the never-participants
Boltons Triple AimStory
  • Oct 2007 Joined as Triple Aim Proof of Concept
  • Focus on one area of deprivation Farnworth
  • Integrate Public Health and Primary Care
  • Reduce A and E admissions
  • 2008 TA becomes our Mantra
  • 2008/9 Objectives
  • Big Bolton Health Check
  • 2009-2014 Strategic Plan
  • Big Bolton Health Debate
  • 2009 Triple Aim in Primary Care
  • Reducing A and E attendance
  • Improving CVD management
  • Reducing Speciality Waste
  • (reducing referrals)
  • Improving prescribing

Bolton in Greater Manchester is the 28th most
deprived borough in England in terms of numbers
of people who are income deprived. A third of the
borough's population lives in seven wards which
are amongst the 10 most deprived in England.
Data Population Health
Farnworth Workstreams
  • Integrate public health and primary care
  • Better knowledge of population
  • Community survey - behaviours
  • Population Stratification, for primary care
  • Parr
  • Cardiovascular screening
  • AE attendance prevention
  • Aligning investment with deprivation

Measuring the Big Bolton Health Check
Physician Views of Health System
Everyone is looking for a better way
Respondents asked which statement expresses
their overall view of their countrys health
system only minor changes are needed
fundamental changes are needed system needs to
be completely rebuilt.
Source 2009 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians.

Triple Aim as Social Movement
  • Triple Aim is now an international movement of
    60 organizations engaged in health system
  • All from countries with a high levels of medical
    technology -- recognize that science / technology
    itself does not deliver health outcomes
  • All with different delivery systems and
  • Creating our best possible health
  • How care is delivered is a major determinant of
    health, experience, cost, at every level from the
    bottom up
  • What is delivered must include much more than
    medical therapies, addressing social determinants
    as well
  • Who drives change critically determines how
    effectively any system truly meets the wants and
    needs of those it is meant to serve.

What Creates Value in Health Care?
  • New Triple Aim Paradigm Health systems are
    accountable for population outcomes
  • System design recognized as a determinant of
  • Value is created by systems of care with
    appropriate expertise
  • New emphasis on patient engagement, patient
    driven care
  • Quality redefined as best possible medical
    service delivery AND best possible health and
    cost outcomes

Triple Aim Moving Forward
  • Regional Triple Aim Initiatives
  • Bending the cost curve
  • Integration Medical and Social Services
  • Realignment of incentives ACOs?
  • Regional Triple Aim Collaboratives?
  • Multiple Triple Aim efforts within a region
  • Local learning systems

Stages of Facing Reality
  • The data are wrong
  • The data are right, but its not a problem
  • The data are right it is a problem but it is
    not my problem.
  • I accept the burden of improvement
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