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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

The Triple Aim Must Overcome the Triple Threat

What you’re about to read may be considered modern day health care heresy: the Triple Aim for health systems is not enough.

Image: ojogabonitoo/Thinkstock

The Triple Aim—defined as enhancing the experience of care for the patient, improving the health of populations, and reducing the per capita costs of health care—has become the guiding light of American health policy in the last decade. And the aims are the right ones.

I first heard the Triple Aim articulated by Don Berwick, MD, MPP, whose Institute for Healthcare Improvement (IHI) developed the concept and gave health systems not only the vision but also a pathway to improve care in these 3 important dimensions. Now president emeritus and senior fellow at the IHI, Berwick served as my predecessor running the Centers for Medicare & Medicaid Services (CMS). What was so compelling to me about the Triple Aim is that we desperately need overarching cultural aims rather than a maze of incentives, partnerships, regulations, and the like to fumble our way forward.

The Triple Aim done right is more than goals; it can be the basis for cultural change that can be put into real action. I’ve visited with health systems around the country that now measure their results along the dimensions of the Triple Aim—focusing on unnecessary admissions, the number of central line infections, patient waiting times for appointments, and many other things—and act on them. Even where many of these things may be measured for various incentive-based payment programs, the Triple Aim importantly takes these specific items and puts them back into a patient and societal context.

So what is standing in the way of the Triple Aim—or, for that matter, the Quadruple Aim, which includes a focus on reducing clinician burnout—from transforming our health care system?

The problem is not the aims, but that we ignore and to a great extend perpetuate 3 major threats that hobble the Triple Aim. If the Triple Threats are not addressed, I’m afraid they overwhelm the potential for any significant progress.

Threat 1: Health Disparities

The first threat is the overwhelming health disparities to our communities and their true underlying causes. Life expectancy levels are highly correlated with incomes, zip codes, and race,  and that’s because all evidence indicates that the ways we deliver care and how it is accessed vary significantly for people by those factors. Treatment for depression, diabetes, and maternal mortality rates are staggeringly different between less fortunate and more fortunate populations.

Here’s the issue: progress against Triple Aim and other goals are often only measured as averages across the population. That must stop; we must measure the gap between the best and worst care that is delivered and work hardest to improve the care for those in groups that receive the worst care. This will lead us to think differently about how we allocate our resources and work, especially on the many nonclinical factors that affect certain populations disproportionately.

Threat 2: Revenues, Revenues, Revenues

The second threat is that despite adding a new way of thinking about our overall goals, the Triple Aim didn’t replace the existing foci, particularly revenue, the one measure—the “single aim”—that in practice still supersedes all others in the minds of decision makers. Revenue drives much executive decision making, spoken and unspoken, including where and how services are delivered, mergers, expansions, and compensation structures.

Agitated CEOs or their lobbyists rarely called on me as CMS Administrator to protest things that led to bad quality of care, but that was not the case if a change from Washington threatened someone’s revenue stream. If revenue were not the all-consuming “single aim,” more care would be delivered at home, in more comfortable settings, and often by qualified individuals with less formal training. Revenue need not ever be put aside entirely as a consideration, but approaches that minimize it, such as capitation or all-payer rate setting, would prevent it from overshadowing other important aims.

Threat 3: The Politicization of Health Care

The third threat is the politicization of the human health care system. As the money in health care has grown, so have the politics. Many in the United States can’t access affordable medications when they’re sick, yet the prices of insulin, generic medications, and cancer medications grow unabated. Vaping companies and gun rights groups have significant influence on public health and massive lobbying operations that fly directly against the Triple Aim. But for the influence of political lobbying, much of Medicare could be competitively bid without harming quality.

More importantly, millions in our country are still left out of the system; their ability to get coverage or basic protections, such as insurance for preexisting conditions, is a political football. When logical compromises to improve the Affordable Care Act or other legislation are put forward, improvements often don’t go anywhere because of the fundraising and election spoils that come from politicizing health care.

At a time when polls show US individuals are more unified than ever in calling for universal coverage, too many politicians have yet to catch on, and instead put forward plans to cut into the safety net or important consumer protections. Politics can be tamed only when the influence of voters again supersedes that of money and influence and when we elect representatives who support investments in public health, coverage, and smarter ways of paying for care.

Making the Triple Aim part of the mission of health care system, while necessary, is wholly insufficient. We must take on the Triple Threat with equal force. We need to put equal energy into visibly and publicly identifying and eliminating the causes of disparities, reduce the focus on revenues as primary aim, and reduce the harmful effects of politics on our health care system. Otherwise, our small steps toward progress will be drowned out and overwhelmed by the parts of our system that are still more powerful and more corrosive.

About the author: Andy Slavitt, MBA, served as the Acting Administrator for the Centers for Medicare & Medicaid Services under President Obama from 2015 to 2017, where he focused on advances in health care coverage and accelerating health care delivery system transformation. He has 2 decades of private–sector health care leadership, both as a senior executive at Optum, a health services and innovation company, and as an entrepreneur. He tweets at @aslavitt. (Image: US Department of Health and Human Services)
1 Comment for this article
Andy Slavitt's Comments and Don Berwick's Moral Determinants article
Avram Kaplan, MPH | UCLA
I teach a course in the UCLA Fielding School of Public Health EMPH program called Integrated Health Systems, where the overarching goal is to achieve the Triple Aim and Quadruple Aim.

We start the course with a short video called It's A Dog's World, so that the course starts with the care of the patien first.

The next three videos, Triple Aim, Quality Chasm, and Moral Determinants sets the tone for the course, which is always covered by my guest lecturers on health systems, to cover how those are achieved, and the impediments to doing so.

focus of my course is the capitated global risk proposition and value-based payment and incentives, aiming toward prevention and addressing social determinants.

Mr. Slavitt's comments are supportive of my teaching goals, and I appreciate his comments.