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May 5, 2015

Change From the Inside Out: Health Care Leaders Taking the Helm

Author Affiliations
  • 1Institute for Healthcare Improvement, Cambridge, Massachusetts

Copyright 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA. 2015;313(17):1707-1708. doi:10.1001/jama.2015.2830

Even as politicians and pundits continue to debate the merits of the Affordable Care Act (ACA), it is time to look beyond it to the next phase of US health care reform. Although many physicians contributed to the development and implementation of the ACA, the forces that have steered it so far have been primarily governmental. Leaders from within health care should now more firmly take the tiller. To borrow a phrase contributed by Splaine and colleagues,1 it is time to move from change forced from the “outside in” to change led from the “inside out.”

The ACA has set the stage. The law has 2 major thematic aspects. The first, and by far the most visible in public discourse, extends health care coverage through a combination of Medicaid expansion and subsidies on newly established private insurance marketplaces. The second aspect of the ACA, far less often discussed in the public arena, is not about coverage; it is about changing the way in which health care is delivered and experienced. The mechanisms the ACA offers are numerous and the potential is profound.

The response to this second theme, changing care, has been substantial, accelerating the adoption of new care structures in both the public and private sectors. For example, from a standing start just 4 years ago, more than 600 accountable care organizations (ACOs) now exist, many with private insurance, as well as Medicare, sponsorship.2 Thousands of hospitals are seeking or have begun participating in bundled payment contracts. More than 5700 medical practices have earned certification by the National Committee for Quality Assurance as medical homes.3

The challenge now is to follow through on such structural changes and ensure that they actually lead to improvement for patients and families. Berwick and colleagues4 have characterized a proper goal of all these changes as the “Triple Aim”—simultaneous pursuit of better care for individuals, better health for populations, and lower per capita costs of health care. Early results offer hope. The Centers for Medicare & Medicaid Services has released reports showing unprecedented declines in Medicare hospital readmission rates,5 improvements in patient safety,6 and the slowest rate of rise of Medicare costs in decades.7 How many of these improvements are attributable directly to the ACA is uncertain.

However, the quality chasm has not closed. Challenges with respect to the reliability and safety of health care delivery remain widespread even though other complex industries have found ways to improve these dimensions by orders of magnitude. Obesity and diabetes remain at near-epidemic levels. Even with the increase in costs slowing, US health care expenditures per capita remain almost double those of any other developed nation.

Without the ACA, it is doubtful that much of the progress made so far would have happened. Yet continued reliance on the ACA alone is wholly insufficient to accelerate delivery system reform to the level needed. Laws, regulations, and payment changes cannot, alone, create health systems that realize the full promise of the Triple Aim. Leaders involved in health care must be actively and directly involved in catalyzing change needed to achieve the Triple Aim. The reasons are several.

First, a properly redesigned care system requires detailed local, social, and technical adaptations to leverage contextual differences. Innovations that work well in one setting often do not work in another without substantial modification. For example, telemedicine has immense potential to revolutionize the reach of expertise and to reduce costs and inconveniences for patients, families, and clinicians. The approaches for applying this technology will differ substantially between, for instance, rural and urban care settings. However, laws and regulations, such as those governing telemedicine applications, are blunt—often frustratingly insensitive to these contextual variations.

Second, innovations in delivery mature at a far faster pace than laws and regulations evolve, even in far less contentious political times than today’s. For example, productive new health care roles, such as community paramedics, community health workers, and resilience counselors, emerge at a rate that legal requirements and reimbursement policies simply do not match.

Third, to achieve unprecedented improvements in care will require trust from the public. Messages about needless care coming from clinicians stand a much greater chance of public acceptance than the same messages from insurers or the government. Similarly, public policy is no match for the patient-clinician relationship in helping people recognize and adopt healthier lifestyles.

Fourth, today’s polarized politics too often prevent authentic dialogue and exploration in the public arena that are essential in designing a better system of care. For example, the toxic and ill-informed “death panel” rhetoric in Washington stalled meaningful policies to improve the care of those with advanced illness. It has not been government but rather enlightened communities like LaCrosse, Wisconsin, and alliances of caregivers and civil society leaders who have kept the flame of progress alive.

Needed, and now forming under the aegis of the Institute for Healthcare Improvement, is a Leadership Alliance of major health care organizations that commit publicly to partnering with their patients, their communities, and one another to deliver on the promise of the Triple Aim at levels not yet achieved and not even hinted at by the ACA (a list of the Leadership Alliance organizations is in the eAppendix in the Supplement).

In its goals, the Leadership Alliance embraces, but goes beyond, those set out in the 2001 Institute of Medicine report Crossing the Quality Chasm, which suggested 6 aims for improvement: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. These are, and remain, goals for the first leg of the Triple Aim—better care. However, an appropriate goal to meet today’s social need is broader: to continuously and dramatically improve with respect to the Triple Aim of better care for individuals, better health for populations, and lower per capita costs—in partnership with our patients, members, workforce, and communities.

The Chasm report set out simple rules for care designs capable of progress on the 6 aims it proposed. Similarly, reliable progress on the Triple Aim will require a revised set of care design principles, such as the following:

  • Design and nurture systems that expect and embrace change, in the continual pursuit of improvement.

  • Change the balance of power, so that health and well-being can be coproduced in partnership with patients, families, and communities.

  • Cultivate and mobilize the pride and joy of the health care workforce.

  • Make it easy. Continually reduce waste and all nonvalue-added requirements and activities for patients, families, and clinicians.

  • Move knowledge, not people. Exploit all helpful capacities of the modern digital age, and continually substitute better alternatives for visits and institutional stays. Meet people where they are, literally.

  • Cooperate and collaborate, above all. Eliminate silos and tear down self-protective institutional and professional boundaries that impede flow and responsiveness.

  • Assume abundance. Use all the resources that can help, especially those brought by patients, families, and communities.

  • Return the money from health care savings to other public and private purposes. Aim for total health care expenditures at or below 15% of gross domestic product.

Public and professional confidence is key; these changes are not achievable without trust. Therefore, the Leadership Alliance proposes to speak with a collective voice about its vision, values, and progress. Its intent is not to defend the status quo, or to argue for new resources in a US health care system that already consumes far too much. Rather, its members will together promise to deliver, in concert with their communities, better care and better health at continually lower cost per capita, and to show others how.

Governments will continue, of course, to have an important role in reform. But the Leadership Alliance, from the “inside out,” will act, not wait. It will lead, not follow. It will thrive, not just survive.

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Article Information

Corresponding Author: Saranya Loehrer, MD, MPH, Institute for Healthcare Improvement, 20 University Rd, Seventh Floor, Cambridge, MA 02138 (sloehrer@ihi.org).

Published Online: March 26, 2015. doi:10.1001/jama.2015.2830.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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National Committee for Quality Assurance.  Patient-centered medical homes.http://www.ncqa.org/Portals/0/Newsroom/2013/pcmh%202011%20fact%20sheet.pdf. Accessed March 12, 2015.
Berwick  DM, Nolan  TW, Whittington  J.  The Triple Aim: care, health, and cost.  Health Aff (Millwood). 2008;27(3):759-769.PubMedGoogle ScholarCrossref
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US Department of Health and Human Services.  New HHS data shows major strides made in patient safety, leading to improved care and savings.http://innovation.cms.gov/Files/reports/patient-safety-results.pdf. Accessed March 12, 2015.
Centers for Medicare & Medicaid Services.  Projections of national health expenditures: methodology and model specification. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ProjectionsMethodology.pdf. Accessed March 12, 2015.