Achieving the Triple Aim:Achieving the Triple Aim:The Simultaneous Pursuit of

Population Health Population Health Enhanced Individual CareEnhanced Individual CareControlled Costs Controlled Costs

David Labby MD PhDDavid Labby MD PhDMedical DirectorMedical Director

CareOregonCareOregonOregon Health Policy Board PresentationOregon Health Policy Board Presentation

May, 2010May, 2010

The Institute for Healthcare The Institute for Healthcare Improvement (IHI)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 practices – 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, R&D, – 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.

www.ihi.org

““Triple Aim” 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 of: – Improved health– Enhanced experience of care – Reduced cost per capita

Potential Triple Aim Outcome Measures 11/09

Dimension MeasurePopulation

Health1. Health/Functional Status: single-question (e.g. from CDC HRQOL-4) or multi-domain (e.g. SF-12, EuroQol)

2. Risk Status: composite health risk appraisal (HRA) score

3. Disease Burden: Incidence (yearly rate of onset, avg. age of onset) and/or prevalence of major chronic conditions; summary of predictive model scores

4. Mortality: life expectancy; years of potential life lost; standardized mortality rates. Note: Healthy Life Expectancy (HLE) combines life expectancy and health status into a single measure, reflecting remaining years of life in good health. See http://reves.site.ined.fr/en/DFLE/definition/

Patient Experience

1. Standard questions from patient surveys, for example: -Global questions from US CAHPS or How’s Your Health surveys-Experience questions from NHS World Class Commissioning or CareQuality Commission -Likelihood to recommend

2. Set of measures based on key dimensions (e.g., US IOM Quality Chasm aims: Safe, Effective, Timely, Efficient, Equitable and Patient-centered)

Per Capita Cost 1. Total cost per member of the population per month

2. Hospital and ED utilization rate 4

Health Adjusted Life ExpectancyHealth Adjusted Life Expectancy(HALE)(HALE)

HALE = Product of average life expectancy and% rating their health status good or higher

• Average Life Expectancy = Average number of years ababy born in a particular year is expected to live ifcurrent age-specific mortality trends continue to apply

• Self-rated Health Status = Response to the question“How is your general health?” on a 5 pt. scale from poorto excellent

Kindig, D. Purchasing Population Health, 1997

Triple Aim InitiativeTriple Aim Initiative

• Initial Prototyping (Sept ‘07 – April ‘08): – 15 Organizations recruited to a Learning Institute – 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 aims?– 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 Workgroups2007-10 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 CARE REDESIGN PATIENT AND FAMILY EXPERIENCES POPULATION HEALTH MEASUREMENT PREDICTIVE MODELING Prevention & Health Promotion, including Social Marketing R & D - Population Health Measurement Reducing Clinical Variation SPECIALTY WASTE/OPTIMIZATION OF SPECIALTY CARE SUCCESSFUL COALITIONS AND POPULATION HEALTH

INSTITUTE FOR HEALTHCARE

IMPROVEMENTTECHNICAL BRIEF: 90-

DAY PROJECT

Predictive Modeling January 31, 2008

I. Research and Development Team:

North American Triple Aim SitesNorth 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)Martin’s Point Health Care (ME)Presbyterian Healthcare (NM)Southcentral Foundation and Alaska Native Medical Center (AK)Vanguard Health SystemVeterans Health System:

• VISN 10—Cincinnati VAMC (OH)• VISN 20—Portland VAMC (OR)• VISN 23—Nebraska, Western Iowa VAMC (NE)

Wellstar Health System• Public Health Department

Washington DC Department of Health (DC)• Social Services

Common Ground (NY)

• 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 Children’s Hospital Medical Center (OH)Erlanger Health System (TN)Fort Healthcare (WI)Genesys Health (MI) (Ascension)

• Safety NetColorado 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)

• Employers/BusinessesQuadGraphics/QuadMed (WI)

• CanadianCentral East Local Health Integration NetworkSaskatchewan Ministry of Health British Columbia Team

• State InitiativeVermont Blueprint for Health (VT)

Last Updated 12/1/09

International Triple Aim SitesInternational 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 England)• 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

(Australia) • Western Health and Social Care Trust

(Northern Ireland)

Last Updated 10/5/09

Drivers of a Low-Value Health System

Low Value

High Cost Low Quality

Supply-Driven

Demand

No mechanismto controlcost at the

population level

New Drugsand

Tech ≠Outcomes

Over-Reliance

On Doctors

Under-valuing

“system”design

Insignificant role for

individuals and families

Key Issues:Key Issues:

• Social Determinants of HealthSocial Determinants of Health

• Fragmentation of Health Fragmentation of Health ServicesServices

• Misalignment of IncentivesMisalignment of Incentives

Determinants of Health and Their Determinants of Health and Their Contribution to Premature DeathContribution to Premature Death

Social circumstances

15%

Environmental exposure

5%

Health care10%

Behavioral patterns

40%

Genetic predisposition

30%

Adapted from: McGinnis JM, Williams-Russo P, KnickmanJR. The case for more active policy attention to health promotion. Health Aff

(Millwood) 2002;21(2):78-93.

Proportional Contribution to Premature Death

Help!

Where We Are Today: What’s Wrong With This Picture?

Dis - Integration

JusticeMedical Home

MH Home School

Welfare Social Services

Needed: The Needed: The “Integrator”“Integrator”• It may or may not be a new structure or

organization.• 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”Initial Triple Aim “Macro-Integrators”

• Hospital-Based Systems– Cincinnati Children’s Hospital

Medical Center (OH)– 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 (NY)• 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?

Per Capita Cost

PopulationHealth

Individual Experience

•Act with the Individual and Family •Learn for the Population

Design and Coordination of Care

April 1, 2002 - March 31, 2003 Includes Members with >4 months Enrollment Only

0%

5%

10%

15%

20%

25%

30%

35%

% of Members % of Total Dollars

% of Members 23% 12% 24% 29% 9% 3%

% of Total Dollars 1% 2% 8% 30% 31% 29%

Non Users

Healthy Users

Low Mod HighVery High

10% SavingsHas $12MM

Annual ImpactOn CareOregon

CareOregonCareOregon = Starting with the Costliest Members

Bus Pass $23 versus ED $1400

• “Member was seen in the ED 21 times in Dec. 2007.”

• “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

$1,948.00

$1,044.00

$1,545.00

$697.00

$0.00

$500.00

$1,000.00

$1,500.00

$2,000.00

$2,500.00

Total PMPM

Pre CS Post CS

Average cost for CareSupport Enrolled Members (N=1991) 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.

Hospital PMPM

Total PMPM

•$400/member/mo

•$5000/member/yr

•$7 Million Program Total

•Return on Cost = 4:1

23-04-21 Concept Triple Aim Norrbotten BILD 23

Starting a Triple Aim Concept in Norrbotten, Sweden

Population Health

Per Capita CostPatientExperience

- Life expectancy, mortality

- Healthy life expectancy (years gained, including economic assessment)

- Health outcomes and behaviours, self reported health, summary of disease burden

- 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

= to develop

23-04-21 Concept Triple Aim Norrbotten BILD 24

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

23-04-21 Concept Triple Aim Norrbotten BILD 25

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 population

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!

Parts of the Concept to Be Developed

Design of a Triple Aim EnterpriseDefine “Quality” from

the perspective of an individual member of a defined population

The “Triple Aim”

Health care Public healthSocial services

Per capitacost reduction

Integration

System-LevelMetrics

$E

PH

Definition ofprimary care

4

Patients andfamilies

Prevention andHealth promotion

= to develop

23-04-21 Concept Triple Aim Norrbotten BILD 26

Implementation 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 Health

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 implementation.

• 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 company.

Largest private printer11,600 employed$1.8 Billion sales

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

Mercer

TA Model and QuadMed

Design of a Triple Aim EnterpriseDefine “Quality” from

the perspective of an individual member of a defined population

The “Triple Aim”

Health care Public healthSocial services

Per capitacost reduction

Integration

System-LevelMetrics

$E

PH

Definition ofprimary care

1

Patients andfamilies

Population healthmanagement

• 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 registry

• Achieving accreditation (AAAHC), including as medical home

• Integrating specialty care

LeanYou! 2008: Marrying Wellness and Benefits

• LeanYou! Healthcare Premium Reduction (Employee only)– $2 / week reduction:

• Sign up for LeanYou! program• Biennial on-line HRA (“How’s 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: “How’s Your Health?”

36

38

40

42

44

46

48

50

NoBurden

SomeBurden

2006

2007

2008

“Care is Perfect”

0

5

10

15

20

25

30

35

40

NoBurden

SomeBurden

2006

2007

2008

“Exactly the Care Needed”

QuadMed Wellness ResultsCost Trends for Employees*

$3,474$3,714$3,420

$3,011$3,056$2,301

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

2006 2007 2008

ParticipantsNon-Participants

* Wellness program employee-repeaters experienced a 2% increase in group health costs vs. a 31% increase among the never-participants

Bolton’s Triple AimStory

• Oct 2007 Joined as Triple Aim Proof of Concept site• 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• A&E attendance prevention• Aligning investment with deprivation

Measuring the Big Bolton Health Check

37

Physician Views of Health System

Percent saying*AUS

CAN

FRGER

ITA NET NZNOR

SWE

UK US

Only minor changes are needed

23 33 41 18 38 60 42 56 37 47 17

Fundamental changes are needed

71 62 53 51 58 37 57 40 54 50 67

System needs to be completely rebuilt

6 4 6 31 4 1 1 2 7 3 15

* Respondents asked which statement expresses their overall view of their country’s 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.

Everyone is looking for a better way…Everyone is looking for a better way…

• Triple Aim is now an international movement of 60+

organizations engaged in health system redesign– 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 outcomes…

• 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.

Triple Aim as Social MovementTriple Aim as Social Movement

What Creates What Creates ValueValue in Health Care? in Health Care?

• New Triple AimTriple Aim Paradigm: Health systems are accountable for population outcomes– “System design” recognized as a determinant of

health– 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 ForwardTriple 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 it’s not a problem”• “The data are right; it is a problem; but it is

not my problem.”• “I accept the burden of improvement”