Achieving the Triple Aim

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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
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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
  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, 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.

www.ihi.org
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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
  
  

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Potential Triple Aim Outcome Measures 11/09
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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
  apply
• Self-rated Health Status Response to the
  question
• How is your general health? on a 5 pt. scale
  from poor
• to excellent
• Kindig, D. Purchasing Population Health, 1997

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Triple 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

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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
  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 Improvement technical
brief 90-Day Project   Predictive Modeling
January 31, 2008   I. Research and Development
Team
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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
  (OH)
• 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
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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
  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
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Drivers of a Low-Value Health System
Low Value
High Cost
Low Quality
Supply- Driven Demand
No mechanism to control cost at the population
level
New Drugs and Tech ? Outcomes
Over- Reliance On Doctors
Under- valuing system design
Insignificant role for individuals and families
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Key Issues

• Social Determinants of Health
• Fragmentation of Health Services
• Misalignment of Incentives

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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.
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Help!
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Where We Are Today Whats Wrong With This
Picture?

• Dis - Integration

Justice
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Needed The 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.

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Initial Triple Aim Macro-Integrators

• Hospital-Based Systems
• Cincinnati Childrens 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)

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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

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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
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CareOregon Starting with the Costliest Members
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Cost
Hospitalizations
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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.
  

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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

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Starting a Triple Aim Concept in Norrbotten,
Sweden
- 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
PatientExperience
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
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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

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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
  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!

to develop
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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.

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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
  company.

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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
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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
  registry
• Achieving accreditation (AAAHC), including as
  medical home
• Integrating specialty care

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LeanYou! 2008 Marrying Wellness and Benefits

• LeanYou! Healthcare Premium Reduction (Employee
  only)
• 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

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Patient Experience of Care Hows Your Health?
Care is Perfect
Exactly the Care Needed
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QuadMed Wellness Results
Wellness program employee-repeaters experienced
a 2 increase in group health costs vs. a 31
increase among the never-participants
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Boltons 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.
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Data Population Health
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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

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Measuring the Big Bolton Health Check
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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.
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Triple Aim as Social Movement

• 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.

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What Creates Value in Health Care?

• New Triple 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

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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

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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