The triple aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. The goal is to improve the quality of care and the health of population while decreasing the cost of health care. The Patient Protection and Privacy Affordable Care Act (PPACA or ‘Obamacare) was passed in part to fulfill the goals of the Triple Aim. For example, the PPACA was enacted to decrease the cost of health care (Title I), improve the quality and efficiency of health care (Title III), and prevent chronic diseases and improve public health (Title IV). Preliminary data suggests that the PPACA is having an impact on Medicare spending as the amount spent on Medicare for each beneficiary has declined in real terms from $12,000 in 2011 to $11,200 in 2014. This is in part due to provisions in the law that encourages the use of bundled payments and value based purchasing. These provisions link payments to quality and efficiency of care. Health care organizations are incentivized to provide “better quality care” and conversely penalized for poor or inefficient care.
However, unless we can make inroads in meeting the goals of Title IV of the PPACA, these gains will remain mediocre at best. We must tackle the epidemic of chronic diseases to make a significant impact on the cost burden. Currently, 140 million Americans live with a chronic condition and that number is expected to rise to over 170 million by 2030. According to a study by the Miliken Institute, the economic impact of chronic care is $1.3 trillion annually. More than 75% of health care costs are due to chronic conditions. Additionally, research indicates that Americans are much less healthy than their European counterparts at all socioeconomic levels. A mind boggling 60% of Americans between the ages of 50 and 74 have mobility limitations. This is almost 1/3 higher than in Europe. In my opinion, the big reasons for this variation are based on two interrelated factors: (1) the focus on the medical determinants of “health” and the relative dismissal of the non-medical determinants of health in the United States. This medicalization results in the range of $75 billion of medical costs per year. Moreover whereas, Scandinavian countries invest significantly more (25-31% v 19% of GDP) in social factors such as food and housing insecurity, physical environment, work conditions, income support, and unemployment support rather than US focused medical metrics such as more medications, hospital days, and medical procedures. (2) the difference in health system goals specifically measured by the focus on primary prevention with a focus on primary care. In the US, there are 50% more specialists in comparison to primary care physicians, whereas in Canada this ratio is 1 to 1. However, previous evidence has suggested that a strong primary care system is associated with better health outcomes, and a higher specialist supply has inverse associations.
The PPACA seeks to address these sources of variability via a focus on social services, prevention, and public health interventions/innovations. The move to bundled payments and value based purchasing is reinforcing this idea of prevention and forcing health systems to bridge the gap between health and social services. The first step in developing such a strategy is to have a system of coordinated, integrated care throughout the care continuum. Chronic disease management requires not only intra-health system coordination but also synergies between the health system and social services. Additionally, these services will have to be scaled to supply a projected 170 million patients with chronic diseases and a concurrent projected shortage of 45,000 primary care physicians. This double whammy of increased volumes and decreased supply of physicians can only be solved with a pervasive and robust technology infrastructure. On the health system side, current iterations of electronic health records will be insufficient and will have to transform from data repositories to information facilitators. The next iteration of EHRs will have to liberate health care providers from the minutiae of data entry and coding/billing and facilitate decision making with decision support tools and user-friendly interfaces. Additionally, electronic health records will have to be interoperable and serve as the hub of communication along the entire care continuum ranging from the home to outpatient ancillary care visits. Secondly, as smart phones and the associated wireless infrastructure become ever more omnipresent, they will serve as the conduit for sensor mediated remote monitoring and real-time information transfer. This will obviate the need for “face to face” patient encounters. A single primary care physician will be able to deliver and coordinate care for multiple patients remotely utilizing data from the smart phone and via intermediaries such as nurse practitioners, physician assistants, social workers, home health coordinators, and physical therapists.
The age demographics of the United States is undergoing a dramatic shift over the next 50 years. It is estimated that by 2050, the population aged 65 and over will constitute greater than 20% of the total population. This is an increase of 5% or approximately 40 million people. This aging of the population will have wide range health care implications for the country, especially if this population is disproportionately riddled with disabling chronic diseases. Moreover, we are facing a critical shortage of providers that is not going to be ameliorated just by training more physicians. A focus on technology driven strategy that coordinates care throughout the health care continuum must be implemented to provide the necessary resources to empower providers and improve care for an aging population.