Many thanks to those who offered some great blog ideas for 2011 – reader suggestions are always welcome. Jay Gold’s question about the Triple Aim caught my eye because it’s something I’ve been giving a lot of thought to recently: “How in your view does population health tie in with the other two elements (quality of care, cost-effectiveness) of Berwick's Triple Aim?”
This is a relevant and timely question, since the Triple Aim is getting much more attention since Don Berwick became the Administrator of the Center for Medicare and Medicaid Services. In a blog interview with John Whittington last fall, we explored the origins of Triple Aim within the Institute for Healthcare Improvement and their emerging regional strategy beyond individual health systems or plans.
I am a big fan of Triple Aim and have been privileged to present at several of their recent meetings. My appreciation for this work is based in the belief that IHI/Triple Aim is one of the leading forces in the U.S. to motivate healthcare systems to stretch beyond traditional clinical roles and work towards broad population health improvement. In fact, population health is prominently featured at the top of the Triple Aim triangle:
It’s great to see population health front and center in a model. But there’s a communication problem here that needs to be acknowledged: what does “population health” in the Triple Aim model actually represent?
My concern is that people looking at the Triple Aim model won’t necessarily know what to make of the “population health” leg of the triangle. As a result, they may focus on the other two more concrete goals of improving the experience of healthcare and reducing per capita costs of healthcare. In no way do I want to diminish the importance the model’s clinical goals, which may represent our best short-term strategy. However, the reality is that even major progress in these two areas over the next decade will not help us achieve our goals related to healthy life expectancy and disparity reduction.
To achieve our broad population health goals we need to understand and intervene across the whole spectrum of determinants, not just health care. Triple Aim leaders understand and appreciate this, but I’m not sure this is clearly communicated by the Triple Aim model so I’ve drafted an alternate view that combines the Triple Aim model with our model of population health.
As the figure shows, two of the legs of the Triple Aim stool relate only to a single determinant, healthcare. I’d like to see the population health part of the Triple Aim model more clearly defined to make it clear that population health outcomes (among populations or individuals) are influenced by multiple determinants, most of which are beyond health care (note the reddish boxes in the figure above).
I have discussed this constructive criticism openly with Triple Aim leaders and will continue to do so. They have a powerful brand which is serving us well in many regards. But when Berwick and others talk about “better health” as a shorthand for “population health” in the Triple Aim model, let’s be certain that everyone understands this means actions beyond just health care. Several Triple Aim sites have developed impressive population health agendas and are moving forward with broad and ambitious health goals. But I can’t help but wonder if a revamped model might enhance existing efforts and spur new dialogue and action in AND out of the health care system to improve health.
David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.