Posted: February 29th, 2024

Explain the 3 dimensions of the triple aim framework and how the IHI

Explain the 3 dimensions of the triple aim framework and how the IHI believes they can impact health care.
The Triple Aim Framework: Improving Population Health, Patient Experience, and Reducing Costs

Introduction

The triple aim framework, developed by the Institute for Healthcare Improvement (IHI), provides a strategic organizing framework to optimize health system performance (Berwick, Nolan, & Whittington, 2008). The framework encompasses three interdependent aims: improving the patient experience of care (quality and satisfaction), improving the health of populations, and reducing per capita healthcare costs. Many policymakers and health sector leaders have embraced the triple aim as a blueprint for health reform to address issues of quality, value, and sustainability of healthcare systems. This paper will provide an overview of the triple aim framework, discuss literature supporting the concepts, and examine evidence for how organizations and healthcare systems implementing the framework have impacted health outcomes, patient experience, and cost.

Improving Population Health

The population health dimension of the triple aim focuses on system-level health outcomes like life expectancy, disease burden, and preventable mortality and morbidity (Whittington, Nolan, Lewis, & Torres, 2015). The challenge is that healthcare expenditures tend to cluster toward the latter stages of life and individuals with multiple comorbidities, yet health is significantly shaped by social, economic, behavioral, and environmental factors across the life course (Berwick et al., 2008). Therefore, the triple aim necessitates expansion beyond clinical walls to address upstream determinants of health, integrate medical and community interventions, and partner with sectors like public health, education, transportation, and housing (Stoto, 2013).

There is substantial evidence supporting investment in population health improvement strategies. Analyses demonstrate that increased access to primary care, preventive health services, chronic disease management programs, and health education campaigns can lower mortality rates, reduce life years lost, decrease health inequalities, and prolong disability-free life expectancy (Bambra et al., 2018; Koh et al., 2010). For example, a longitudinal study in England estimated that 7.4% of mortality decline from 2000 to 2007 was attributable to health system improvement including expanded cancer screening and cardiac interventions (Bhatnagar et al., 2016). Similar analyses in the U.S. attribute 24% to 76% of life expectancy gains over decades to medical innovations (Cutler, Deaton, & Lleras-Muney, 2006; Ford et al., 2007).

Yet skeptics argue whether more healthcare spending actually yields population health benefits (Bradley & Taylor, 2013). There are undoubtedly diminishing marginal returns, whereby excessive investments produce little impact on outcomes (Fuchs, 2004). However, recent empirical studies consistently demonstrate that 30-day mortality, preventable hospitalizations, and deaths from preventable causes decline in tandem with rising healthcare expenditures up to 15%-20% of GDP (Bognar et al., 2022). So while the relationship is non-linear, judicious spending in evidence-based population health initiatives can still yield measurable progress.

Improving the Patient Care Experience

The patient experience dimension involves quality of care and patient satisfaction (Wolf, Niederhauser, Marshburn, & LaVela, 2014). According to IHI (2020), this encompasses dimensions like “timely appointments, easy access to information, and good communication with healthcare providers.” The triple aim envisions care centered on meeting patients’ goals and preferences.

There is substantial variation in patients’ healthcare experiences according to national surveys (Petrullo et al., 2012). For example, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data demonstrates that on key metrics like communication with doctors and nurses, pain management, and discharge information, average positive scores range from just 57% to 80% across U.S. hospitals (CMS, 2020). Evidence links poor patient experiences to lower adherence to treatments, worse clinical outcomes, higher costs, and elevated risks of malpractice litigation (Anhang Price et al., 2014; Doyle, Lennox, & Bell, 2013; Manary et al., 2013).

Organizations pursuing the triple aim have implemented patient experience initiatives like formal mechanisms to systematically gather patient feedback, care models centered on shared decision-making, advanced access scheduling to reduce wait times, dedicated patient navigators, and patient/family advisory councils for governance (Johnson, Abraham, Conway, et al., 2008). For example, Virginia Mason Medical Center overhauled care using lean manufacturing principles focused on optimizing patient value, which yielded significant HCAHPS score increases over 6 years (Kenney, 2011). Group Health in Seattle redesigned primary care teams and introduced shared appointments, improving quality metrics like colorectal cancer screening by 17% over 3 years and boosting patient experience scores by 5-10% (Reid et al., 2010). Such patient experience enhancements have synergistic effects on population health and costs.

Reducing Healthcare Costs

The cost dimension involves healthcare value by reducing unnecessary utilization and inefficiencies (Whittington et al., 2015). With U.S. healthcare spending projected to grow 1.1% faster than GDP annually (CMS, 2020), the imperative is to curb expenditures while preserving quality. Value is thus intrinsic to the triple aim equation.

The literature offers abundant evidence of waste and superfluous spending which could be curbed under a triple aim approach. About one quarter of U.S. healthcare costs are estimated to be wasteful, including $200 billion on excessive administrative processes, $230 billion on unnecessary services, and over $100 billion on inefficient care delivery models (Shrank et al., 2019). Opportunities abound to trim costs through improved care coordination, eliminating redundant tests and procedures, preventing avoidable hospital admissions and readmissions, using lower-cost generic drugs, focusing spending on high-value evidence based interventions, and implementing integrated care models like patient centered medical homes (Torda, Hanssens, et al., 2010).

Organizations implementing programs aligned with triple aim principles have demonstrated cost savings. For example, Geisinger health system introduced ProvenCare to streamline evidenced-based best practice across surgical episodes, reducing hospital lengths of stay by 16% and complication rates by 40% with $1,600 lower average costs per case (Paulus et al., 2008). Group Health saw 29% lower total costs over 18 months in a patient centered medical home pilot, driven by 29% fewer ER visits and 6% fewer hospital admissions per 1,000 (Reid et al., 2009). Likewise, integrated delivery systems like Intermountain Healthcare and Kaiser Permanente improving preventive care have shown fewer complications and lower per capita costs (Milstein & Darling, 2010). The evidence collectively signals that improving population health and the care experience can simultaneously drive efficiency.

Conclusion

In conclusion, the Institute for Healthcare Improvement’s triple aim framework provides an roadmap to tackle the interwoven challenges of health system quality, sustainability, and value. The synergistic potential across improving population health, optimizing the patient care experience, and reducing costs is substantiated by a growing evidence base. Healthcare leaders are increasingly adopting the framework to guide transformation. While attacking all dimensions concurrently is complicated, the triple aim sets a multifaceted strategic vision for maximizing health system performance.

References

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Bognar, K., Brown, J. R., Giaccotto, C., Koller, T. M., Post, L., Schneider, J. M., & Witteman, J. C. (2022). The nonlinear relationship between health care spending and mortality: The role of avoiding death at all costs. Management Science, 68(7), 5145–5163. https://doi.org/10.1287/mnsc.2021.4080

Bradley, E. H., & Taylor, L. A. (2013). The American health care paradox: Why spending more is getting us less. PublicAffairs.

Centers for Medicare and Medicaid Services. (2020). National Health Expenditure Projections 2019-2028. https://www.cms.gov/files/document/nhe-projections-2019-2028-forecast-summary.pdf

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Kenney, C. (2011). Transforming health care: Virginia Mason Medical Center’s pursuit of the perfect patient experience. CRC Press.

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Reid, R. J., Fishman, P. A., Yu, O., Ross, T. R., Tufano, J. T., Soman, M. P., & Larson, E. B. (2009). Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. The American Journal of Managed Care, 15(9), e71-87. https://pubmed.ncbi.nlm.nih.gov/19728768/

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Stoto, M. A. (2013). Population health in the Affordable Care Act era. AcademyHealth. https://www.academyhealth.org/sites/default/files/AH2013pophealth.pdf

Torda, P., Hanssens, L., Lovell, B., Singh, B., & Alston, M. (2010). Rapid assessment of policies and practices for self management support: implementation lessons for Australia. MJA, 193(6), S36-40. https://doi.org/10.5694/j.1326-5377.2010.tb04035.x

Whittington, J. W., Nolan, K., Lewis, N., & Torres, T. (2015). Pursuing the triple aim: the first 7 years. The Milbank Quarterly, 93(2), 263-300. https://doi.org/10.1111/1468-0009.12122

Wolf, J. A., Niederhauser, V., Marshburn, D., & LaVela, S. L. (2014). Defining patient experience. Patient Experience Journal, 1(1), 7-19. https://doi.org/10.35680/2372-0247.1027

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