Thoughts on the Triple Aim

Medicine is a funny business. I mean, odd. In Canada we have one employer. We pay for our education, or office overheads and society dues. We are paid “fee for service” usually, which means the more you see the more you earn. GPs and specialists are—in general—complementary. But more often than not, we don’t see each other or have any appreciation of the pressures the other works under. Paper hasn’t disappeared from our world: We still have faxes and letters, although hopefully the digital revolution will eventually catch up. We are regulated—through our College fees—by an agency that represents patients. We don’t have a pension, but do have matching contributions to investments (RRSPs). This complex and highly responsible business structure is learned piecemeal, not in university, but on the job, through locum work and experience. We work long hours, sometimes on call, doing highly responsible work in hospital and clinic roles, interfacing with EMRs and other caregivers to various degrees—in challenging times. Some of us have little or no interface with administration, or community health teams, which can lead to misunderstanding, mistrust and disengagement. They say that healthcare services contribute 20% toward patient health—that the social determinants of disease, and various disparities, count for so much more. So, we think we are doing a great job, but quite honestly, we should be investing in the root cause of ill-health: poverty, under-education, unemployment, gender and ethnic disparity, etc. Archaic systems lead to miscommunication, and limited access denies care. Read: Dr. Baillie on The Distribution of Care Do you know? How many cases of pulmonary embolism came in to the ER of your hospital last month? What percentage of your patients over 50 don’t have a will? What percentage of your patients over 80 still drive? What the biogram is of your community for urinary pathogens? What the intracranial hemorrhage rate is for thrombolysed patients? How many diabetics skip dental care for lack of funds? What the average blood pressure is for your patients over 65? What percentage of your patients are without a job, and living on an income that is borderline? Data is so important. Many of these questions do not have an easy answer. But for statistics related to healthcare, we do have the answers. It’s just you don’t get told the answers. That would be too obvious, too practical and too revolutionary. Often, they are in a data-warehouse, just sitting there. Give providers the data they need to understand their job and allow research into more efficient, effective and economic solutions. Give every provider responsibility for health outcomes, through a management association, and recognize and reward good results (hmm, what would that look like?). The Institute for Healthcare Improvement’s Triple Aim initiative is focused on: improving individual health, improving population health and reducing cost per patient. It tells us to focus on the patient and the determinants of health. Value is defined as the ratio of quality-cost. Clinicians should be valued as key providers of care. They should deliver good frontline care to individuals (safe, effective, patient-centric, equitable, efficient and timely) with minimal waste or redundancy. Are they familiar with these concepts? In my career, I have seen opportunities to save money—without compromising care. In fact, I think I could save my health authority $1 million a year. But why should I see this as my problem, why should I engage? What incentive is there for clinicians to change practice if they don’t see value—to their practice, or their patients? As an example, I established and ran a Heart Function Clinic in my hospital. For 11 years. This population of vulnerable patients is expensive when they decompensate and are admitted through ER to a hospital bed. They stay a week, use up resources (nurses, blood tests, scans, consults, ICU time), and are treated with costly drugs and devices. An outpatient HFC kept patients informed, educated, and in touch with trained nurses—monitoring progress and up-titrating drugs. The annual mortality rate of HF is 10%, worse than any malignancy (except lung cancer). But having a hub of specialized care gave them, and their family, the security they needed—and a way of staying healthy at home. Ironically, investment “upstream” in HF-care never matched the demand: 1.4 nurses, 0.2 secretaries and two occasional doctors for a population of 400,000. Now if I was a healthcare economist, I would look at this as a wonderful opportunity to save on admission costs. Oh-oh, savings in admissions doesn’t get re-routed into salaries for clinic staff. Maybe this is a good QI project for a return-on-investment analysis. In an ideal world, all doctors would be familiar with patient safety, quality, system re-engineering, economics and the social determinants of health. By embracing a bigger role, the value we could bring to individual and population health could increase. And the cost of care per patient could be reduced. The Triple Aim. To paraphrase Kennedy, “Ask not what matters to you, but what matters to your patient.” You might be surprised by the answer. Read: Dr. Baillie on Unusual cases

Thoughts on the Triple Aim

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Hector Baillie

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