Editor’s Note: In a paper in the recently released May/June issue of Health Affairs, Donald Berwick, John Whittington, and Tom Nolan of the Institute for Healthcare Improvement lay out a strategy for improving American health care through the pursuit of the “’Triple Aim’: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.” Today, the Health Affairs Blog presents commentaries on the Triple Aim paper by David Kindig (below) and Cathy Schoen.

Berwick, Whittington, and Nolan will discuss their paper on a conference call today (Monday May 19) at noon, and IHI will hold a June 23-24 conference in Washington DC on achieving the Triple Aim. For free full-text access to the Triple Aim paper and to learn more about the call and the conference, visit the IHI Web site.

Donald Berwick and colleagues once again do our health care system a favor with their proposal for the Triple Aim of improving the experience of care, improving the health of populations, and reducing per capita costs of health care. It would be hard to argue that we would not be much be much better off with their five financial and competitive dynamics of

(1) global budget caps on total health care spending for designated populations, (2) measurement of and fixed accountability for the health status and health needs of designated populations, (3) improved standardized measures of care and per capita costs across sites and through time that are transparent, (4) changes in payment such that the financial gains from reduction of per capita costs are shared among those who pay for care and those who can and should invest in further improvements, and (5) changes in professional education accreditation to ensure that clinicians are capable of changing and improving their processes of care.” (p 767)

However, while Berwick and his coauthors suggest that the Triple Aim is in part to improve health rather than health care, almost of the paper is really limited to reform of the health care system. There is nothing wrong with that, because there is much to be done within the medical determinants of health. Medical care accounts for from 10% to 50% of the multiple determinants of broad health outcomes, and this is no small undertaking. But when they cite the relative position of the United States on life expectancy and infant mortality, where they correctly indicate that we lag far behind other countries, they leave the unwise impression that the Triple Aim alone can address the broader issues that lead to such population health outcomes.

The authors are not entirely silent on this point. When they discuss population health management as the function of an integrator, they do indicate that the “actual” causes of mortality in the United States lie in behavior that the individual health care system addresses unreliably or not at all, such as smoking, violence, physical inactivity, poor nutrition, and unsafe choices. An integrator would increase preventive efforts. An integrator would also encourage and cooperate with governmental policies, agencies, and programs to discourage smoking, combat obesity, provide alternatives to violence and substance abuse, and address community determinants of mental health problems” (p. 764).

The key question is, Who will be this integrator? All of the examples listed are of innovative health care delivery organizations, whose role will be to “induce coordinative behavior among health service suppliers to work as a system for the defined population” (p 763). This is a worthy and challenging goal, which I commend. But it is not just semantics to say that such an integrator has the potential to improve and coordinate health care but not necessarily health. Berwick and colleagues hope that the integrator will “in one way or another link health organizations (as well as public health and social service organizations)” (p.763). The problem is that the primary sectors with opportunity for health improvement perhaps lie more on those inside the parentheses, as well as others outside of the health care system. The role of nonmedical sectors as determinants of broad population health outcomes requires equal if not greater integrating attention than health care (Evans R, Stoddart GC., Consuming Health Care, Producing Health, Soc. Sci. Med. 1990, 33:1347-1363). How do we move the nonmedical determinants out of the parentheses that they currently occupy in population health policy?

I do not suggest that this is easy. In a 1997 book I proposed the concept of a Health Outcomes Trust, an integrator that would have financial incentives to coordinate resources and policies across the public and private organizations addressing medical care, public health, education, income, and individual behaviors. I indicated that “some set of agents and relationships will have to take the responsibility for creating intersectoral incentives for health outcome improvement,” that a “seamless and efficient integration of the largely private medical care systems and the largely other public determinants will await forms of integration across these sectors not yet developed in theory and practice,” and that such models will likely involve “virtual rather than ownership integration strategies, with networking and collaborative relationships to insure appropriate boundaries and resource allocation”.

Needed: A Pay For Population Health Performance System

A decade later there is little to show for this challenge. While some Healthy Communities activities have had this goal, few have had the real resources or strong outcome measures to achieve this goal. While it is possible for health care systems to provide such leadership, such coordination is beyond the mission and capability of any to date, in the United States, at least. The integrator required is a “Pay for Population Health Performance System,” which goes beyond medical care to include financial incentives for the equally essential nonmedical care determinants of population health. The challenges are even greater than Berwick and colleagues realize for the Triple Aim within medical care; they include agreement on population health measures, financial incentives, ways to avoid unintended consequences, coordination across sectors, resistance to the reallocation of resources, and the triage trap that favors immediate or downstream interventions. Dan Fox also warns us that the population health policies favored by academics might not be aligned with the views of policymakers in the public and private sectors.

So I commend the authors for providing needed leadership for progress within our health care system. It may be all that we can do in the short run, and it will likely improve our health by improving health care quality and lowering cost. But the “inconvenient truth” is that even were such models to become reality within a decade, we would not achieve the life expectancy or health-related quality of life or health (not health care) disparity reduction we desire. All of us need to think carefully about the important ideas proposed in the Triple Aim strategy, but we should also turn our attention to financial and organizational models that perform the integrator function beyond medical care across the sectors representing the multiple determinants of health.