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Don Berwick’s Vision: The Triple Aim



April 20th, 2010

Yesterday, President Obama made it official: He nominated Don Berwick, president of the Institute for Healthcare Improvement, to lead the Centers for Medicare and Medicaid Services, which has been without an administrator since October 2006.

Berwick, a pediatrician who is also a professor at the Harvard Medical School and the Harvard School of Public Health, is one of the nation’s most respected voices on improving the health care delivery system. Assuming he is confirmed, Berwick will be a pivotal figure in the implementation of health reform, particularly in the development and testing of new payment and delivery models.

Berwick has been a frequent presence in the pages of Health Affairs. In an article in the May/June 2008 issue of the journal, “The Triple Aim: Care, Health, and Cost,” Berwick and coauthors laid out their vision for reforming the American health care system through the simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Cathy Schoen and David Kindig offered reactions to the article on the Health Affairs Blog, and you can read more about the Triple Aim on the IHI Web site.

“Most recent efforts to improve the quality of health care have aimed to reduce defects in the care of patients at a single site of care,” wrote Berwick and his IHI colleagues Thomas Nolan and John Whittington in their Health Affairs article. “Work to improve site-specific care for individuals should expand and thrive. In our view, however, the United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals.”

Berwick, Nolan, and Whittington observed that “we face a paradox with respect to pursuit of the Triple Aim. From the viewpoint of the United States as a whole, it is essential; yet from the viewpoint of individual actors responding to current market forces, pursuing the three aims at once is not in their immediate self-interest.” Among other conditions, achieving the Triple Aim requires an “integrator,” they wrote: an entity that “accepts responsibility for all three components of the Triple Aim for a specified population.”

The simplest integrators are organizations such as Kaiser Permanente, with “fully integrated financing and either full ownership of or exclusive relationships with delivery structures.” However, other entities might function as integrators: “that role might be within the reach of a powerful, visionary insurer; a large primary care group in partnership with payers; or even a hospital, with some affiliated physician group,” the authors noted. As originally conceived by Paul Ellwood, HMOs were intended to be integrators “exactly as we propose, in pursuit of the Triple Aim,” but “the HMO movement was eventually defined by its organizational structure rather than its aims and performance.”

How could the United States move toward the Triple Aim? Berwick, Nolan, and Whittington laid out the following steps:

If we could ever find the political nerve, we strongly suspect that financing and competitive dynamics such as the following, purveyed by governments and payers, would accelerate interest in the Triple Aim and progress toward it: (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.

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