The pressure to transform health care has been building for many years, and many frameworks have been proposed for this transformation. The ‘Triple Aim’ concept of improving the health of the population, improving the experience of the patient, and controlling cost can be used as a guide post for the adoption of the necessary changes to thrive in a new construct of women’s health care. Following these guiding principles should lead to improved clinical outcomes at affordable costs with high patient and provider satisfaction. The actual changes will come in the form of various ‘transformational forces.’ One of the driving forces will be conversion of the current payment structure from a fee-for-service model to value-based payments. In addition, the methods of care must be redesigned into a ‘team-based’ approach in which providers and patients use best practice protocols that are individualized to specific patient needs. Redesign will continue to drive consolidation of providers into larger groups to cover the cost of the needed infrastructure.
The Problem
Improving the delivery of care to our patients requires an underlying framework to guide the necessary changes.
A Solution
Use the principles outlined in the ‘Triple Aim,’ which involves assessing the changes by the degree to which they improve the health of the population and the experience of the patient and control costs. The ‘transformational forces’ needed will involve payment reform and redesigned care delivery methods.
Second of 3 parts. Part 1 appeared in the November issue.
A Solution
Use the principles outlined in the ‘Triple Aim,’ which involves assessing the changes by the degree to which they improve the health of the population and the experience of the patient and control costs. The ‘transformational forces’ needed will involve payment reform and redesigned care delivery methods.
Second of 3 parts. Part 1 appeared in the November issue.
Using the Triple Aim to guide choices
The aims are straightforward and simple. We can use them to ask a series of questions about proposed changes to care and new technologies. The best and most successful approaches will achieve all 3 core goals. Furthermore, we believe that any proposed changes must satisfy at least one of these aims without conflicting with the other aims. We would also assert that innovations or changes that do not achieve any of the 3 aims should be rejected. Table 1 lists these suggested questions broken down by the specific aims. We can also use the principles of other industries to add “improve the provider experience” under the patient experience goals. Companies such as Disney, Southwest Airlines, and Nordstrom have demonstrated that the best customer experience is produced by engaged employees who are satisfied with their work experience.
| Improve the health of the population |
| Increased morbidity and mortality rates? |
| Longer, healthier, more productive lives? |
| Improved quality of life? |
| Reduces prevalence of the disorder? |
| Allow for earlier detection and intervention? |
| Benefits outweigh risks? |
| Obtain the best experience |
| Allows respectful interaction? |
| Respects patient autonomy? |
| Allows active patient participation? |
| Proper security and privacy? |
| Provides better care environment? |
| Less interference of patient’s normal life pursuits? |
| Fewer side-effects? |
| Control costs |
| Reduces ‘total’ cost of the disease? (medical and nonmedical) |
| Fewer health care resources used? |
| Move care to lower cost setting? |
| Patient and family can administer or use? |
| Is care provided by the lowest level provider? |
| Prevents duplicate or repeated care? |
| Reduces waste and complexity? |
We can use this framework to evaluate a number of past health care changes and better understand the reasons for their success and/or failure. Managed care organizations flourished during the early 1990s. According to the National Bureau of Economic Research, by 1998, 75% of Americans were insured in some form of managed care plan, and 48% were covered by Health Maintenance Organizations. Managed care was very successful at reducing health care spending, with the report suggesting that, for every 10% growth in managed care, the country saw a 0.5% drop in health care spending. However, the strict practices and harsh restrictions of patient choice did not satisfy the second aim of “obtaining the best experience for the patient.” These practices led to public backlash and the passage of patient’s rights laws curbing many of these practices. Furthermore, managed care did not demonstrate that it was improving the health of the population. In contrast to managed care organizations, some research has shown that, in certain situations, the Medical Home Model can satisfy all 3 goals by improving the health of the population, improving the patient experience, and resulting in cost containment. We believe that health planners of the future should and will use the Triple Aim framework to support or eliminate new strategies and therapies. Unless a new strategy can demonstrate overwhelming improvement in clinical outcomes, improvement in the health of the population, and a reduction in costs, it will not survive.
Transformational forces: changes to achieve the Triple Aim
What are the possible changes that we must push forward to achieve the Triple Aim? What are the innovations that will help us provide health care that reduces costs, improves the health of a population, and maximizes the patient/provider experience? We can divide these changes into 4 major groupings of categories that we describe as ‘Transformational Forces.’ These transformational forces include (1) payment reform, (2) care system reform, (3) digital conversion of clinical data and health information technology, and (4) disruptive clinical innovations. These forces are additive and complementary to one another in improving health care. Each of the transformational forces contains certain ‘disruptive ideas’ that, particularly if enacted simultaneously, should improve care and accelerate improvement ( Figure ). The complexity of our health care system means that different organizations and populations may require or be affected by each of the forces differently. Similarly, the culture and abilities of our local and regional health care providers may determine which changes ultimately succeed in their unique circumstances. In short, there will be no 1 size fits all approach, and likely trial and error approaches will be used widely. Regardless, the most successful transformational forces will be those changes that are true to the Triple Aim, and the most effective organizations will be those that widely use all of these transformational forces to adapt their care. Examples of changes likely to affect obstetrics and gynecology are listed in Table 2 .
| Payment reform |
| Moving away from fee-for-service payment to value-based reimbursement |
| Rewarding good outcomes rather than volume of care |
| Credible data on outcomes and costs for every patient |
| Care system reform |
| Consolidation of providers |
| Practicing ‘team’ medicine |
| Patient-centered medical homes/accountable care organizations |
| More care in nonacute care settings |
| More use of physician extenders |
| Consolidation of clinical roles |
| Clinical quality assessment and feedback |
| More standardized protocols/care maps |
| Well-defined goals and performance metrics |
| Educational reforms to train to new roles |
| Expansion of graduate medical education to meet new volume needs |
| Digital clinical data/health information technology |
| Electronic records |
| Clinical data expanded to all media types |
| ‘Big data’ analytics |
| Transparency within a system of all provider-related metrics and peer pressure |
| Privacy and security rules that protect rights but allow proper exchange |
| Telemedicine/telehealth |
| Computer-added diagnosis/interpretation |
| Home monitoring devices |
| Enhanced communication between providers/patients |
| Disruptive technologies |
| Personalized medicine |
| Genomic/proteomic diagnostics |
| Minimally invasive surgeries and diagnostics |
| Genetic/epigenetic therapy |
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