The 'Triple Aim'

The ‘triple aim’ - improving health; reducing costs of care; and improving patients’ experience of care – is an increasingly popular one for health systems, but also commonly (less appropriately?) now specified for interventions/new models of care for health services at the sub-system level.

Having a triple aim implicitly assumes that these three aims can be achieved simultaneously, but can they? Is anyone actually aware of any (robust) evaluations of organisational health service interventions that show benefits across all three aims? (Genuine question, if anyone has any references please comment below).

I would suggest that we should be sceptical of the ‘triple aim’. It seems to me a ‘trilemma’ that all three can be achieved simultaneously and in full. Similar trilemmas have been suggested in political economy, for instance, ‘democracy, national sovereignty, or global economic integration’; in management, ‘fast, good, or cheap’; in life more generally, ‘work, sleep, or play’: pick any two!

What’s the evidence against?

There is evidence in the literature that suggests possible conflicts in the triple aim.

Fenton et al published a study in JAMA Internal Medicine in 2012 looking at ‘the cost of satisfaction’. In a nationally representative sample (in the USA) they found higher patient satisfaction associated with less A&E use, but higher inpatient use, higher overall healthcare and prescription costs, and increased mortality.

Integrated care interventions frequently explicitly try to improve the triple aim. However, a review by Nolte & Pitchforth in 2014 showed some evidence of improvements in quality of care, improved health and patient satisfaction, but very limited evidence of any benefits to system costs, concluding “there may be a need to revisit our understanding of what integrated care is and what it seeks to achieve”. An even larger systematic review by Baxter et al published this month found similar results, with increased healthcare utilisation and costs in many instances.

The triple aim most recently had to be upgraded to a ‘quadruple aim’ (with the addition of preventing physician burnout) in an attempt to protect providers of care from the adverse effect to their own health of having to do more with less.

Why not?

There are good reasons why these conflicts would arise, for instance:

· Information asymmetries: At the end of the day, medicine is a profession that requires years of continuous training. In essence, we as the patient don’t tend to know what’s good for us (yes, even in the age of Google), as the practitioner often draws on their experience over time with imperfect evidence available. What will satisfy the patient is not necessarily what is good for their (or the wider population’s) health and will more than likely cost more.

· Interactions across the aims: Satisfaction is partially determined by our pre-existing health, our health outcomes as a result of treatment, and (especially if we are co-paying), cost too. In general, we all know that quality costs. Indeed, the most important causal drivers of increased healthcare expenditure are found to be improving quality of care, improving access to care, and linked to both, improving (expensive) new healthcare technologies. ‘You get what you pay for’…

Who cares?

So, what? Why can’t we at least try and maximise all of these noble aims?

Well, there is a potential danger of trying to do so (especially in a tax-funded system). This is because it is easiest to achieve increased satisfaction over the other two aims. I’m sure all of us could think of a way of improving patient satisfaction right now. For instance, we could give each patient in the waiting room a free hot toddy as they wait to be seen. But, as the evidence above shows, this might require trade-offs and negative spill-over effects on other aims.

In a tax-funded system especially, if we continue to place added emphasis on patient satisfaction over other aims (or do this by naïvely striving for all three in parallel), we risk ever-increasing, fiscally irresponsible costs as we achieve satisfaction at the expense of other aims. Alternatively, we risk compromising our underlying value system as we struggle to keep pace with these costs, and an adaptation to the funding (and value) system of the NHS is eventually forced (as the argument for an insurance-based system becomes easier to sell to the voting public).

What’s your point?

The reality is, in an overall health system, there are a wide variety of (often conflicting) aims that we should be measuring and trying to balance in some way. For example, while cost-effectiveness (health and cost – i.e. bang for the public’s buck) might be the priority aims in a tax-funded system, the NHS still needs to be mindful of being relevant to an increasingly consumer-focused public and justify its tax-based income to voters. So, it will always need to consider patient satisfaction to some extent at least (and, of course, the health of those who deliver its services for sustainability).

But, it is important to remember that we will not necessarily be able to achieve all aims in equal measure, certainly not within each intervention/model of care within the health system. The place of satisfaction in our aims should be up for debate. This has important implications in determining, for example, how popular agendas such as ‘person-centered care’, ‘care planning’, ‘shared decision-making’ and ‘patient and public involvement’ can and should be implemented.