The Triple Aimers have missed the mark

This is one of those columns that will risk the respect and friendship of some of my closest colleagues in the health care world. In addition to disagreeing with me, they may argue that I am giving aid and ammunition to “the enemy,” where the enemy might be viewed as those forces in the health care world who really don’t want things to change. But as you shall see, I will assert that it is those very colleagues who–by focusing on an overly simplistic ideological approach to health care policy–are inadvertently giving succor to that same group by providing political cover for nefarious behavior.

I refer to many of the most prominent advocates of the Triple Aim.

As set forth in this article and elsewhere, the Triple Aim is described as follows:

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. In the aggregate, we call those goals the “Triple Aim”: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.

At first blush, who can argue with this set of desiderata? The three components seem ineluctable.

But policy-making is not so simple as setting forth seemingly self-evident or self-fulfilling goals. Policy-making must take place in the cauldron of competing private and public interests. The transmogrification of goals into policies, statutes, regulation, and corporate and individual action can be ugly and can result in unintended consequences. It is on this point that I argue that the Triple Aim has been hijacked.

It has been hijacked by powerful political and economic forces–often represented by the nation’s hospitals in general and by academic medical centers in particular–but also aided and abetted by federal action.

The clearest representation of the Triple Aim, baked into federal legislation and supported by many health care advocates, is the creation of Accountable Care Organizations (ACOs.) The idea is that a group of health care institutions and practices in a given geographic area will join forces as an ACO to provide management of care across the continuum of care. The argument goes further, that by shifting from a fee for service rate-making formula to one based more on an annual per capita (risk-adjusted) budget, the ACO should have an interest in the health of the population–resulting in an increase in wellness programs, preventative care, early intervention, and a decline in more expensive hospitalization and procedures.

An interesting policy hypothesis, but what happens when policy turns to practice? First, we see that the dominant player in many an ACO is the community’s academic medical center (AMC) or tertiary hospital. It is not the local multi-specialty practice that has the long-term relationship with a person or family, and which might shop among the region’s hospitals for the best care patterns and cost efficiency. No, the area’s largest hospital is the one that sets up the ACO in most places and controls its governance and cash flow.

As a matter of corporate structure, a general hospital is often an exemplar of an over-capitalized, inflexible organization with an excessive amount of overhead. As Clayton Christensen has noted:

The traditional general hospital is not a viable business model. . . . [T]he agglomeration of many business lines and a desire to serve all kinds of patients results in a very high overhead burden rate — roughly $9 for every $1 spend on direct patient care.

In light of this corporate structure, many hospitals have best been defined as “cost centers in search of revenue streams.” As I have noted:

It’s not that the doctors and nurses are any less caring or dedicated, but rather that the leaders of these centers have become calcified with regard to their social mission. They focus instead on expanding market share, growing margins, and attracting philanthropists to contribute to unnecessary and flamboyant edifices. They have no real interest in reducing costs, but rather in obtaining and securing revenue streams to cover ever-increasing costs. Most importantly, they neglect the harm they cause to patients in their facilities, preferring to assert that they deliver high quality care without being willing to be transparent with regard to actual clinical outcomes.

I hesitate to give examples, for fear that they will be considered simply as anecdotes. But the trends they demonstrate are more pervasive than anecdotal. Plus, it is important that we look at the some of the organizations often cited as among the best in the country. Places like Mayo Clinic, investing $180 million in a proton beam facility when there are similar facilities within easy traveling distance for those very few families who can benefit clinically from them. Places like North Shore-Long Island Jewish, belying its stated strategic objectives (“to realize cost efficiencies and ensure patient safety through adherence to best practices”) by providing space, support, and publicity for a prominent doctor who affirmatively advocates overuse of diagnostic tools. Places like the University of Illinois-Chicago, the University of California, and dozens of others who gladly accept “walking around money” for themselves and their surgeons from a medical equipment supplier to invest in market-share-growing robotic surgery.

It would be one thing if the tertiary hospitals and AMCs just engaged in revenue-generating activities. But using the “population health” rubric of the ACO, they seek to consolidate market power by acquiring other facilities and practices in their geographic area. And those same hospitals often attempt to foreclose consumer choice by purchasing electronic medical records systems that are not interoperable outside of their network and forcing that choice on their newly acquired clinical partners. Regular readers know that my favorite local example is Partners Healthcare System, but others have documented the same pattern in New York and elsewhere. The goal is simple, to have leverage over local insurers to drive rates up.

In addition, the hospitals, the equipment manufacturers, and the investment counselors use their political clout to obtain favorable ratemaking treatment from the federal government for expensive new technologies, either to get paid directly from CMS or to allow excess payments from consumers.

Here’s my point in going through all this background: We hear little or nothing from the prominent Triple Aim advocates about this tremendous use of political and economic power, power that is limiting customer choice and raising costs. Instead they focus on Triple Aim “fixes,” mainly in terms of insurance plan design and reimbursement penalties that are supposed to support their population health objectives.

But do those fixes work? What about the adverse impacts on low income families when insurers and employers push high deductible health plans (ostensibly to get consumers more engaged in health care spending) because overall costs are rising? What about poorly constructed penalties, like the one on readmissions, that have an adverse impact on safety net hospitals? The comment I most often get on the latter matter is, “Well, it’s not a perfect measure, in the grand scheme of things, but it has moved hospitals to focus on the discharge process in a far more meaningful way, and that’s making a difference.”

Is that really the best the Triple Aim advocates can do? While billions are being extracted from insurers by growing monopolies, while billions more are being extracted from all of us by complicity between hospitals and equipment manufacturers, while low income families are forgoing care because they can’t afford the deductible, we relish a single digit percent improvement in readmissions that has the consequence of hurting facilities carrying for the poor?

And where is the outrage when an entire industry arises around unsupported wellness programs, leading employers to engage in expensive and coercive practices with employees?

Look, there’s nothing wrong with the Triple Aim objectives. What’s wrong is that its most prominent advocates–some of the most influential health care experts in the country–have focused so heavily on that ideological approach to health care policy that they have absented themselves from the real battles over power, money, customer choice, and cost. They are losing ground every day. While they glance elsewhere, the Triple Aim is being turned on its head: The individual experience of care will degrade; the health of populations will decline; and the per capita costs of care for populations will rise.