Market Innovations Driving the Quadruple Aim
Introduced in 2007 by the Institute for Healthcare Improvement (IHI) and adopted as the vision for the US healthcare system by the Centers for Medicare & Medicaid (CMS) in 2010, the Triple Aim seeks to improve the patient experience, improve population health and reduce healthcare costs per capita. These aims and the relevant policies created incentives for improving care coordination through data infrastructure and innovative team-based care models. Since then, calls for a Quadruple Aim have been made by many stakeholders to consider provider experience in national health care decisions.
Aim #1 Better Care (aka Patient Experience)
Patient experience encompasses the range of interactions that patients have with the health care system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other health care facilities. As an integral component of health care quality, patient experience includes several aspects of health care delivery that patients value when they seek and receive care, such as getting timely appointments, easy access to information, and good communication with health care providers. CAHPS surveys, produced by AHRQ, measure patient experience. They are used to help determine provider reimbursement by some commercial payers and Medicaid.
Aim #2 Better Health for Populations
Population health – the effort to drive the delivery of high value care across a population rather than just treating acute conditions at a late stage – is part of the Triple Aim. It is important to any risk-bearing entity, since early interventions can reduce costs down the road. The goals around population health are largely what are driving the heavy reliance on data analytics, the emphasis on disease prevention, and the Social Determinants of Health.
Aim #3 Lower Cost per Capita
Cost management, also part of the Triple Aim, is the driving force behind trends ranging from utilization management and provider consolidation to the adoption of evidence-based clinical and care pathways and participation in the 340B Drug Pricing Program. HEOR; utilization management; HEDIS appropriate use/resource use; readmissions measures; value-based purchasing with third parties e.g. pharmaceutical companies
Aim #4 Better Provider Experience. Amid high reports of “physician burnout” and low satisfaction among providers, providers called for a fourth aim to reduce burdensome regulations that have led to physicians having less time for patient interactions.
Innovations to Drive the Quadruple Aim
Computerized Physician Order Entry (CPOE) (also sometimes referred to as Computerized Provider Order Entry or Computerized Provider Order Management) is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE systems and protocols are used within medical practices and systems of care to coordinate patient care across providers and caregivers.
Evidence-based Medicine (EBM) is the use of current best clinical evidence in making decisions about the care of individual patients. EBM seeks to assess the strength of the evidence of risks and benefits of treatments (including pharmaceuticals) and diagnostic tests.
Healthcare Information Technology (HIT) ) is the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, government and quality entities, and insurers. Health information technology (HIT) is in general increasingly viewed as the most promising tool for improving the overall quality, safety, and efficiency of the health delivery system.
Insurer Acquisition of Systems of Care (SOC). In addition to ongoing consolidation among healthcare providers, insurance providers are buying large physician practices and with that, doctors become employees of insurers. Insurer acquisitions of systems of care are driven by the shift of financial risk inherent in emerging payment models, and the desire of the insurer to play a larger role in driving efficient, quality care.
Integrated Delivery Networks (IDNs) are networks of organizations that provide or arranges to provide a coordinated continuum of healthcare services to a defined population and are willing to be held clinically and fiscally accountable for the outcomes and health status of the populations served.
Medicaid Disproportionate Share (Medicaid DSH) payments are supplemental payments made to selected hospitals that care for high numbers of low income patients. Hospitals assume financial losses to care for these patients and the purpose of Medicare DSH is to help compensate them for those losses.
Population Management To better manage all aspects of health from wellness to complex care, healthcare delivery organizations are increasing their focus on raising the quality of care, improving care coordination across all care settings, and applying this approach over a much longer period than that of a single episode of care.
Provider Consolidation is a current market trend evidenced by physicians migrating their practices and/or some services from community practices to hospitals to cut down on costs and risk. This is being driven by lower reimbursement rates, increasing operation costs related to compliance, technology, physician employment, and movement toward new models of care continue to drive mergers and acquisitions among hospitals and health systems. Increased consolidation has also spurred heightened antitrust regulation and involvement from the FTC.
Regionalization of Healthcare is a major environmental trend as many aspects of healthcare reform are being implemented differently on a state-by-state basis. Specific implementation of coverage expansion options including HIMs and Medicaid Expansion, combined with the presence of increasingly consolidated provider networks lead to regional differences that will result in differences in both the scale of the opportunity for industry, as well as the decision-makers involved in capturing the opportunity.
Systems of Care (SOC) is a framework which healthcare is provided, comprising healthcare professionals; recipients, consumers, or patients; energy resources or dynamics; organizational and political contexts or frameworks; and processes or procedures. Current theory recognizes that an analysis of the provision of healthcare requires knowledge of the systems of care.
Patient Engagement and Activation. Patient engagement is a measure of the level to which a patient takes on the role of managing their health and health care. Patient activation goes a step further to measure the motivation, knowledge, skills and confidence a patient has to take on that role. Increasing the engagement of patients in their health, especially those with significant socioeconomic challenges, is one of the greatest challenges to driving the Quadruple Aim.
Social Determinants of Health (SDH) include access to stable housing and other poverty indicators such as access to health care, education, and safe neighborhoods. Knowing the SDH of patients impacts all of the aims, and has been shown to support provider satisfaction.