Sunday, April 14, 2013

Constraints and Healing: The "Triple Aim" Meets the Reality of Illness


The “triple aim” of health care has been present for a long time but that particular term was first voiced by Don Berwick, ThomasNolan and John Whittington in 2008, in an article in Health Affairs.  That triple aim is care, health and cost.  This month’s Health Affairs is dedicated to the “triple aim” going global as more countries around the world struggle to find solutions to the care, health and cost dilemma. 

In the original article in 2008, the authors wrote about the need for three constraints to be put into place to drive us closer to the triple aim.  They were “(1) recognition of a population as the unit of concern, (2) externally supplied policy constraints (such as total budget limit or the requirements that all subgroups be treated equitably), and (3) existence of an “integrator” able to focus and coordinate services to help the population on all three dimensions at once.”  These constraints have societal and population concerns as the focus.  The “integrator” is there to “help the population” rather than to help the person.  I worry about a certain professional arrogance that is inherent when one defines constraints for people rather than asking people as individuals, what they need.  While populations are made up of individuals, individual’s values and views may be minimized when the population is the focus.  When the first step is the development of constraints, the individual is likely to see those constraints as being against their own best interest. 

This focus on the population, as it is currently interpreted, runs the risk of minimizing the need to understand the many human elements in dealing with illness.  It can downplay the fact that the ability of any one person to heal is often as dependent or even more dependent on the social, economic, psychological and spiritual parts of their life as it is on medical science and health system operations.  People need to have some help balancing their life with their illness when they are sick.  People, as individuals need to have a trusted resource to help them through a maze of difficult decisions and difficult choices that poor health demands.  People need help finding their own voice in a system that can appear to be more concerned with population needs than with individual patient care. 

Good health care is labor intensive and the labor is expensive.  Much of that labor is involved in the technical aspects of care but patients and their families also value expert assistance in decision making requiring knowledge and skill that is totally focused on the individual and their own understanding of how they want to live their life and how they value the options before them.   Traditionally physicians and nurses have taken central roles in that communication and decision making.  However our attempts to create efficiencies, as our population grows more diverse and our health system grows even more complex, have caused doctors and nurses to spend less and less time understanding the person as a person, understanding their values and respecting their autonomy.  Doctors and nurses are considered too expensive to be used in such a way.  But that human need is still there and the emphasis on doctor and nurse productivity has led to a void as the time to understand the patients before them as people is not seen as productive.  That void, has led to higher costs as people give in to their fears and isolation and flail around a health care system as they try to find their way to healing. 

An article in the “triple aim” issue of Health Affairs by Michael Macdonnell and Ara Darzi entitled “A Key to Slower Health Spending Growth Worldwide Will Be Unlocking Innovation to Reduce the Labor Intensity of Care” addresses this issue of the cost of expert health labor.  In the United States, 56% of health care costs are labor costs. They point to labor saving technologies, telemedicine services, and the high productivity centers in India at which “the hospital uses expensive assets such as cardiac catheterization laboratories at a rate five times that of US hospitals” to achieve a resultant lowering of the labor costs for each procedure with an efficient assembly line approach.  They speak of the need for more “patient self-service” especially in the management of chronic disease.  They do not address the need to treat the whole person; the need to address the fear, isolation, loss of autonomy, possible loss of job, and possible loss of feeling of personal worth that can easily be a part of any illness. 

We continue to try to find solutions to the triple aim but always appear to focus on the costs and to focus on disease as divorced from life.  Until we truly understand and address the issue of illness from the point of view of the person who is sick and from the family who cares about that person, we will miss the boat. 

At Accolade, the company I have had a part in building, we have addressed the labor economics by addressing individual’s issues of life and illness directly.  We have created a new profession of Health Assistant.  The Health Assistant offers expert decision support and expert knowledge of the whole person and their family to help with all the implications of the illness.  Each Health Assistant maintains a focus on the specific needs of that person and family and helps them from their perspective.  They are serving that person and that family and purposely not focusing on the triple aim goals of the health policy experts.  The irony of this focus is that by maintaining the focus on the person as part of a family and community unit, savings are achieved that are greater than in programs that constrain and greater than in programs that attempt to tell people what is best for them. 

Our new profession is in the business of helping the person find his or her own path to health and healing but not in diagnosing and treating disease.  Our innovation is focused on building a skilled work force to focus on the needs of the individual and the family from their reality and their prospective as they access health care while living their lives.