Monday, August 11, 2014

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way – Part 1

In May 2008, Donald Berwick and his colleagues wrote about the triple aim of the US health care system.  They wrote, “Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing the per capita costs of health care.”  Today that triple aim remains the goal of those of us in the trenches trying to improve care and access for all Americans.  This is difficult and some would say impossible without real constraints on individual’s decision making.  In that same article, the authors say “Pursuit of the Triple Aim is an exercise in balance and will be subject to specified policy constraints, such as decisions about how much to spend on health care or what coverage to provide and to whom.”   For Berwick and his colleagues, the most important of the constraints is “the promise of equity; the gain in health in one subpopulation ought not to be achieved at the expense of another subpopulation.”  While I agree with that statement I do not consider it the most important constraint.  For me, the most important constraint is that the pursuit of the triple aim must never compromise the individual’s right, working with the health professional, to obtain care in a way that matches their values and their goals. 

I say that because in my thirty years trying to impact this difficult equation, I have seen many well-meaning, and intellectually elegant solutions, that pass the “equity” test however they fail in maintaining individual autonomy and dignity in a way that fosters trust which is a necessary precursor for the best care. 

Ultimately, the value of care, which is inherent in “improving the experience of care” which is the first of the Triple Aim, must be in the eyes of the patient and their family.  If good individual decisions are made by patients and doctors working together the population’s health in aggregate will improve and costs will lower.  We first have to acknowledge, that the Triple Aim as addressed in our society thus far, has focused more on reducing the per capita costs of health care than either of the other two goals as defined.  Lowering costs is extremely important as that allows more people more access to care and best allows for the equity in the system that Dr. Berwick speaks of. 

My starting equation to achieve the cost aim of the Triple Aim is:

Total Population Costs = Volume of Services X Unit Cost of Service

However, I have tried to develop answers and approaches that give equal, if not more importance to the aims of improving the experience of care and improving the health of the population.  That requires obeying the following rules:

  1. Maintaining trust between health professionals, patients and families must always be paramount.  Any system that impairs, in any way the trust relationships will make policy solutions unsuccessful.  Ultimately, medical care involves a person putting their life in the hands of another and trust is a necessary pre-requisite.
  2. Never lower volume of services across all services, but rather lower unnecessary services.  In other words, lowering health care cost should focus on the cost of avoidable unnecessary care, rather than total cost and care.  While this may seem obvious, our solutions today often take the view that all health care cost is bad. 
  3. In order to lower unnecessary services, always understand the real needs of the individual and find the necessary services that best address those needs from their point of view. These are often not related to biology but to emotions, culture, family, finances, time constraints, and competing life requirements. 
  4. Do not lower unit costs by devaluing the contribution of trained professionals.  Trying to pay physicians less per service often leads to less personalized, more hurried care, which impairs trust and careful evaluation. 
  5. Instead lower unit costs by having the right professionals, working in the right collaborative environment maximize the talent needed for the individual’s issues.  For many problems, for example, that may mean a social worker instead of a physician, or it may mean a community health aid instead of a social worker. 
  6. As we optimize unit costs by using the right professional at the right time, never allow any person in need to feel as though they are being “handed off” and always foster the type of coordination and trust that continuously communicates that the patient’s needs and values are paramount. 


In future blog posts, I will attempt to talk about how to potentially succeed at this three dimensional chess game but will also acknowledge that this is no game.  This is people’s lives and families and thus any answers need to be implemented carefully and with study.  My own belief is that as strive for the Triple Aim, as long as we measure everything we do, against the primary “constraint” of maintaining and fostering individuals’ dignity and autonomy, we will succeed.