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Let's Talk About Triple Aim


The Triple Aim has created immense pressure to integrate the care we provide into the larger healthcare system, at great cost to our practice.

If you are going to MGMA16 at the end of October in San Francisco, please join Leann and other primary-care management leaders as they discuss the influence of Triple Aim on the delivery of care.

Coined in 2008 by the Institute for Healthcare Improvement, "Triple Aim" quickly moved from industry jargon to an accepted societal goal as hospitals, large physician networks, payers, and even the public at large adopted its easy-to-understand concept. Of course, we all thought we should be able to balance and achieve the three main objectives of modern healthcare, namely:

1. Have a positive individual experience of care;

2. Improve the health of our entire population; and

3. Meet those objectives while keeping cost at an absolute minimum.

As most of you know, however, the reality of achieving the Triple Aim objective has been challenging.

The greatest impact of Triple Aim on our practice over the past eight years has been the immense pressure to integrate the primary care we provide into the larger healthcare system which is dominated by hospitals, payers, and pharmaceutical companies. While many of our colleagues have felt pressure to abandon private practice for hospital-based groups, we have been able to retain some independence by joining an independent physicians' association (IPA). At first we loved our IPA, but currently the relationship is challenging. Ten years ago when we first joined the IPA was 100 percent our champion, playing quite well the role of the physician's professional union placing collective bargaining pressure on payers. Over the years, however, under the pressure of Triple Aim, the IPA has had to concede to hospital needs ahead of independent primary-care docs in order to meet new, integrated payment models. These days, we think of our IPA more like a mob boss who, as long as we pay our "protection money," allows us to stay in the practice we've built and that our patients love.

Although we're joking a bit, we do think it's critical that we talk about the "protection money." Our payer reimbursement is tied to impossible-to-reach "quality goals," while we are paying literal cash money for technology that we can't really afford. In May of 2015, we wrote about our struggle with meeting quantifiable, and yet utterly meaningless, "quality" measures. And, believe it or not, we're one of the best performing practices in the IPA!

The real problem currently, however, is paying for technology. Last year our IPA mandated that in order to stay in the IPA all practices had to switch to a common EHR system. Although we joined with colleagues in the IPA to try to persuade the decision makers to not go through with the mandate, in the end we lost, and are now paying three times as much for a new system that we don't believe will move us any closer to the goals of Triple Aim.

Implementing new health insurance plans and better technology, which is supposed to make healthcare more efficient, is actually having the opposite effect. High-deductible plans designed to keep patients out of the doctor's office unnecessarily is, more often than not, keeping out patients who could benefit from low-cost, early intervention. As we've written about before, the high-deductible plans are keeping middle-class families out of our office which means we have overall less revenue to offset the low fees generated from Medicaid patients. For us, this has meant lowering the number of low-income patients we are willing to see. Our experience is consistent with national trends of Medicaid patients having limited access to care.

Many have been speaking lately about adding a so-called "fourth aim" - physicians' professional satisfaction. It is no secret that the push toward integration and Triple Aim is burning out U.S. physicians. Eight years in, Triple Aim is still touted as our collective goal, and yet, from our perspective, we are still missing a critical piece of the puzzle. That piece today is the same piece Dr. Donald Berwick wrote about in Health Affairs when he launched Triple Aim eight years ago: single payer. Dr. Berwick wrote in that article, "The remaining barriers to integrated care are not technical; they are political." Don't we know it.

*What do you think? Please comment below or, better yet, join us at MGMA16, the Specialty Hot Topics Roundtables, on Monday, Oct. 31, at 3:45 pm.

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