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If the Triple Aim Lost a Leg, Would It Still Stand?

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The Triple Aim is an oft-cited health care mantra frequently invoked by health care’s informed clergy. A recent expensive demonstration project has produced outcomes that suggest one of its legs may be missing in action. It’s not the hoped-for result, but does it necessarily ring the death knell for the Triple Aim?

Don Berwick and the Institute for Healthcare Improvement (IHI) coined the term in 2008 to serve as a pithy aspirational antidote addressing upward spiraling health costs and poor outcomes in the United States. The US ranks first in the spend category—total health care costs as a percent of GDP (17.1 percent). This statistic might not be an issue if our health outcomes matched the ranking. Unfortunately, we also rank 37th in terms of quality care based on key health outcomes for industrialized nations, according to the World Health Organization’s World Health Report 2000.

A Kaiser Health News report has provided preliminary data suggesting that the “cost-reduction leg” may be missing in action.

Thus was conceived the Triple Aim slogan with noble targets:

⇓ Decrease care costs

⇑ Improve health outcomes

 Improve the experience of receiving care

With this triple aim in mind, the Center for Medicare and Medicaid (CMS) funded multiple state and national pilot programs, intended to reorganize the care delivery system. Care coordination and complex care management programs for complex and high-risk individuals were introduced as innovative solutions to address fragmented care delivery and the routine failure by providers to follow evidenced-based clinical practice guidelines.

A good idea that didn’t deliver

A Kaiser Health News report has provided preliminary data suggesting that the “cost-reduction leg” may be missing in action. A $57 million care coordination demonstration program sponsored by the Department of Health and Human Services for high-risk Medicare individuals in more than one hundred communities apparently has not decreased care costs in demonstration programs.

One of the project’s goals was to cut unnecessary hospital visits by providing increased care transition coordination. It did not deliver. Despite best intentions, hospital admissions and emergency room care, as well as overall medical expenses, increased relative to the rate of non-participating entities. The RAND Corporation, an independent monitoring body retained by CMS, has stated the demonstration will not achieve the projected cost savings.

CMS funded medical health homes at community health centers primarily serving the poor. Care managers worked with individuals having chronic conditions, such as diabetes, asthma, chronic obstructive pulmonary disease, and congestive heart failure, to follow their care plans, take medicines as prescribed, eat well, and call the doctor’s office rather than head to the hospital as a first response to a health setback. The primary care doctor served as the captain of the team directing interventions.

Given the less-than-hoped-for financial outcomes resulting in a wobbly health care reform platform, is it already time to look for a new operational design to meet the Triple Aim? Is a Triple Aim even achievable?

Don’t let perfection be the enemy of the good

Important questions to ask, but it might be premature to abandon the Triple Aim’s aspirational destination and its care coordination vehicle. Like most ambitious new undertakings, “failures” often inform the next generation’s success. Further, what if the member clinical outcomes were nevertheless superior to the usual care model, offsetting the increased costs? What if two objectives of the Triple Aim were met, but not three?

Clinical outcomes and member experience of care delivery were also referenced in the Kaiser/RAND outcomes report. For example, attention to mental health issues and subsequent care showed significant improvements in the demonstration practices.

With this in mind, imagine that a hypothetical care coordination program for a population of individuals with Severe Mental Illness (SMI) produced the following results:

⇓ Improved health outcomes

⇓ Higher satisfaction with the health care process

⇑ Increased care costs (commensurate with the improved health outcomes)

Imagine that such a program addressed one of the frequently quoted behavioral health disparity mantras, the “25-year life mortality gap.”[i] This saying references the decreased life expectancy of individuals with SMI conditions compared to the rest of the population due primarily to poor care for chronic co-morbid medical conditions.

Like most ambitious new undertakings, “failures” often inform the next generation’s success.

Imagine individuals with SMI conditions experiencing increased life expectancies, reducing a 25-year gap discrepancy to a 10-year, or better yet, zero-year gap. And, imagine this envisioned program ended up costing affordably more than currently allocated.

Imagine individuals with SMI conditions living longer with greater satisfaction as a result of better care routinely delivered by a smarter health care system.

Would this two-legged stool stand? Might it even start walking on its own?

Hitting two out of three of the Triple Aim would be considered downright amazing. Three for three?

Unimaginably perfect.


[i] Parks, J.,et al. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council.



1 Comment. Leave new

sherrie Bieniek
August 13, 2015 8:15 pm

Well said, Marti, I agree, there are many definitions of success. It goes hand in hand with the question of how we measure value. Thanks!


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