Sunday, January 6, 2013

The Crosshairs of a Triple Aim

“Better Care for Individuals, Better Health for Populations, and Lower Per Capita Costs” []

If you stop to think about the holy grail of health care reform, also known as the Triple Aim, it sounds like a grand challenge involving wizardry or wishful thinking or worse, propaganda for the masses, particularly the last part. It’s like attempting to build a better driving machine, with better fuel efficiency at lower cost. Or maybe it’s like trying to make a chocolate cake that is most scrumptious, quicker to prepare and has very few calories. Yeah, right…. You can have one of the three, and maybe two, but certainly not all three. Not that there is anything wrong with trying…. And when it comes to health care it is actually imperative that we try, and failing will have dire consequences for all but the very few who are always shielded from consequences.

The Institute for Health Improvement (IHI) who introduced the Triple Aim philosophy, now adopted by the government, is also proposing a methodology for achieving this, larger than the moon landing, challenge.  The IHI will be having a seminar this spring, where those engaged in achieving the Triple Aim will presumably share success stories and strategies with those interested in doing the same.  IHI believes this learning event is “ideal” for folks working for insurers, employers, government, integrated health systems and other businesses and organizations. Individuals, populations and their doctors don’t seem to be part of the IHI target market. It seems that IHI believes that the Triple Aim of research institutions should be achieved by corporations, for the people of this country and the world in general. It also seems that this particular view is shared by our government, who is feverishly pushing for the creation of corporate health care entities (a.k.a.  ACO), and, patient-centered rhetoric notwithstanding, is largely ignoring doctors and their patients, who are assigned to care corporations sometimes unbeknownst to them.

In addition to a slew of financial incentives/disincentives, Health Information Technology (HIT) is one of the most powerful levers applied to the system in order to change its fabric from a multitude of small and varied health care establishments to a unified landscape of large standardized health services entities, which as IHI, and obviously all other “decision makers”, “thought leaders”, etc., believe are best suited to build a system for achieving the Triple Aim in an orderly and measurable fashion. A health care system as opposed to a sick care system; a system where populations get all their shots and screenings for every imaginable disease, carefully tabulated and monitored to show progress, and a system where care for the sick is optimized for “value” to the IHI “ideal” stakeholders; a system that requires massive computation power to constantly drive costs down by feeding millions of digital histories of people to complex algorithms; a sophisticated supply chain system that replaces continuity of care with electronic coordination of services, and generally keeps the proverbial trains running on time; a system powered by billions of dollars of computers, software and IT guys.

And here is where the “official” strategy gets really weird, wasteful, and luckily for all of us individuals, populations, and our doctors, it also contains the seeds of its own eventual demise. How so? Big business will always be saddled with expenditures on big technology, which is useless for small business, but technology has its own way of growing and advancing, independent of political whims, and independent of governmental master planners. Technology today is on a path to ever shrinking size (and price) and ever growing power, and as such it has morphed itself into a tool that truly empowers individuals and small business because those much maligned programmers, who don’t know anything about health care, are expert at building cool things for people and are some of the most nonconformist and visionary out-of-the-box inventors around. And they are now coming to health care seeking fame and fortune.  But we have to give them time and we have to do our part in this dreadful game of world domination.

If you are a primary care physician in private practice, here are some things to keep in mind:
  • Don’t buy technology that does not serve your patients and does not serve your business. Don’t be tempted by incentives and don’t be afraid of penalties. If you collect say, $500,000 per year and 40% of that is Medicare, a 1% penalty amounts to $2,000 per year or $40 per week. Even if all your billings are Medicare, this still amounts to only $100 per week. Would you buy a stethoscope outfitted with sharp little nail heads (to improve the grip), if someone threatened to charge you $8 a day for using your old stethoscope? Would you hire an assistant to hold the prickly stethoscope for you and a steel worker to sharpen the nail heads periodically, just so you are in compliance with Prickly Use?
  • Do buy technology that serves you and your patients. If you are convinced that a particular EMR will help you provide better care and make your work more efficient, then by all means, go for it. Make sure you understand the total cost of ownership over the next five years or so, and make sure you’re not buying the cow just to get a glass of milk. If all you want is to store your paper charts in a computer, you don’t need a certified EMR. If you just want to communicate electronically with patients and business partners, including labs & pharmacies, you don’t need a certified EMR. If you want to track your chronically ill patients and make sure all are taken care of, you still don’t need a certified EMR. You do need a certified EMR if your patients routinely end up at the ER unconscious, alone and naked, halfway across the country, which seems to be the preferred use-case of those who build “infrastructure” for health care.
  • Today’s technology renders physical location and business affiliation irrelevant to in-person collaboration. You should explore using some of this technology, and much of it is nearly free. A three-way video call with a home-bound patient, a neurosurgeon and you is as simple and cost effective as sending a fax. Heck, you can even conduct the entire thing on your mobile phone while on vacation somewhere nice and warm. This is not a futuristic “tricorder instead of doctor” type of thing. This is an example of real and tangible benefit you, and your patients, can derive from technology this afternoon.
  • Selling your practice to a hospital system because the “business” is too complex and because technology is too expensive (and because you’re scared) is most likely something you will live to regret, bitterly in some cases. Consolidation of health systems is not driven by a desire to achieve the Triple Aim. It is happening in defensive reaction to it, particularly the part about lower costs. You are not being courted (or pressured) because you are a great doctor. The coveted asset is your client list, which once integrated into the massive computerized system of the hospital, renders you irrelevant. There are cheaper ways of providing services in a system not designed for sick care than employing a physician, and those will eventually be put in place, because technology is like nuclear power: it can be used to do a lot of good things, but it can also be used for pure destruction.
  • Look around you. Most people in this country are hurting financially. Way more than you do. People are cutting down on food. Do you think you can cut down on inefficiencies inherent in most practices? Do you think you can use cheap or even free technology tools to accomplish that? Do you know what’s available out there? Are you way too busy seeing patients, and cannot be bothered with details? Instead of hiring accounting firms to valuate your business and lawyers to make believe that you are actually “negotiating” with the hospital, how about hiring a bright business consultant specializing in turning bloated small businesses into lean and mean survivors? We all know that there is a shortage of primary care physicians, which is projected to get much worse over the next couple of decades. If you owned a little gold mine, and the markets projected a shortage of gold lasting well beyond your life expectancy, would you sell your small enterprise to the Newmont Mining Corporation for next to nothing, because upgrading mining equipment is too complicated and way too irritating for your lifestyle? 
  • Stand up and step forward. Keeping your head down and hoping that this too shall pass is not going to work this time around. You have more power than you realize. Speak up, and use technology to make your voice heard. If you are one of those business savvy physicians who figured out how to maintain a sustainable private practice, share your knowledge. Teach. Start a blog. Build a community. Publish a paper. Write a case study (or let me know and I’ll write it for you... ). Every time an independent practice gets swallowed by a system, and every time another physician is forced to abandon his or her patients at the hospital door, something is taken away, from you personally, and from the people you wanted to help when you chose this profession. Your silence is harmful to your patients.
If you are a patient or think that someday you may need to be a patient, consider this:

When you find yourself in a strange room, partially covered by a large paper towel, and otherwise completely naked, contemplating the upcoming prodding of your most private body parts by shiny instruments and strange hands, what do you want to know most about the person about to enter the room? Would you feel better knowing that the stranger turning the knob on that door has an iPhone compatible website for you to peruse from the comfort of your cubicle at work? Would you feel safer knowing that he or she has financial responsibilities and commitments to a faceless corporate office for which your naked body is just a line item on the balance sheet, perhaps a socially responsible balance sheet, but a balance sheet nevertheless?  If it’s your small child under that paper towel, would you be comforted knowing that this person’s prime directive is to minimize your child’s “per capita” cost (not price) of care? And when you’re done making imaginary deals with your God or the devil, would you experience great relief knowing that the doctor walking into the room now is not really “your” doctor, but the shepherd of “populations” and the averter of deficits and fiscal cliffs?

Don’t answer these questions now, or right after you finish your morning run. Answer them when you are actually sitting in that room because Google said that the pesky little thing you found last week is most likely nothing serious, or of mild concern, or a cancer that will kill you in a year or two. Depending on your answers, you may want to seek out an independent physician for your next appointment, because the opposite of “independent” may be hazardous to your health.

The IHI concludes the promotional blurb for its Triple Aim seminar by proudly stating that these seminars were attended by “senior leaders, vice presidents or directors” in the past, and although individuals are welcome, ”experience has shown that Triple Aim implementation is dependent on the collaborative effort of leaders and strong program involvement”, so according to the IHI "leaders", if you’re not a corporation or powerful enough organization, don’t waste your time (and $1,975) and don't worry your little head about it, because individual people cannot make a difference in health care.
It’s probably high time that we took some triplicate aims of our own, don’t you think?


  1. Margalit, you are on a roll. And you're right -- until doctors reassert control of medicine in a Guild-Like way, we are completely sunk. Yes, as Makary points out, accountability is key. This begs the question "Accountable to whom?" Makary seems to think the answer is "to hospitals" -- if hospitals were controlled by doctors and operated as a kind of Guild Asset, he might have a point. As it is...

    Happy New Year.

    1. Howdy Tom,
      Happy New Year to you too! We are sunk... :-)

  2. Replies
    1. I haven't decided yet... I don't do well with big crowds in general :-)

  3. On deck this month, there are four "critical" vulnerabilities that affect Windows, Internet Explorer, Office, and Windows Server, including one for Silverlight that affects both Windows and Mac machines.