12 Steps to the Triple Aim or Value Based Healthcare

by Gregg A. Masters, MPH

It has been challenging at times being in the ‘innovation conversation’ dating back to the 70s (who remembers ‘WIN’ [whip inflation now], PSROs or even HSAs (no, not the privatization funding mechanism, but the CON overlords) watching what get’s reported by industry press or online media as ‘innovation‘ or ‘bold new thinking‘ amidst a ‘cottage industry’s’ 3x trillion spend rate – including it’s culpable supply chain and many vendors (some may even say ‘pigs’) at the trough.

As indicia of the impending collapse of our aging house of cards healthcare delivery and financing industry (continued burnout rates driving physician exits to direct practice or concierge medicine, un-ending and nauseating opposition to the ACA, mega and no so mega hospital mergers, associated practice acquisitions and health plan consolidation, not to mention the codification of the cost shift charade via the lower metals designations of the ACA and including armies of dissatisfied patients suffering in a provider centric culture) continues to accumulate, it affirms what Esther Dyson once presciently characterized as the ‘calcified hairball‘ given it’s ‘resistance is futile’ [to change] nature.

Healthcare Inflation

Recent healthcare inflation moderation trends notwithstanding (see: ‘2014 National Health Spending; The Great Moderation Likely Not Over‘ by healthcare futurist Jeff Goldsmith) whether a function of ACA implementation in part of as a whole, the industry has essentially and collectively failed to deliver on the principles of the triple aim – which existed in spirit considerably before it’s labeling by the Institute for Healthcare Improvement (IHI). Providers continue to maximize their profits or ‘excess revenues over expenses’ for the ‘non-profit’ [aka tax exempt’ sector] often at the expense of community benefit.

Perhaps no other chart series in line item detail captures and evidences this slow burn of fail as the progressive and relentless growth of one man’s healthcare premiums in California. Take note of the persistent [cost] shift from the payer (health plan) to the patient or beneficiary.  If this is the best we can do via ‘wholesale purchasers’ (market savvy health plans) leveraging millions of members and ‘medical management’ and network contracting infrastructure, how can an army of independent and often clueless if not dis-empowered agents (patients, members sometimes at the point of service) do better?

[Editor’s note: one reason for an earlier post on the need for a ‘new IPA’ i.e., independent patient association]

This testimony was provided by Josh Libresco to the Department of Managed Care in California during their consideration of rate hikes by health plans.

Time for a New Manifesto?

With this history as both context and some may say ‘institutional memory’, I thought I might make sense to take heed of what’s become rather well known in the 12 step recovery community (from AA to Al-anon and many derivatives) which is to admit our ‘addiction’ to the arguably ‘easier softer path’, i.e., fee for services medicine.

Perhaps this can be a manifesto of sorts to embrace as we embark upon this journey for volume to value based healthcare?

Adapted from the 12 Steps of Alcoholics Anonymous

1. We admitted we were powerless over our addiction to fee-for-services medicine – that our healthcare delivery and financing model had become unmanageable.

2. We came to believe that power greater than ‘do more to earn more’ incentives (global capitation) could restore us to sanity and move the needle on the triple aim.

3. Recognizing the finite nature of our healthcare resources we made a decision to dedicate our will and our professional lives to the pursuit of the triple aim and its associated sustainable healthcare economy.

4. We made a searching and fearless moral inventory of our contributions to a seemingly ‘resistance is futile’ healthcare borg.

5. We admitted in our silo-ed huddles and to one another the aggregate nature of our [well intended, though] collective wrongs.

6. We were entirely ready to have a calling to the ‘greater good’ that transforms a profit maximization – at any expense- operating culture.

7. We humbly asked our ‘higher power’ for faith in a value based healthcare economy and for the support to let go of the fee for services addiction.

8. We made a list of all patients, payers, or employers we had harmed, and became willing to make amends to them all.

9. We made direct amends to such stakeholders wherever possible, except when to do so would injure them, others or our ability to facilitate the journey from volume to value.

10. We continued to take personal inventory and when we felt the temptation to default to legacy inertia – promptly admitted it.

11. We sought through mindfulness, meditation and collaboration to improve our vision and practice of value based healthcare, sharing openly for the knowledge, capacity and willingness to deliver on this historically elusive goal.

12. Having had a professional – if not spiritual – awakening as the result of these steps, we tried to carry this message to one another and practice these principles in all our affairs.