Achieving the Triple Aim:

1. Achieving the Triple Aim: The Simultaneous Pursuit of Population Health Enhanced Individual Care Controlled Costs David Labby MD PhD Medical Director CareOregon Oregon Health Policy Board Presentation May, 2010

2. The Institute for Healthcare Improvement (IHI) • Independent not-for-profit organization helping to lead the improvement of health care throughout the world. • Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action. • First Decade: identification and spread of best practices • The Breakthrough Series Collaborative model. Work was organized around reducing defects and errors in microsystems such as the ED or the ICU.  • Second Decade : focus on innovation, R&D, • Broad-scale Idealized Designprojects, such as the Office Practice and the Medication System • Pursuing Perfection initiative in 2002 with the Robert Wood Johnson Foundation, working with ambitious organizations seeking total transformation of all major care processes.  • 100,000 Lives Campaign and 5 Million Lives Campaign, in which IHI spread best practice changes to thousands of hospitals through the United States, and created a national network for improvement focused on reducing needless deaths and preventing harm from care. • IHI is currently engaged in improvement initiatives in England, Scotland, Ghana, Malawi, and South Africa. www.ihi.org

3. “Triple Aim” Proposed by Berwick and Nolan in 2007 to re-vision healthcare around 3 core values What would it look like if health care were aligned to: The Triple Aim requires the simultaneous pursuit of: Improved health Enhanced experience of care Reduced cost per capita Population Health "Triple Aim" Experience of Care Cost per Capita

4. Potential Triple Aim Outcome Measures 11/09 4

5. Health Adjusted Life Expectancy(HALE) HALE = Product of average life expectancy and % rating their health statusgood or higher • Average Life Expectancy = Average number of years a baby born in a particular year is expected to live if current age-specific mortality trends continue to apply • Self-rated Health Status = Response to the question “How is your general health?” on a 5 pt. scale from poor to excellent Kindig, D. Purchasing Population Health, 1997

6. Triple Aim Initiative Initial Prototyping (Sept ‘07 – April ‘08): 15 Organizations recruited to a Learning Institute Integrated Delivery Systems, Health Plans, Safety Net Organizations, Self Insured Employers, State Agencies What can youdo to accomplish these goals? Define a target population that you can impact What are you trying to accomplish for all three aims? What population oriented intervention are you going to implement? How will you measure impact? Rapid growth to an international collaborative “learning system” of countries with technically advanced medical systems National, International Collaborative Meetings Biweekly conference calls Focused workgroups "Triple Aim"

7. 2007-10 Triple Aim Workgroups *No New Money *Regional Health Improvement Initiatives *Regional Information Technology (IT) *Socially Complex Testing Applying the Triple Aim to a Region Children and Families Population Delivering within a 15% Cost Savings Employed Population Individuals 65+ Population Measurement MEDICAL HOME/PRIMARY CARE REDESIGN PATIENT AND FAMILY EXPERIENCES POPULATION HEALTH MEASUREMENT PREDICTIVE MODELING Prevention & Health Promotion, including Social Marketing R & D - Population Health Measurement Reducing Clinical Variation SPECIALTY WASTE/OPTIMIZATION OF SPECIALTY CARE SUCCESSFUL COALITIONS AND POPULATION HEALTH Institute for Healthcare Improvement technical brief: 90-Day Project Predictive Modeling January 31, 2008 I. Research and Development Team:

8. North American Triple Aim Sites • Health Plans Blue Cross Blue Shield of Michigan (MI) Capital Health Plan (FL) CareOregon (OR) Essence Healthcare (MO) UPMC Health Plan (PA) Independent Health (NY) • Integrated Delivery Systems (w/ Health Plans) Caromont Health System (NC) HealthPartners (MN) Kaiser Permanente, Mid-Atlantic Region (MD) Martin’s Point Health Care (ME) Presbyterian Healthcare (NM) Southcentral Foundation and Alaska Native Medical Center (AK) Vanguard Health System Veterans Health System: • VISN 10—Cincinnati VAMC (OH) • VISN 20—Portland VAMC (OR) • VISN 23—Nebraska, Western Iowa VAMC (NE) Wellstar Health System • Public Health Department Washington DC Department of Health (DC) • Social Services Common Ground (NY) • Integrated Delivery Systems (w/o Health Plans) Allegiance Health (MI) Bellin Health (WI) Bon Secours - St. Francis Health System (SC) Cape Fear Valley (NC) Cascade Healthcare Community, Inc. (OR) Cincinnati Children’s Hospital Medical Center (OH) Erlanger Health System (TN) Fort Healthcare (WI) Genesys Health (MI) (Ascension) • Safety Net Colorado Access (CO) Contra Costa Health Services (CA) Health Improvement Partnership of Santa Cruz County (CA) Nassau Health Care Corporation (NY) North Colorado Health Alliance (CO) Primary Care Coalition Montgomery County (MD) Queens Health Network (NY) • Employers/Businesses QuadGraphics/QuadMed (WI) • Canadian Central East Local Health Integration Network Saskatchewan Ministry of Health British Columbia Team • State Initiative Vermont Blueprint for Health (VT) Last Updated 12/1/09

9. International Triple Aim Sites • Jonkoping (Sweden) • NHS Blackburn With Darwen PCT (NW England) • NHS Bolton PCT (NW England) • NHS Bournemouth and Poole (SW England) • NHS East Lancashire Teaching PCT (NW England) • NHS Eastern and Coastal Kent PCT (South East Coast England) • NHS Forth Valley (Scotland) • NHS Heywood, Middleton and Rochdale PCT (NW England) • NHS North Lancashire Teaching PCT (NW England) • NHS Medway (South East Coast England) • NHS Oldham PCT (NW England) • NHS Salford PCT (NW England) • NHS Somerset PCT (SW England) • NHS Swindon PCT (SW England) • NHS Tayside (Scotland) • NHS Torbay Care Trust (SW England) • NHS Blackpool PCT (NW England) • NHS Bury PCT (NW England) • NHS Central Lancashire PCT (NW England) • NHS Sefton PCT (NW England) • NHS Warrington PCT (NW England) • NHS Western Cheshire PCT (NW England) • NHS Wirral PCT (NW England) • State of South Australia, Ministry of Health (Australia) • Western Health and Social Care Trust (Northern Ireland) Last Updated 10/5/09

10. Drivers of a Low-Value Health System Low Value High Cost Low Quality New Drugs and Tech ≠ Outcomes No mechanism to control cost at the population level Supply- Driven Demand Over- Reliance On Doctors Insignificant role for individuals and families Under- valuing “system” design

11. Key Issues: • Social Determinants of Health • Fragmentation of Health Services • Misalignment of Incentives

12. Determinants of Health and Their Contribution to Premature Death Proportional Contribution to Premature Death Adapted from: McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78-93.

13. Help!

14. MH Home Medical Home Welfare Social Services School Where We Are Today: What’s Wrong With This Picture? Dis - Integration Justice

15. Needed: The “Integrator” It may or may not be a new structure or organization. It pulls together the resources to support a defined population. It builds alliances and coalitions. It optimizes the Triple Aim for the sake of a defined population. It works with and helps to improve micro-systems to support individuals.

16. Initial Triple Aim “Macro-Integrators” Hospital-Based Systems Cincinnati Children’s Hospital Medical Center (OH) Bellin Health (WI) Genesys Health (MI) (Ascension) Integrated Health Systems Group Health (WA) HealthPartners (MN) Health Plans CareOregon (OR) New York-Presbyterian System SelectHealth, LLC (NY) State Initiative Vermont Blueprint for Health (VT) Safety Net CareSouth Carolina (SC) Contra Costa Health Services (CA) North Colorado Health Alliance (CO) Primary Care Coalition Montgomery County (MD) Queens Health Network (NY) International Jönköping (Sweden) Bolton Primary Care Trust (England)

17. Early Triple Aim Examples • Vermont Blue Print for Health: All Payer Community Health Teams • Jonkoping County Council: Health System – School System Collaboration to reduce childhood obesity • Common Ground: Proactive outreach to high risk homeless population • Health Partners: Integrated Medical System/ health plan focused on high quality, cost effective care

18. Triple Aim Model: Micro integratorsCan We Begin with the Individual and Scale Up? Per Capita Cost Population Health • Act with the Individual and Family • Learn for the Population Design and Coordination of Care Individual Experience

19. CareOregon= Starting with the Costliest Members 10% Savings Has $12MM Annual Impact On CareOregon

20. Cost Hospitalizations

21. Bus Pass $23 versus ED $1400 “Member was seen in the ED 21 times in Dec. 2007.” “History of heroin use, transportation barriers to receiving Methadone treatment and from seeing her PCP on a regular basis.” “We bought a bus pass.” “No ED visits for two months and she is much more engaged in CD treatment and her PCP relationship. ”

22. Evaluating Cost per Capita:PMPM Total for CareSupport Enrolled Members Average cost for CareSupport Enrolled Members (N=1991) during the time period of Jan. 1, 2007 and May 31, 2008. Pre-CS = claims paid for 12 months prior to enrollment in CareSupport and Post-CS = claims paid for 12 months following enrollment in CareSupport. • $400/member/mo • $5000/member/yr • $7 Million Program Total • Return on Cost = 4:1 Total PMPM Hospital PMPM

23. Starting a Triple Aim Concept in Norrbotten, Sweden - Life expectancy, mortality- Healthy life expectancy (years gained, including economic assessment)- Health outcomes and behaviours, self reported health, summary of disease burden = to develop Population Health PatientExperience Per Capita Cost • Economic assessment of healthy years gained • Other cost measurementse.g. cost per patient, health expenditure per inhabitant - Population surveys, patient questionnaires, health status e.g. EQ5D Concept Triple Aim Norrbotten

24. Concept Goal and Target Groups • Goal: Lower disease burden caused by overweight and obesity • Target groups:- Children through childrens primary care, dentists and schools- Families through the children- Risk patients through primary care and screening at age 30, together with specialist care- General public through local alliances Concept Triple Aim Norrbotten

25. Parts of the Concept to Be Developed = to develop • Patients and families- see the whole context, especially for the cronically ill and complex patients- jointly planned care based on patients needs- information and knowledge about treatment, including over time- enable patients to manage their own health- learn from the patient and family (to improve) • Definition of primary care- including integration with social care- responsibility for a defined population (economic incentives)- accessability (via e.g teambased care)- coordination with specialist care- health screening at age 30 • Integration- coordination with specialist care - treatment agreements, care plans • Per capita cost- lower total health costs- economic incentives to promote a healthy population • Prevention and health promotion- alliances within and between organizations- private and public sector, NGOs- use project model and PDSA-cycles- work on local level- focus on doing and measuring! Concept Triple Aim Norrbotten

26. Implementation • Use Triple Aim as lever! - Coordinate with and enhance work already in progresse.g. strategy for obesity patients, public health management, the County Political Strategy for Population Health • Build project structure with coordinator from the county council together with coordinator for the municipalities for the local alliances • Select two pilot municipalities/primary care centres to act as PDSA-cycles before county-wide implementation. Concept Triple Aim Norrbotten

27. Largest private printer 11,600 employed $1.8 Billion sales • Created in 1990 as a subsidiary of Quad/Graphics to provide affordable, high-quality healthcare for the 11,000 employees while controlling escalating health care costs • Today employs its own medical staff, operates its own laboratory, pharmacy, fitness and rehabilitation centers, and contracts with local hospitals for specialized and advanced care. • Employees more actively participate in preventive healthcare and spend fewer days in the hospital, at a cost 30% less than the average Wisconsin company.

28. Mercer Consulting Study Quad/Graphics’ healthcare costs are consistently below the benchmark, when adjusted for demographics and benefit design: • 18% below in 1998 • 19% below in 2000 • 17% below in 2002 • 26% below in 2004 • 32% below in 2006 Mercer

29. TA Model and QuadMed • Applying “Lean” principles to primary care to improve provider and patient experience • Leveraging benefit design to improve engagement and population health • Enhancing data and outreach using a disease registry • Achieving accreditation (AAAHC), including as medical home • Integrating specialty care

30. LeanYou! 2008: Marrying Wellness and Benefits • LeanYou! Healthcare Premium Reduction (Employee only) • $2 / week reduction: • Sign up for LeanYou! program • Biennial on-line HRA (“How’s Your Health?”) • Commit to having a LeanYou! health evaluation during the year • $8 / week additional reduction: • Sign tobacco-free attestation • LeanYou! Achievement Award (Employee and Spouse) • Increased cash rewards: $400, $175, $50

31. Patient Experience of Care: “How’s Your Health?” “Care is Perfect” “Exactly the Care Needed”

32. QuadMed Wellness Results * Wellness program employee-repeaters experienced a 2% increase in group health costs vs. a 31% increase among the never-participants

33. Bolton’s Triple AimStory • Oct 2007 Joined as Triple Aim Proof of Concept site • Focus on one area of deprivation – Farnworth • Integrate Public Health and Primary Care • Reduce A and E admissions • 2008 – TA becomes our Mantra • 2008/9 Objectives • Big Bolton Health Check • 2009-2014 Strategic Plan – • Big Bolton Health Debate • 2009 – Triple Aim in Primary Care • Reducing A and E attendance • Improving CVD management • Reducing Speciality Waste (reducing referrals) • Improving prescribing Bolton in Greater Manchester is the 28th most deprived borough in England in terms of numbers of people who are income deprived. A third of the borough's population lives in seven wards which are amongst the 10% most deprived in England.

34. Data – Population Health

35. Farnworth Workstreams Integrate public health and primary care Better knowledge of population Community survey - behaviours Population Stratification, for primary care Parr ++ Cardiovascular screening A&E attendance prevention Aligning investment with deprivation

36. Measuring the Big Bolton Health Check

37. Physician Views of Health System Everyone is looking for a better way… * Respondents asked which statement expresses their overall view of their country’s health system: only minor changes are needed; fundamental changes are needed; system needs to be completely rebuilt. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

38. Triple Aim as Social Movement • Triple Aim is now an international movement of 60+ organizations engaged in health system redesign • All from countries with a high levels of medical technology -- recognize that science / technology itself does not deliver health outcomes • All with different delivery systems… and outcomes… • Creating our “best possible health…” • Howcare is delivered is a major determinant of health, experience, cost, at every level from the bottom up… • Whatis delivered must include much more than medical therapies, addressing social determinants as well… • Whodrives change critically determines how effectively any system truly meets the wants and needs of those it is meant to serve.

39. What Creates Value in Health Care? • New Triple Aim Paradigm: Health systems are accountable for population outcomes • “System design” recognized as a determinant of health • Value is created by “systems of care” with appropriate expertise • New emphasis on patient engagement, patient driven care • “Quality” redefined as best possible “medical service” delivery AND best possible health and cost outcomes

40. Triple Aim Moving Forward • “Regional” Triple Aim Initiatives • Bending the cost curve • Integration Medical and Social Services • Realignment of incentives: ACOs? • Regional Triple Aim Collaboratives? • Multiple Triple Aim efforts within a region • Local “learning systems”

41. Stages of Facing Reality • “The data are wrong” • “The data are right, but it’s not a problem” • “The data are right; it is a problem; but it is not my problem.” • “I accept the burden of improvement”