ADVERTISEMENT
Modify the “Triple Aim” Framework to Fit Behavioral Healthcare
Few ideas for improving healthcare delivery have had as wide an impact as the “triple aim” framework. Don Berwick’s IHI team proposed in 2008 that we should simultaneously pursue 3 key dimensions for improvement: care experience, population health, and per capita costs. The model has been embraced for improving many systems of care.
The idea of pursuing simultaneous change may be the key insight. Interdependent aims are meant to be pursued in a balanced way. It is a multidimensional, yet cohesive, goal-driven approach applicable to all healthcare fields. However, the specific dimensions prioritized may not be universal. In fact, they are not a good fit for behavioral healthcare. Our top priorities for change are different.
While Berwick’s 3 aims surely are meaningful for behavioral healthcare, they are not the central struggles our field must surmount to improve. This might be expected since our field has been on a separate track from the rest of healthcare for most of its existence. The triple aim framework needs some modifications to address our field’s unique characteristics.
The Triple Aim of Behavioral Healthcare
The top priority for our field is improving access to care. People with advanced substance use and mental disorders have poor access rates, and our early detection and intervention efforts are paltry. Our field has been challenged in this domain by stigma, inadequate funding, and the absence of biological markers for screening. Little else matters when access is so deficient.
While the triple aim’s focus on population health may be broadly applicable, it is too ambitious as a top-tier goal for our field. General healthcare has long had solid metrics for monitoring health and performance. Our field has never committed to measurement-based care (MBC), and this is a prerequisite for tracking population health. Our priority must first be the broad adoption of MBC.
Healthcare costs warrant inclusion in our third aim, but they should be part of a more complex quality indicator. We need not focus on cost reduction like many other areas of healthcare. Indeed, we will need greater spending to fix our access problems. Also, our costs are too often valued for reducing other healthcare costs (i.e., medical cost offset) or for bringing economic value to investors (i.e., ROI).
Our costs reap good clinical results. It is time to stop asking for cost justifications beyond this. The ACA in 2010 set the stage for this by declaring our services “essential” on their own. Our costs should be tracked as part of improving the value of our services. We need an internally focused value metric, one that integrates cost and outcome. Our value is not primarily derived from producing external benefits.
Value is most often discussed today in connection with value-based care, a model that ultimately seeks to fund and manage our services in concert with other healthcare services. While this has advantages, it could distract us from the primary value of behavioral care and shift focus to our secondary impact on other health issues. We must stay rooted in our costs and outcomes—that is, the value of our work.
A Cohesive Goal for Our Field
Berwick’s triple aim model seeks to avoid pursuing one goal at the expense of another. Changes in 3 domains are monitored as a cohesive single goal. This makes sense for our field as well. In the simplest terms, our field should ensure consumers can find easy access to affordable, high-quality care. This embraces all 3 of our core dimensions in 1 realistic, patient-centered objective.
Goals require measurement. Straightforward calculations for our access and MBC goals stand in contrast to a more complex formula for value. Yet calculating value in healthcare is not new. It was a focus for economists long before value became virtually synonymous with value-based care.
A seminal 2004 paper in Harvard Business Review argued that competition among health systems should focus on improving value rather than reducing costs:
The right goal is to improve value (quality of health outcomes per dollar expended), and value can only be measured at the disease and treatment level. (p. 67)
Value is dependent on knowing health outcomes, and in our field, this will only be possible when MBC is routine. At that point, our cohesive, triple aim goal becomes synergistic and powerful. We can monitor access, outcome, and value for behavioral health systems and reward the best for their performance.
Our field needs its own objectives, not aims imported from medical care. Nonetheless, integration with healthcare is potentially revitalizing. We have much to offer. For example, patients with chronic medical conditions need help with behavior change. Yet our goals should be tied to our current realities, and medical integration might be one way to accelerate pursuit of our triple aim.
We must develop an index number for value that facilitates comparisons of programs and services. This value index, based on a ratio of outcome and cost, is the final metric for a cohesive triple aim. My next article will describe such an index.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, Addiction Professional, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
References
