Dr. Berwick's vision

The closing keynote address at the conference was given by Don Berwick, President and CEO of the Institute for Healthcare Improvement. It was entitled Health Care Leaders and the “Triple Aim”. It’s risky to summarize a Berwick talk because it is always well constructed and elegant. I’ll take a chance with a few highlights.

His focus was on what’s left to do, rather than what’s already been done. There’s a lot to be done. There is a big gap between what we have and what we could have. Looking at what is spent in the US on health care, we see that we spend a lot, and we do not get our money’s worth -- either in terms of access or results. We need to grapple with the fact that we have a low value system.

It is also a system characterized by extreme variation in spending, over $3000 per capita in Medicare spending between the lowest quintile and highest quintile parts of the country. There is no positive correlation between spending and results. In fact, it is a negative correlation. In other words, this is $3000 of negative return.

We don’t have one big problem here. We have two, and this requires a sophisticated and parsed solution with two separate paths.

One path is about getting better care when you are sick. This is based on achieving the following dimensions of excellence when you are sick and need care: Safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. This is done by designing better processes and deploying them.

The second problem has to do with the drivers of the low value system. On the high cost side, this derives from the constant entry of new technology, drugs, and the like without documented relationships to outcomes; no mechanism to control costs; and supply-driven demand. On the low-quality side, it comes from over-reliance on doctors for things that non-doctors can do; no foreign competition; and undervaluing system knowledge.

Berwick’s approach to this is defined as the “Triple Aim”: Improve the experience of care + raise the level of the health status of the population + control the per capita cost. He states that the root of the problem is that the business models of almost all health care organizations depend on keeping these aims separate. Berwick proposes a system that will focus on individuals and families; offers strong primary care services; provides population health management; imposes a cost control platform (i.e., a strict population budget); and enforces system integration to make this all happen.