Fatal Flaws in the American Healthcare System: Policy Analysis of the Triple Aim

Executive Summary

American healthcare is currently focused on the actualization of a policy known as the Triple Aim. This initiative is concerned with improving the health of communities and patient perception of care, as well as reducing the cost of healthcare. However, these goals will never be achieved due to an increased burden on providers. As an alternative to the Triple Aim, the Quadruple Aim has been introduced. It includes a fourth tenet that considers the well being of healthcare providers and what employers and legislators can do to enhance the careers of providers. The Quadruple Aim recognizes that providers need to be at their best in order to provide the best quality care to their patients, and that there are a number of legislative initiatives that can help with the realization of the improvement of healthcare in America.

Background

There are problems in the American medical system that create an environment that is dangerous for both providers and patients. Hospitals are run as a business, and an infatuation with profit on the part of CEOs and administrators has caused healthcare providers, particularly nurses and physicians, to be overworked. When providers are given too much responsibility and not enough resources, preventable deaths occur. These overburdened providers are also the victims of this fatal flaw of the American healthcare system. These problems can only be fixed by focusing on the expectations and workplace of health care providers.

Burnout: Nurses and physicians accompany patients through the most difficult parts of their lives. They are the victims of violence, the bearers of devastating news, and the witnesses to the most tragic aspects of human existence. Since the 1980s, the psychological impact of this unique role in society has been called “burnout”, the “combination of emotional exhaustion, depersonalization, and low personal accomplishment caused by the chronic stress of medical practice,” (2). Burnout has both professional and personal consequences, meaning that the lives of patients and physicians can be negatively impacted by this emotional exhaustion. The aspect of burnout that contributes the most to these negative consequences is emotional exhaustion, which occurs when the provider’s emotional resources are depleted (3).

Healthcare providers are certainly the witnesses to events that are wildly outside the range of the typical human experience. Even highly trained medical professionals can be traumatized by what they see during their work. This trauma can lead to the development of post-traumatic stress disorder (PTSD), which is defined as “the pathologic state of persistently re-experiencing a traumatic event causing distress and functional impairment;” the prevalence of PTSD is 15% higher amongst surgeons than the general population and even higher amongst trauma surgeons (6). In addition to exposure to traumatic events, these surgeons with PTSD reported working in less than favorable conditions, including a lack of support, overwhelming professional responsibilities, bad outcomes, and inadequate work-life balance (6). The existence of this mental health disorder amongst valuable providers increases the cost of healthcare and inhibits the improvement of outcomes and patient experiences.

Physicians: In 2019, 21,622 students began medical school in the United States (7). In 2023, these students will begin residencies in surgery, pediatrics, radiology, family medicine, orthopedics, or any one of the many options that physicians have for their specialty training. In residency and beyond, these doctors will face challenges that are unique to the profession; burnout, PTSD, depression, and suicide. Among male physicians, the suicide rate is 40% higher than the general male population; among female physicians, the suicide rate is a staggering 130% higher (3). The consequences of suicide are obvious, but the implications of physician burnout, and the work environment that leads to burnout, are less so, and will be explored in this policy analysis.

Nurses: Bedside nurses in the hospital are also the victims of hostile work environments. Unlike physicians, nurses are responsible for the continual observation and care of patients. Their many responsibilities include continual assessments and reassessments, as well as the administration of medications and many procedures. In addition to these responsibilities, nurses are now responsible for hours of charting on electronic health record systems. These conditions are infringing upon the opportunities that nurses have to provide real care. The repeated trauma of being forced to provide inadequate care for patients has led to an increase in suicide amongst nurses. In England, the suicide rate of female nurses is 24% higher than the average female rate (8). A study has not been done in the United States on nurse suicide rates since 1990 (9).

Patients: The final group at risk due to problems with the American healthcare system are the patients. The Triple Aim has placed an emphasis on improving patient satisfaction as well as objective health outcomes. Regarding the former, a study at Virginia Commonwealth University found that patients who encountered physicians who were high in the depersonalization aspect of burnout reported lower satisfaction with their care, and even had a longer recovery time after discharge (1). With concern to improvements in objective health outcomes, one fairly straightforward metric by which this can be measured is survival following in-hospital cardiac arrest. An increase in nurse staffing has been shown to increase survival in this situation; witnessed cardiac arrests are twice as likely to survive to discharge, while chances of survival decrease by 5% with each additional patient per nurse (11).

The impact of burnout on patients include a decrease in quality of care, an increase in medical errors, and a decrease in patient satisfaction- which is in direct conflict with the goals of the Triple Aim (3). The cost of healthcare is increased due to medical errors and patients receiving unnecessary medications, which are prescribed more often by providers experiencing burnout (3).

Existing Policy Environment

Triple Aim: In 2007, the Institute for Healthcare Improvement (IHI) developed the framework for an initiative known as the Triple Aim (12). The ultimate goal of this initiative was to improve healthcare in the United States by integrating three separate goals: (1) improved patient experience, (2) reduced cost, and (3) improved population health (12). The problems with healthcare in the United States are easy to summarize with one statement: healthcare outcomes are no better than in any other country, yet the cost of the system is more than twice that of any other country (13). The most radical aspect of the IHI’s Triple Aim program is that it requires all three foci of improvement to be approached together.

In order to determine the success of the Triple Aim, outcomes must be measured. This can be done by organizations such as The Joint Commission and/or by centers of research at academic healthcare settings (14). Some of the indicators used to measure the success of the Triple Aim are the prevalence of evidence-based care, patient education, community outreach, access to primary care, level of communication among providers, shared treatment plans, the use of information technology, the reduction of waste, coordination of care, and the effective use of resources (15).

In his article, Berwick states, “the Holy Grail of universal coverage may remain out of reach unless we can reduce per capita costs,” (13). This statement suggests that some see the Triple Aim as the pathway to universal healthcare coverage. His article, however, makes no mention of the role of insurance agencies in the astronomical costs of the United States healthcare system, and appears to not even believe that these companies play a role. This leaves the burden of change on the hospitals rather than the insurance companies or the government- a wholly inefficient route.

An important feature of the Triple Aim is the integrator, which is an organization or company responsible for achieving all aspects of the Triple Aim (13). The integrator would bear similarities to the original concept of health maintenance organizations (HMOs) developed by insurance companies. A more successful example of an integrator is the Kaiser Permanente healthcare system in California. One purpose of the integrator would be to reduce costs by eliminating extraneous procedures, tests, visits, and eradicating medical errors and the use of unscientific data when treating patients (13). It is unclear what the ideal integrator consists of, and what authority it should have over the practice of healthcare providers.

A study on the feasibility of Triple Aim implementation at 23 residency programs found that focusing on multiple areas of improvement simultaneously is difficult (14). There were also barriers to data collection despite an effective electronic health record. However, the study did demonstrate the value of leadership involvement and strategic planning in quality improvement (14). The need for the integration of local goals was also noted, which may emphasize the reality that the Triple Aim may be seen as a one size fits all approach to healthcare improvement.

States with Nurse Staffing Laws: California became the first state to pass a law mandating nurse to patient ratios in 1999 (17). Assembly Bill No. 394, part of California’s Health and Safety Code, was inspired by a concern for patient safety (California Legislature, 1999). The potential effect of increased nurse staffing is obvious, as nurses are the only members of the healthcare team who are constantly with the patient. Another potential factor that contributed to the passing of this California law is the reduction of costs to the hospital that may come with decreased adverse events related to nursing care. Since the enactment of this law, outcomes such as “fail to rescue” after a cardiac event have improved (18).

Massachusetts has also tried to implement mandatory nurse to patient ratios. In 2014, HPC Regulation 958 CMR 8.00 mandated that intensive care units in acute care hospitals staff with no more than one or two patients per registered nurse, dependent upon patient acuity (20). In the 2018 election, Question 1 on the Massachusetts ballot sought to expand nurse staffing mandates to other types of units. This referendum failed, which was seen as a success by the American Nurses Association but not by many nurses (21).

The International Council of Nurses (ICN) released a position statement in 2009 on the benefits of appropriate nurse staffing. These include a reduction in costs, improved outcomes, fewer adverse events, and enhanced patient experience (23). Unlike other attempts by organizations to achieve the Triple Aim, the ICN also recognized that appropriate nurse staffing could improve the health and wellbeing of nurses. It is also one of the few suggestions that calls for an increase in resources rather than an absolute decrease- an increase in nurse staffing should be seen as an investment in better patient outcomes and eventually a reduction in costs due to fewer medical errors and adverse events.

Obviously, only one state has actually enacted comprehensive nurse staffing laws. Research on the impact of these laws has shown positive results, suggesting that such mandates should be more widespread, and perhaps even enacted on a national level. However, no research appears to have been done on the impact of these laws on the well-being and job satisfaction of nurses. Coupled with the position of the ANA as anti-regulation, this suggests that the well-being of nurses is not a priority of healthcare administrators. An investment in nurse safety, mental health, and professional development is the necessary approach in order to achieve the goals of the Triple Aim.

AAMC Resident Work Hour Limits: Historically, medical residents would stay at the hospital 24/7 in order to learn how to become a competent physician- endless work days and long periods without sleep were thought to be essential components of medical resident training. Eventually, the Accreditation Council for Graduate Medical Education (ACGME) realized that such long work hours led to burnout and depression among medical residents (25). In response, the ACGME implemented regulations on resident duty hour limits in 2011. These limits include working no more than eighty hours a week and working no more than 24 hours in a row (25).

Despite these improvements, medical residents are still sleep deprived and socially isolated, leaving patients at risk of harm and residents at risk of depression, suicide, and burnout. In order for medical residents to perform at their best, the basic human need of adequate sleep must be met. Physicians are not superhuman and should not be expected to perform the incredibly difficult tasks required of them on an inadequate amount of sleep. Improved patient experience, outcomes, and reduced cost of healthcare can only occur when medical residents and physicians are working within an environment that recognizes their need for rest.

Policy Alternatives

The Quadruple Aim

The Triple Aim initiative has the admirable goal of trying to improve healthcare quality and cost; however, it will fail to fulfill its purpose if providers are continually asked to do more with less. Some health policy researchers and medical professionals have proposed the addition of a fourth aim to the Triple Aim that focuses on the support of the healthcare provider (1). This Quadruple Aim has arisen from the belief that provider strain and burnout lead to an increase in medical errors and a decrease in patient satisfaction, thereby increasing cost and decreasing health outcomes.

The administrative tasks that have been implemented to track the progress of the Triple Aim are a cause of physician dissatisfaction; physicians reported spending 25 to 50% of their day on the computer, and only 28% of the day with their patients (26). The Quadruple Aim would encourage healthcare organizations to look for ways to reduce the administrative load on providers; some physicians already have scribes who can write their notes and put in their orders.

Support of nurses would also be essential to the achievement of the Quadruple Aim. Though most studies and proposed interventions have been focused on physician burnout and the impact on patient outcomes, nurses are an essential part of the healthcare team who must be considered in any effort to improve care. Attempting to decrease cost by decreasing nurse staffing will have a negative effect on patient experience, thereby undermining the Triple Aim. It will also inadvertently increase medical errors and turnover, thereby failing in the original goal of reducing expenditures. Bedside nurses also experience required over-documentation, having to constantly re-document the same information rather than focusing on significant events or findings.

Both physicians and nurses can experience burnout, compassion fatigue, and variants of traumatic stress disorder due to the environments in which they work. This may lead to an intention to leave one’s job thereby decreasing a sense of ownership in their current practice, or leaving the environment all together. Both scenarios decrease productivity and increase cost; the cost of replacing a family practice physician was estimated to be $250,000 (26).

The largest obstacle to achieving the Triple Aim is lack of regard for providers and the largest obstacle to achieving the Quadruple Aim is an aversion to investment in the healthcare workforce. Increased nurse staffing and hiring scribes to document for physicians will require an increase in employees. These employees will also have to be trained and given the materials necessary to do their jobs. A culture change will also have to occur amongst healthcare leadership that leads to an appreciation for the essential roles that nurses and physicians play within their organizations, and that their wellbeing is essential to a functioning system.

Recommendations

Implement Mental Health Care in Schools and Workplace: Registered Nurses and physicians spend years in school learning how to care for patients with a variety of pathologies and personalities, and how to do so while remaining professional and dealing with unique dynamics. However, this education must be adapted to suit the needs of providers to care for patients who are older and have more chronic illnesses. They need to know how to take a blood pressure and make a diagnosis, but they also must know how to protect themselves from the stressors of their work environment.

Schools can address the issue by teaching providers to follow the primary and psychiatric care advice that is given to all patients; go to the doctor, eat a balanced diet, get enough sleep, exercise, and receive treatment for illnesses both physical and emotional (29). Educators must also encourage thorough debriefing of traumatic events and consider the effects that they may have on inexperienced trainees.

Workplace support is at the heart of achieving the Quadruple Aim. Since medical and nursing training and practice are so hierarchical, leaders can foster wellness in younger generations by modeling it in their own lives (29). Another intervention that has been implemented with success in the hospital environment is a “second victim” response group that helps caregivers to deal with traumatic events in the workplace; in this same thread, some organizations have sessions with caregivers that aim to reduce compassion fatigue, burnout, and help reestablish a connection with the profession (29).

Consider the Social Determinants of Health: Patients are becoming more complicated as healthcare improves; patients who at one time would have been doomed are now being saved and left with permanent disabilities and a need for lifelong healthcare. The improved population health aspect of the Triple/Quadruple Aims will not be met unless the social determinants of health are considered by providers when providing patient care. The outcomes of chronic illnesses are related to provider satisfaction and burnout because repeated hospitalizations of patients can be perceived as a failure by providers.

Providers need to be supported by allied health professionals. Social workers, chaplains, and case managers can all make assessments and recommendations based upon their unique skill sets. However, providers need to be taught how to work with these individuals and need to have their own basis of knowledge concerning the social determinants of health.

Providers also need to have the financial ability to address the social determinants of health for their patients. Currently, treatment in this area is not reimbursed as it should be (30). However, addressing these concerns may prevent chronic illness exacerbations and acute events in patients- contributing to an overall decrease in the cost of healthcare in the United States. An appreciation for the social determinants of health would decrease cost, increase provider perception of success, and improve health outcomes for patients.

Universal Healthcare: The United States is the richest nation in the world, yet it is one of the few developed countries that lacks a system to provide healthcare coverage to all of its citizens. In 2010, the Obama administration passed the Affordable Care Act with the goal of increasing the number of Americans with health insurance. However, it is still not a universal plan, and most Americans are still covered by insurance provided through their employer. A lack of health insurance coverage for anyone in America will prevent the success of the Triple Aim. Provider burnout will increase, patients will be sicker, and healthcare costs will be much higher due to a culture of responding to rather than preventing chronic disease.

The current race for the Democratic nominee for the presidential election of 2020 is focused in part on the candidates’ stances on universal health coverage. A few, including Senators Elizabeth Warren and Bernie Sanders are promising a federal approach to health care coverage with the belief that healthcare is a human right. The implementation of a federal healthcare system will be essential to the realization of the Quadruple Aim and a truly amazing American healthcare system.

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