Moving from the Triple to the Quadruple Aim

Early in the development of modern medicine, a simple transactional relationship was established between the physician and the patient. The physician talked to the patient, examined the patient, and collected data to arrive at a diagnosis before embarking on a therapeutic regimen. This methodology has defined the profession across time and cultures. Doctors entered brief data in the medical record, and this worked for hundreds of years. Physicians entered the profession as a calling and worked for long hours, to the detriment of their families, but seldom complained of burnout. As a matter of fact, complaints of burnout were seldom heard in surgeon lounges or where physicians congregated. And, until recently, controlling costs and managing entire patient populations was never a consideration.

The term Triple Aim was first added to the healthcare lexicon in 2007 by the Institute for Healthcare Improvement (IHI).(1) When IHI first proposed the Triple Aim concept, the idea was: (1) to improve the patient care experience; (2) to improve the health of a population; and (3) to reduce healthcare costs. These were lofty goals and an ambitious concept that wasn’t easily accepted by mainstream medicine. Now it has become apparent that one more aim has to be added to the equation: the wellness and emotional well-being of physicians.

The Triple Aim has noble goals of improving outcomes, reducing costs, and increasing patient satisfaction. The focus of the Triple Aim is the altruistic goal of improving the lives of our patients. The end game of the Triple Aim is to put patients at the center of care. However, in order to achieve the Triple Aim, a fourth component, physician satisfaction, should be considered as an addition to the equation—thus a new term in the lexicon of delivering health care: the Quadruple Aim.(2)

Failure to recognize physicians and their needs and wants is to flirt with confusion regarding patient care, leading to professional dysphoria and lack of harmony between patients, doctors, and other caregivers.

I think we all can agree that if the physician is not involved in participating in the Triple Aim, little advancement in contemporary healthcare can be achieved. The physician’s role and participation in the clinical experience of the patient must be considered. If the physician isn’t included, the three other patient-centric aspects, the Triple Aim, will not be possible.

Modern physicians have expectations and responsibilities that their predecessors did not experience. These expectations may seem to be natural extensions of the physician’s responsibility and incrementally appropriate, but the cumulative effect is to radically alter the traditional ways that physicians have functioned. Failure to recognize physicians and their needs and wants is to flirt with confusion regarding patient care, leading to professional dysphoria and lack of harmony between patients, doctors, and other care givers.

So how can we add the physician’s happiness and joy back into healthcare in order to reach the Quadruple Aim?

The following suggestions will aid in reaching the Quadruple Aim:

• Reduce the time physicians spend on the computer entering patient data. Doctors need to make more use of nurses, medical assistants, or other staff who can enter some or all documentation into the EMR. These assistants can help with order entry, prescription writing, and charge capture. These activities do not require 8 to 10 years of medical training to accomplish. Likewise, it does not have to be the physician who enters patients’ previous surgeries, medications, over-the-counter drugs, supplements, smoking and alcohol use, and occupational and social history into the computer record. In fact, allied healthcare professionals can record the chief complaint and the review of systems into the medical record. Physicians should do what we do best: diagnose and treat medical conditions rather than entering data into a computer.

• Ask patients to complete their paperwork—demographics, insurance information, health questionnaire, prior authorization—before their visit with the doctor. This can easily be accomplished using the practice’s website. Now patients do not have to spend 30 to 60 minutes in the reception area completing paperwork, which can significantly reduce the efficiency of the practice.

• Use pre-visit planning and pre-appointment laboratory testing to reduce time wasted on the review and follow-up of laboratory results. For example, if a man comes for his annual exam, request the PSA test before the visit with the doctor and have the results of the test available prior to the office visit. Now the patient has only one visit, and no follow-up or phone calls are required. This allows more slots in the schedule for new patients or patients requiring more time.

• Ask our leaders and specialty organization to create useful and practical guidelines to legally expand roles allowing nurses, NPs, PAs, and medical assistants to assume responsibility for certain aspects of medical care under supervision.

• Embrace new technology such as telemedicine. This technology initially as used to connect patients who were at a great distance from the brick-and-mortar practice. Today, telemedicine has been shown to work for many patients who do not need a face-to-face visit with the doctor. Using telemedicine will certainly increase the efficiency and productivity of the practice. Legal caveats must be made clear on a state-by-state basis so that doctors can safely and securely make use of telemedicine without going afoul of the law.

• To avoid shifting burnout from physicians to practice staff, ensure that staff who assume responsibilities for patient care are well-trained and understand that they are contributing to the health of their patients and also helping re-engineer unnecessary paperwork out of the practice.

• Our leadership needs to have a public relations campaign to address the chasm between society’s expectations and the shrinking number of American physicians, especially in rural areas.

• Population health is a new approach to healthcare that makes an effort to reduce high-cost reactive care and replace it with lower-cost proactive services. This includes prompting female patients to have mammograms, encouraging male patients to have appropriate screening PSA testing, and notifying patients at risk for flu, pneumonia, and shingles to take advantage of the vaccines that are available.

• We have to make every effort to enhance the patient experience. Evidence shows that patient compliance with treatment regimens and use of prescribed medications is increased if the patient had a positive experience with the practice. This ultimately results in improvement in clinical outcomes.(3)

Your patients are going to be surveyed by payers—and those physicians or practices that have favorable patient satisfaction surveys will be compensated or receive a bonus.

More financial and personnel resources should be dedicated to improving physician satisfaction and controlling the burnout epidemic currently affecting 50% of physicians.

Part of the Quadruple Aim is to place an emphasis on reducing the cost of healthcare. The American healthcare budget accounts for 17% of the GDP—more than $3 trillion per year. The projected rate of increase in healthcare spending is more than 5% per year. We have the greatest per capita spending on healthcare in the world, but we do not have improved outcomes to show for the increased spending. At the current rate of growth in healthcare spending, it will exceed 20% of GDP by 2026, which is not sustainable.(4)

One way to control healthcare spending is by making a concerted effort to reduce hospital readmission rates, because readmissions are very expensive. Some hospital readmission-reduction programs currently in place penalize hospitals financially by payment reductions if their readmission rates exceed the national average. We have learned that patients require follow-up support after discharge from the hospital to be certain they understand their discharge instructions, how to take their medications, wound management, and when to schedule their follow-up appointment. Timely post-discharge follow-up by telephone has been shown to be effective at decreasing preventable readmissions.(5)

Finally, more financial and personnel resources should be dedicated to improving physician satisfaction and controlling the burnout epidemic currently affecting 50% of physicians. The Physician’s Foundation found that nearly 80% of surveyed physicians sometimes experience feelings of burnout.(6) Studies have documented patient satisfaction scores are lower when doctors and nurses are dissatisfied or burned out.(7)

Physician burnout has a direct economic impact. The Department of Health and Human Services (HHS) has predicted that there will be a shortage of 90,000 physicians by 2025 and that burnout is one of the drivers of this shortage.(8) At the same time there is a shortage of physicians, there is going to be an increased demand for medical care, especially for baby boomers. Each day more than 10,000 men and women turn 65. These baby boomers have insurance, have more chronic medical conditions, and need more services and medical procedures than younger patients.

Efforts to replace lost physicians come at a steep cost to employers. One estimate of lost revenue per full time equivalent (FTE) physician is nearly $1 million, and the cost of recruiting and replacing a physician can range from $500,00 to $1,000,000.(9)

There is a relationship between burnout and medical errors. The evidence suggests that burnout is associated with increased medical errors compared with physicians not experiencing burnout.(10)

Bottom Line: I’ve heard many times that a successful marriage requires a happy spouse. If the spouse ain’t happy, ain’t nobody happy! The same can be said for physician satisfaction: if the doctor ain’t happy, no one—not the staff or, more importantly, not the patients—will be happy. Let’s direct our attention to make the physician happy and then those other lofty Quadruple Aim goals are doable.

References

1. Whittington JW, Nolan K, Lewis N, Torres T. Pursuing the Triple Aim: the first 7 years. Milbank Q. 2015;93:263-300.

2. Rathert C, Williams ES, Linhart H. Evidence for the Quadruple Aim. Medical Care. 2018;56:976-984.

3. Zolnierek KBH, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Medical Care. 2009;47:826.

4. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Family Med. 2014;12:​573-576.

5. Meterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. Health Serv Res. 2010;45​(5 Pt 1):1188-1204.

6. Hawkins M. Survey of America’s physicians: practice patterns and perspectives. September 18, 2018. www.merritthawkins.com/news-and-insights/thought-leadership/survey/2018-survey-of-americas-physicians-practice-patterns-and-perspectives/ .

7. Berwick DM. Era 3 for medicine and health care. JAMA. 2016;315:​1329-1330.

8. Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial. JAMA Intern Med. 2019;179:1406-1414.

9. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832.

10. Tawfik DS, Profit J., Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018;93:1571-1580.