Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement, recently co-authored Pursuing the Triple Aim, which highlights partnerships among hospitals, employers and their communities that aim to improve population health and the individual patient experience while reducing the cost of care. Bisognano will receive the American Hospital Association/Health Research & Educational Trust TRUST Award at the AHA–Health Forum Leadership Summit this July in San Francisco.
Interviewed by Haydn Bush
What are the key takeaways from your book?
Bisognano: I'm seeing leaders who have moved beyond the vision of taking excellent care of patients — in an office visit or during a hospitalization — and see the Triple Aim as their mission. That involves not only excellent care that's safe, effective, efficient, as least costly as possible and timely, but also seeing beyond the care experience to the health of the population, and bending the cost curve. Ten years ago, when we began to talk about the Triple Aim, it was a rare executive who said, "I can take that on for my community."
Why do you think providers are finally embracing population health?
Bisognano: I think reform opens peoples' eyes to looking at their work in a very different way. The notions of bundled payments and ACOs pushed a lot of people in this direction. But the people we write about didn't mostly motivate through financial reconstruction. At Bellin Health in Green Bay, Wis., when [CEO] George Kerwin faced financial challenges at his hospital, the normal pathway would have been to cut costs or close beds. But George looked at the health of his own workforce. The health of the workforce in the United States is pretty dreadful. Many of us are ignoring the complications of chronic disease and are eating too much and working too many hours. So George went to his own workforce first, and [as they] improved in health and their ability to work, he found that his premium costs were lower. That gave him credibility to go out into his community and say to other leaders, "You can save money by making a healthier workforce." It not only strengthened his workforce, it strengthened Bellin as a whole.
You also talk about hospital/employer partnerships.
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Bisognano: The great opportunity when you're working with a company like Intel or Starbucks or Boeing is that the company knows its workforce. It's a little bit more challenging when a CEO in a hospital is trying to get his or her hands around the health of the community when nobody really owns that whole community. So it's a great place to start.
These companies have very good profiles on their employees. They know how many times employees are out with back injuries, headaches or carpal tunnel syndrome. Having that data allows them to dive deeply into the key problems that are preventing their employees from being fully functional human beings. Combining that with the medical knowledge in the health care community, you can create a value stream. You get a sense of the best way to care for a patient who is newly diagnosed with diabetes, or a woman who has just found out she's pregnant. What's the best way to deal with that, and how do we put all the pieces together in a new design? It's very exciting to see the employers and the health care community redesigning care, because the cost benefits to the company are immediate. The hospital likely will see some shifts in its business model. You are going to see, perhaps, fewer MRIs and more office visits, but [the patients] are going to need managing. I call it building a bridge to a different model of care, where [providers] are seeing downsizing in some parts of their business and increases in others. It's a management requirement to be able to predict those changes and move the staff and technology to the future.
And that gets back to the idea of population health.
Bisognano: Right. I see proactive anticipation and new designs as key leadership challenges. When you move from managing an organization to really capturing the data in a community and building a coalition, it's not management, it's governance at a community level. You're bringing together people who come from well outside of health care — local ministers, people who run 24-hour barbershops, school nurses, mayors — and moving away from the paternalistic view of health care, which is "We'll take care of you when you get sick," to really co-creating health in a community.
Where does patient-centered design fit into that model?
Bisognano: In the book, there is an example from Memphis, where there are health care professionals, but also ministers and other people, around the table. They have their data, they know what the total population is, they know minority representation, they know how many people have diabetes and undiagnosed hypertension. All that data drives very different conversations. We see a minister talking to a physician, saying, "You see these diabetic patients twice a year for 15 minutes. How can you possibly expect to improve their health with such brief interactions and encounters?" [The minister] said, "I see them twice a week for two hours, so I'll take diabetes." And he started changing the food they were serving in the church, and in his sermons, talking about the sanctity of your health and how you have an obligation to God and your family to know your health status.
The CMS shared savings pilot focuses heavily on the Triple Aim. What's your take on the program so far?
Bisognano: In some communities, the conversation is mostly about money. I don't have a whole lot of hope with the idea of shared savings being a part of financial negotiation. I have tremendous hope when I see the conversation being around health and health care producing the savings, and then, what [to] do with those savings. I'm seeing people really wrestle with their population — What does it look like? How many asthmatic children do we have here? What is the status? Is it getting better or worse? Some of these shared savings now are being invested into improvements in health. It's a different conversation than the financial bartering.
Finally, are you optimistic the current focus on the Triple Aim and population health will continue regardless of how the Supreme Court rules on health reform?
Bisognano: I was in Salt Lake City and Seattle [recently] having this very conversation and I'm optimistic. It really worries me if the legislation is repealed, that in some communities people will revert to business as usual. But the visionaries, the people whom I wrote about in the book, the people I am visiting, clearly are on a pathway to the Triple Aim. I don't see that reversing very easily.