In politics, the “iron triangle” denotes the closed, mutually beneficial relationship among three policymaking entities that ultimately benefits the select few rather than the majority. Healthcare’s iron triangle is the Triple Aim to improve healthcare system performance—essentially cost, quality, and access. In practice, an improvement to any one side of the triangle invariably causes one of the other two sides to suffer. If we reduce costs, quality declines or the ability to see more patients is compromised. If we increase access, costs begin to rise or quality deteriorates. In the worst case, managers systematically restrict access or cherry-pick healthier patients with better insurance to reach organizational targets.
Some of the research in this issue of the Journal of Healthcare Management explores the trade-offs in breaking the iron triangle; typically, the studies address two sides at a time. At the end of this editorial, I explain why researchers should address all three sides in a more holistic fashion. Moving beyond the research domain, I explain why leaders should stop trying to address all three simultaneously and suggest the one they should focus on now.
First, this issue presents an interview with Thomas A. LaVeist, PhD, dean of the Tulane University School of Public Health and Tropical Medicine. Dr. LaVeist is one of the world’s leading authorities on health disparities and shares insights on how they can be addressed. You also can listen to our interview as the second installment in our new podcast, “A Leader Who Cares,” available on the JHM website (via www.ache.org/journals) and iTunes.
Next, we conclude our yearlong series of columns on caring for the caregivers with seven things board members should know about burnout, advocated by Tait Shanafelt, MD, Stephen J. Swensen, MD, Jim Woody, MD, PhD, John Levin, JD, and John Lillie. And our yearlong column series on sustaining relevance ends with thoughts on the importance of disruption shared by Ascension President and CEO Anthony R. Tersigni, FACHE.
The first research article revolves around the accountable care organization (ACO) program of the Centers for Medicare & Medicaid Services. Although the program addresses each part of the Triple Aim, the primary goal is to reduce the cost of care delivery. The article, by John Schulz, MD, Matthew DeCamp, MD, PhD, and Scott A. Berkowitz, MD, considers cost control and patient access in ACOs. In the short term, high-performing health systems succeeded by reducing access rather than making structural reductions to their cost profiles. Whether systematic reductions to cost structures can be implemented in the long term remains to be seen.
In the second article, Michelle Kloc, PhD, Tara Trudnak Fowler, PhD, Joseph F. Dorris, Robert Opsut, PhD, and Kimberley Marshall Aiyelawo, PhD, focus on a specific cost category—environmental services (EVS)—and its relationship to patient satisfaction. The satisfaction measure is often used as a proxy for care quality in iron triangle studies. The authors found that hospitals that spent more on their EVS achieved better patient satisfaction scores. Win–win scenarios, in which costs go down while patient satisfaction remains steady or improves, are hard to come by in the literature. Indeed, hospital administrators generally are finding that you get what you pay for.
Next, Bianca K. Frogner, PhD, Cyndy R. Snyder, PhD, and Jaime R. Hornecker, PharmD, take a qualitative look at how managers perceive team-based approaches to care delivery. There is no consensus on what constitutes a team-based care strategy, in large part because different service lines and settings are striving to meet heterogeneous sets of patient needs. Nevertheless, the quotes gathered in this study are telling as managers express concern about controlling the higher costs associated with coordinating teams. In particular, team-based approaches that add professionals to advance continuity of care may not be included in the reimbursement system. Again, the trade-off between cost and quality is always at the forefront of healthcare executives’ minds.
David J. Prottas, PhD, and Mary Rogers Nummelin look directly at the minds and actions of healthcare leaders in their study. They explore managers’ behavioral integrity, which is the alignment between what managers say and what they do, as perceived by employees. The most interesting discovery is that behavioral integrity is positively correlated with employees’ satisfaction and their assessment of care quality. The authors provide sound advice on how hospital managers can engage in self-improvement.
Hospitals’ hiring practices around performance improvement positions are explored in an article by Melanie A. Meyer, PhD. The variety of jobs and the skills required to fulfill them have expanded dramatically in the past few years. In overall numbers, quality assurance and improvement positions have seen the most growth. For managers in charge of designing such positions, this article provides valuable insights into trends in the field.
This issue of JHM is supplemented with three online-only research articles. The first, by Saleema A. Karim, PhD, George H. Pink, PhD, Kristin L. Reiter, PhD, George M. Holmes, PhD, Cheryl B. Jones, PhD, and Elizabeth K. Woodard, PhD, explores another human resource strategy: the pursuit of nursing Magnet Recognition (MR). To attain MR, hospitals make a significant investment in hiring nurses with advanced training. Although the study did not look directly at quality measures, the authors found that Magnet hospitals experience better financial performance.
The second online-only article, by Paulchris Okpala, DHSc, is a meta-analysis of collaborative leadership strategies. Results showed that intrahospital collaboration strategies are the most common, followed by patient-based collaborations. The latter strategy, which is patient centered, was found to yield the best cost reduction results. The other collaboration strategies also yielded positive outcomes.
The third online-only article covers a topic that all managers must deal with: patients who fail to keep their appointments. Sung R. Lee, Daniel B. Dix, Gerald McGwin Jr., PhD, Christopher K. Odom, MD, Cesar de Cesar Netto, MD, PhD, Sameer M. Naranje, MD, and Ashish Shah, MD, suggest interventions that managers can implement to mitigate the risk of a patient failing to show up for an appointment.
Returning to healthcare’s iron triangle, research on cost, quality, and access is voluminous and the findings vary widely depending on each study’s design and context. I suspect one could find a citation to support any position. As I noted earlier, the primary problem is that most studies look at only two of the dimensions. Future studies ought to strive to include all three.
Public policies addressing cost, quality, and access are numerous and varied as well. The problem with public policies is not that they are too narrow but that they try to do too much. The lack of a single, governing value ensures that when one party wants to talk about cost, another wants to discuss access, and so forth. The inconsistency in policies leaves hospital leaders facing a constantly changing payment and regulatory environment. Policymakers should pick one side of the iron triangle and focus on it alone until progress is made. Universal access is the first metric policymakers should address. Until every American has access to healthcare, efforts to reduce costs and improve quality will always come at someone else’s expense.
Finally, I want to call attention to the abstracts featured in this issue. They summarize three outstanding presentations given at the Forum on Advances in Healthcare Management Research, a highlight of the 2018 Congress on Healthcare Leadership of the American College of Healthcare Executives. The abstracts cover the high-impact topics of patient communication, continuing education for nonlicensed healthcare professionals, and the financial value of patient safety efforts.