The Triple/Quadruple Aim has long been recognized as a framework to optimize the US healthcare system. This daunting ambition was given hope with the proposal of accomplishing three goals equally in 2008 and the addition of a fourth in 2014. Theoretically, achieving these goals would alleviate the burden experienced by the healthcare ecosystem and increase the quality of healthcare for all patients. Now, seven years later, the “Quintuple Aim” is taking healthcare by storm, with a focus on health equity as a fifth equal pillar.
The Patient Experience Encompasses Every Touchpoint
Prior to 2008, the focus on improving healthcare was focused on six elements: safety, effectiveness, patient-centeredness, timeliness, equity, and efficiency. While well intentioned, there was still a missing piece to the puzzle. These elements focused solely on what transpired during care and ignored the root causes of most illness: what occurs outside of the exam room. To truly improve health outcomes, we needed to incorporate empathy and engagement at every touchpoint. With these principles, the Triple Aim was conceived. The Triple Aim focused on boosting the patient experience, ameliorating population health, and driving down healthcare spend spiraling out of control. This broader approach was meant to incentivize healthcare leaders to promote the health and wellness of their communities, not just those residing within their brick-and-mortar walls.
Without The Health And Well-Being Of Our Providers, The Healthcare Ecosystem Will Fail
While the Triple Aim set the stage for healthcare reformation/rehabilitation, clinician burnout was running rampant throughout the system. The rate of burnout among nurses and physicians eclipsed 45% and 54% in the US, respectively. This was shown to adversely impact the health of our providers by putting them at increased risk of cardiovascular disease and high cholesterol, as well as suffering from headaches and musculoskeletal pain. With exhausted providers, the patient experience plummeted, population health suffered, and the overall cost of healthcare ballooned. The Quadruple Aim recognized the backbone of the system: our providers. This goal strives to amend the clinical experience by championing provider wellness.
In a post-pandemic future of work, there is still much work to do. After all, a healthcare system performs optimally when the clinician’s health is valued just as much as the patient’s. With one in five healthcare workers leaving medicine since February 2020, the provider experience must be prioritized. In 2021, 61% of providers reported feeling burned out. Forty-six percent of psychologists reported feeling burned out, with 47% reporting stress levels higher than 7 on a 1–10 scale. These levels of burnout crippled the Quadruple Aim. To optimize health system performance, mending the clinician experience is an ethical and business imperative.
Health Equity Is At The Core Of A Vibrant And Prosperous Nation
Now, in 2022, the fifth point on the star is born, with a focus on advancing health equity. Health equity is defined as the ability for every person to “attain his or her full health potential” without being “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health inequity is assessed when looking at disparities between life expectancy; quality of life; different rates of disease, disability, and death; and access to treatment among different populations. A quintessential example is the disparity in heart disease in the US, demonsrated by a higher prevalence in the South. We also saw that life expectancy between Hispanic (79.9), White (78), and Black (72) individuals varied greatly in 2020.
Ignoring Health Equality Sabotages The Mission Of The Quadruple Aim
- Population health cannot advance when segments are negated. By its very nature, the fifth aim requires the population to get healthier together. A lack of access to care, however, is one of the largest barriers. About 14% of the US adult population is uninsured. This closely relates to the one in 10 people who live in poverty in the US. This hurdle is heightened by those who have trouble finding and maintaining a job due to injury, disability, and chronic conditions. This subpopulation needs to be better targeted by the healthcare system so that our population as a whole can become healthier. Ignoring the social determinants of health that make every patient unique is both complacent and counterproductive.
- All patient experiences suffer with health inequity. It’s no secret that patient experience needs to be front and center in healthcare, regardless of one’s zip code, yet technology and access are lacking for the 60 million Americans living in rural areas. This is not only an economic issue but an infrastructure quagmire. The patient experience suffers without reliable internet or an adequate supply of providers. As healthcare moves further and further into the digital realm, with virtual care modalities like telehealth and acute care at home, all patients need access to quality healthcare experiences.
- Costs rise if we don’t become healthy together. It is estimated that disparities currently cost the healthcare market $320 billion annually, and this is expected to increase to $1 trillion by 2040. This would inflate the cost from $1,000 to $3,000 per person annually. Compare this to the current annual household income, and we see that more than 15% would be spent on healthcare — that’s nearly 5% more than the amount of income being spent on food. Underserved populations will have greater difficulty affording care. This in turn will increase inequities that will then increase costs — and so the vicious cycle continues.
Tobacco use, diet and exercise, income, community safety, housing, and air and water quality are all components that significantly contribute to population health. These social determinates of health make up approximately 80% of healthcare outcomes, with the remaining 20% being attributed to the actual care received. Healthcare organizations (HCOs) must address these health determinants if they want to succeed in the future. Adding health equity as a fifth aim provides the weight needed to balance the healthcare scales now and in the future.