Population Health, the Triple Aim, and the Health Effects of Social Services
The Triple Aim: Expanding the Discussion
Five years later, Berwick and colleagues Thomas Nolan, PhD, and John Whittington, MD, MBA, incorporated the concept of population health in their immensely influential article3 that proposed a framework for guiding public and private efforts to improve the healthcare system. They argued that “the United States will not achieve high-value healthcare unless improvement initiatives pursue a broader system of linked goals [consisting of] improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations” (p. 760).3 With that statement the Triple Aim was born. A focus on the health of populations (the “population as the unit of concern”) was critical, they argued, in pursuing the Triple Aim. They wrote, “only when the population is specified does it become, in principle, possible to know about its experiences of care, its health status, and the per capita costs of caring for it” (p. 762).3
The authors proposed that an “integrator,” would be needed to link healthcare organizations and other groups, such as social service providers, and coordinate efforts in pursuit of the Triple Aim. Specifically, among its other responsibilities, an integrator would “encourage and cooperate with government policies, agencies, and programs to discourage smoking, provide alternatives to violence and substance abuse, and address community determinants of mental health problems” (p. 164).3 In a single-payer health system, integrators could be provided with a global budget and charged with using it efficiently to “take care of the healthcare needs of a defined population” (p. 768).3 In regard to the US healthcare system, the authors offered examples of organizations currently playing the envisioned integrator role, but acknowledged the number of true “integrators” was very limited.
The Triple Aim concept has become the directional beacon for many health care organizations and public policy initiatives. It has highlighted the importance of including population health in health policy discussions and, while not its primary focus, advanced the idea that improving population health will require effective integration of medical and social services. Until the “integrator” function is better understood and developed, the authors suggest that large healthcare delivery systems might be best positioned to be integrators in pursuit of the Triple Aim.
Connecting Social Services and Population Health: Establishing the Evidence Base
While Kindig, Berwick, and colleagues noted that social services, living environment, and other non-medical factors can have an important impact on population health, Bradley and her colleagues advanced the evidence base for this notion. In a 2011 article,4 and later in their book The American Health Care Paradox: Why Spending More Is Getting Us Less, the researchers examined macro-level spending data from the United States and other industrialized (primarily European) countries. What they found was striking. The ratio of spending on social services to spending on health services was the lowest in the United States and Mexico (the only countries in their data where it was less than 1) but greater than 2 to 1 in countries like Sweden, Belgium, Denmark, and Austria (page 829).4 (The residents of the aforementioned southern Minnesota community might be disappointed to learn that the ratio for Norway was approximately 1.75 to 1, less than Sweden but at least higher than the United States!)
More importantly, Bradley et al,4 found that “the ratio of social to health expenditures, adjusted for GDP per capita, was significantly associated with greater life expectancy, lower infant mortality, and fewer potential years of life lost.” The authors acknowledged that while this favorable association did not occur in all the population health measures they examined (p. 826), it was still thought-provoking. Bradley and colleagues were careful to point out that their statistical findings did not imply causation and that the number of countries was small. Nevertheless, they modestly suggested that in addition to efforts to improve health status by increasing—or more appropriately targeting—health expenditures, “additional attention to social services is also needed” (p.830). In other work, they reported results from a literature review suggesting that specific US social programs have been found to improve program-related health measures.5
The researchers took a step further, performing essentially the same analysis using the different states in the United States.6 The results were quite similar: states with higher ratios of social to health spending (where social spending was calculated as the sum of social service and public health spending, and health spending was the sum of Medicare and Medicaid spending) had better population health outcomes. They suggested that their findings “may inform efforts among policy makers, clinicians, and researchers to leverage social services and health spending more effectively to improve population health” (p.761).6 But how might this be done in practice?