Sprinting toward the triple aim: Developing new leadership practices to produce better health, better care, and reduced costs

With a single stroke, former CMS Acting Administrator Don Berwick provided a brilliant synthesis of our national goals for health care reform. His ‘Triple Aim” seeks improved population health, better quality healthcare, and reduced costs, all at the same time. As we pursue these joint goals in behavioral health, a major question is how they can and should impact leadership practices in our service programs—the theme of this year’s annual ACMHA: The College for Behavioral Health Leadership Summit held on April 2-5 in Tampa, Florida.

Berwick’s Triple Aim has its origins in the Affordable Care Act (ACA), the national Healthy People 2020 initiative, and recent World Health Organization recommendations on the social determinants of health developed by Sir Michael Marmot and former U.S. Surgeon General David Satcher. Significantly, the three goals are highly interdependent, with several pathways available to link them. Yet, although each has the potential to influence the other two, improved population health is really the first among equals, since improved health has the potential to reduce dramatically both service use and cost. Much recent national work points to the critical importance of making our healthcare system proactive rather than reactive in the quest to improve population health. 

This population health goal has dramatic implications for our leadership practices. Stated most baldly: To achieve this goal, behavioral healthcare will need to adopt the practices of a public health discipline. Why? We will need to mitigate those social determinants that lead to disease and promote those that prevent disease and improve health. Clearly, this will involve dramatic shifts in a field that essentially has been clinically-oriented since its inception. Much of this new work will involve moving from the clinic to the community.

Improved population health (e.g., greater resiliency) also can reduce the early and frequent use of disease care services. For example, it can mitigate health conditions (e.g., obesity) that lead to chronic illnesses (e.g., diabetes and heart disease). Thus, over time, reduced demand for disease care services will permit us to focus much greater attention on improved service quality. An essential tool for accomplishing this second goal will be the creation of integrated health homes under the ACA. High quality health homes will emphasize whole health and wellness, including clinical interventions to prevent disease and promote health. The underlying motif will become service quality rather than service quantity.

Behavioral health will be challenged to respond with the new leadership practices needed for this changed service environment. For example, high quality health homes that span behavioral health, medical care, and, potentially, even other specialties, clearly will demand collaborative leadership which has been virtually absent in the carve-out era.

Efforts to improve population health and care quality should always consider their potential to reduce care costs, the third of the triple aims. A little reflection will show you that, unlike the encounter-based payment systems of the past half century, the emerging case and capitation payment systems are very compatible with the new person-centered, whole health approach underlying the first two goals. We will need to identify new leadership practices to manage these new payment systems effectively.

Richard Beinecke, Summit keynoter and Professor and Chair of the Institute for Public Service at Suffolk University in Boston, sees the Triple Aim as a “wicked problem” that will challenge behavioral health leaders. It will require both transactional and transformational leadership. Dr. Beinecke cited both personal and professional instances in which both types of leadership have been required to address similar difficult issues.

Real-world exemplars were presented of changed leadership practices for programs that are seeking all or part of the Triple Aim. They ranged from integrated care in a rural behavioral health agency (Mountain Health and Wellness), emotional wellbeing in the workplace (Chesapeake Energy Corp.), and Parachute NYC (Bureau of Mental Health, Parachute NYC, and Community Access, Inc.) to mobilizing religious assets (CareNet, Inc.), emerging technologies (CHESS), and value-based care (Optum). These cameos became the diving boards for lively group discussion and future action.

Our Critical Conversations uncovered many gems to frame changes needed in our current leadership principles and practices. Among the best: “With privilege comes power and responsibility.”  “Improvement requires change, but not all changes are improvements.”  We need leadership that “spans boundaries”, is “authentic”, is “nimble”, is “emergent, but not urgent”, is “fearless”, is “flexible and pragmatic” and “includes peers”. Perhaps the most important group learning was that our leadership blueprint for the future is a vision to organize leadership rather than simply a road map.  

Even before we can pursue the Triple Aim in earnest, we have an essential prior leadership task: We must enroll more than 32 million uninsured persons in health insurance through Medicaid and the Affordable Insurance Marketplaces now being implemented. A major federal ACA insurance enrollment initiative has just been launched.

The annual award ceremony is always a highlight of the Summit. This year’s distinguished honorees were Carol J. McDaid from Capitol Decisions (Coakley Award for Behavioral Health Leadership); Jacqueline Pettis from Value-Options (King Davis Award for Emerging Leadership in Promoting Diversity and Reducing Disparities); Jeanette Harrison, private consultant (Barton Distinguished Fellow Award); and William B. White, retired (Saul Feldman Lifetime Achievement Award). Congratulations to each of these outstanding leaders! 

When we return to our leadership roles on Monday morning, all of us who enjoyed the Summit will have a great deal to reflect upon. In fact, one participant quipped at the closing that our major leadership challenge is to answer the question, “Should behavioral healthcare actually survive?”