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Developing and Integrating a Practice Model for Health Finance Reform into Wound Healing Programs: An Examination of the Triple Aim Approach
Abstract
Throughout the United States, government and private payers are exploring new payment models such as accountable care organizations and shared savings agreements. These models are widely based on the construct of the Triple Aim, a set of three principles for health services reform: improving population-based outcomes, improving patient care experiences, and reducing costs through better delivery systems.
Wound programs may adapt to the new health financing environment by incorporating initiatives known to promote the Triple Aim, such as diabetes amputation reduction and pressure ulcer prevention programs, and by rethinking how health services can best be delivered to meet these new criteria. The existing literature supports that programmatic approaches can improve care, quality, and cost, especially in the field of diabetic foot ulcers. Wound healing programs have opportunities to develop new business plan models that provide quality, cost-efficient care to their patient population and to be leaders in the development of new types of partnerships with payers and health delivery organizations.
Potential Conflicts of Interest: none disclosed
What is the Triple Aim?
Although the United States healthcare system spent $7,598 per capita in 2009 compared to $3,311 in the United Kingdom,1 it often achieves suboptimal outcomes and provides poor care experiences.2 The Triple Aim, a construct developed at the Institute for Healthcare Improvement, describes three goals for bettering healthcare services: improving the care experience for individuals, improving population health outcomes, and reducing per capita cost of care through better delivery systems.3
The Triple Aim concept is explicitly tied to federal healthcare payment reform efforts that focus on new financing models, such as accountable care organizations, that tie payments to quality-of-care metrics and population-level outcomes instead of relying on fees for visits or procedures.4 Accountable care organizations that demonstrate the ability to deliver high-quality, cost-effective care will have the opportunity to share in the savings that accrue to the Medicare program.4 This incentivizes healthcare improvements that lower overall costs by mechanisms such as reducing the need for hospital admissions.
In parallel, private health insurance plans increasingly offer contracts that include rewards for quality-of-care and population outcomes, with shared cost savings for more cost-effective care. A 2012 survey5 of 39 health plans found 20% already had more than half their business supported by value-based payment models, 40% believed they would reach that point within 3 years, and 59% believed they would reach it within 5 years. 
Wound healing clinicians may be able to leverage the shifting financial environment in both the private and public sectors to identify and pursue opportunities to best serve their patients and communities. Healthcare systems that hold risk-sharing agreements for increasingly greater proportions of their patient bases may wish to integrate cost-savings innovations into affiliated wound healing programs as part of an overall accountable care approach. Organizations shifting to an accountable care model often are in the early stages of transition and may be seeking programs that can demonstrate quality improvements and cost savings within a relatively short time frame of several years. Private insurers who are pursuing value-based contracting may be attracted to programs with a focus on achieving the Triple Aim. Provider networks may be interested in partnerships with wound healing centers that directly target high-cost care patterns in their patients. Rethinking wound healing services from the perspective of the Triple Aim provides an opportunity for wound healing programs to evolve and thrive in the context of ongoing payment reform.
Unlike the fee-for-service system, which rewards physician encounters, procedures, and hospitalizations instead of outcomes, an approach to health services delivery via the Triple Aim is intended to allow clinicians and administrators to focus on the objective of providing high-quality and cost-effective care for an entire patient population. This enables emphasis on areas not supported by fee-for-service reimbursement, such as continuity of care, communication, collaboration, self-management, prevention, community outreach, and reduction of waste.6 The Triple Aim has been used to improve care and reduce costs in a variety of settings, including employer-based health plans, primary care systems, health services delivery for specific disease entities, transitions from hospital to community, and care management for complex chronic conditions.7,8
The purpose of this review is to explain how the existing wound healing literature can give direction to the field in developing new clinical models that emphasize population-based outcomes and cost-efficiency.
Review of Best Practices in Wound Healing for the Triple Aim
The wound healing literature documents initiatives that fit well with the Triple Aim, including programs that reduce diabetic foot amputations on a population level.9 The US has a rate of 36 diabetic lower extremity amputations per 100,000 people age 15 and older, which is much higher than that of other developed countries such as the United Kingdom with nine, Canada with 11, or France with 13.10 This implies the potential for improvement in diabetic foot care in this country.
A fee-for-service system treating diabetic foot ulcers rewards high-volume outpatient centers, hospitalizations, surgical services, and hyperbaric oxygen therapy. The average cost of a diabetic ulcer episode has been estimated in past review articles11,12 to range from $4,500 to more than $25,000 and amputation as nearly $45,000; inflation likely continues to increase costs. All effective limb salvage services are justified for patients with severe ulcers. However, superior population-level outcomes can be achieved at lower cost through prevention and early treatment and through coordinated care of advanced ulcers. Multiple initiatives (see Table 1) suggest that communities’ amputation rates can be reduced through community outreach,13 patient education,13-19 education or guidelines for primary care providers,13,14,16,20,21 increased podiatry services or development of a foot clinic focused on prevention,14,15,17,18,20-23 provision of preventive footwear,14,15,17,20-23 and/or development of a multidisciplinary treatment team or establishment of specialist treatment guidelines.15,17,20-23 In addition to dramatically improving population outcomes, these programs can improve individuals’ quality of care with consistent and timely preventive care, referrals, and treatment. Such programs can reduce healthcare utilization, including hospitalizations, skilled nursing facility stays, and emergency room visits, and cut total ulcer treatment costs.15,17,20-23 Thus, these programs make not just clinical, but also financial sense in a reimbursement model that rewards cost savings and quality improvement. According to a review of the cost impact of interventions,24 projected potential savings could reach $20 billion annually in the US. Preventing amputations reduces additional uncalculated costs to society, including lost economic productivity, disability payments, public assistance, and increased caretaking burden on families.25
Pressure ulcer prevention is another well-documented wound care initiative that furthers the Triple Aim. Pressure ulcer incidence is an important marker of health outcomes in an inpatient population, and hospital-acquired ulcers represent an inarguably worse care experience for a patient. Effective prevention initiatives include a bundle of practices encompassing comprehensive skin exams, pressure ulcer risk assessments, pressure redistribution services, repositioning of patients, nutritional support, and incontinence management.26 These interventions are not supported by fee-for-service reimbursement models, but they are cost-effective.27 Therefore, a financing model that rewards the Triple Aim can support this work from both the healthcare system’s and insurer’s perspectives. Other drivers of pressure ulcer prevention programs include regulatory oversight, impact on hospital reimbursement, and concerns about medicolegal liability.
Rethinking Wound Healing Services from a Quality-of care and Population Perspective
Wound healing programs often are based on a high-volume outpatient clinic model. However, a population perspective facilitates consideration of the outpatient center as only one component of a program that optimally manages a population’s chronic wound needs through different care settings and in the community. Programs that provide integrated care across settings — into home care, nursing homes, and hospitals — will be able to reach even the most vulnerable patients where they live and follow individual patients through different care settings. Wound healing programs with best-practices for service delivery may offer community-based health promotion activities, specifically address patients’ psychosocial challenges and care preferences, and use population-level data to design interventions that meet communities’ and patients’ needs. To the extent that these innovations improve outcomes and care and lower overall costs, they can be financially supported in a Triple Aim payment model.
Table 2 identifies potential areas for improvement of wound services delivery in the transition from a fee-for-service model to a financial model that emphasizes quality and population health outcomes and where investment in preventive or treatment strategies can save costs by avoiding downstream complications. These are examples of how a shift in approach can lead to new proposals for improved care. Each proposed intervention requires planning for outcomes measures and financial metrics in order to enable evaluation of its effectiveness. Individual health systems may choose different areas of focus based on their capacities and the needs of their communities. However, structuring proposals in the language of the Triple Aim may allow for more effective dialogue with insurers and healthcare systems that partner with wound healing programs. Table 2 describes a population-based focus, multidisciplinary care approaches, integration of care across settings, reduction of insurance barriers to necessary components of care, and integration of wound care into skilled nursing facilities as areas that merit specific investigation as potential effective and cost-saving new care models in wound healing.
Conclusion: The Role of Wound Clinicians in Health Services Delivery Reform
Health services delivery in the US has an opportunity for transformative change as business models strive to reward good care, good outcomes, and efficient resource use. Wound healing programs can build successful new models by identifying strategies to reach patients who are poorly served in the current system, focusing on early detection and secondary prevention of complications, building stronger partnerships with communities, looking outside the walls of the comprehensive outpatient center to address the wound-related health needs of populations across settings, and improving the quality of care within existing clinical sites. These changes will require skills in epidemiology, population health, business modeling, health services delivery design, operations, and assessment. New partnerships may be required with public health professionals, implementation scientists, and health services researchers. As a community, wound healing providers will benefit from becoming active shapers of this process. This can be done by testing, sharing, and diffusing strategies for health delivery systems that optimize care experiences and health outcomes in ways that also contain cost by improving care for patient populations.
Dr. Flattau is a family physician and Director of the Wound Healing Program, Montefiore Medical Center, Bronx, NY. Ms.Thompson is the Inpatient Wound Care Coordinator, Memorial Hospital of Salem County, Salem, NJ. Ms. Meara is Associate Vice President, Network Management, Care Management Organization, Montefiore Medical Center. Please address correspondence to: Anna Flattau, MD, MSc, MS, Montefiore Medical Center Wound Healing Program, 3335 Steuben Avenue, Bronx, NY 10467; email: aflattau@montefiore.org.
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