• Michael Misialek, MD

Value Based Healthcare and the Triple Aim

Effective healthcare reform requires a comprehensive knowledge and implementation of the principles of value-based healthcare and the “Triple Aim”. Two of the most influential thought leaders of our time and proponents of these strategies are Dr. Donald Berwick and Dr. Michael Porter.

The need for change has never been greater. According to the Commonwealth Fund scorecard, US healthcare system is the most expensive in the world. It is outperformed by many countries in most performance measures.

In response, the Institute of Medicine (IOM) issued 6 goals that should form the core needs of healthcare.

  1. Safe

  2. Effective

  3. Patient-centered

  4. Timely

  5. Efficient

  6. Equitable

Despite the IOM report, the US is still lacking in improving care across the continuum.

The Triple Aim

Dr. Donald Berwick is the former CMS Administrator and Institute for Healthcare Improvement (IHI) President Emeritus and Senior Fellow According to Berwick, healthcare reform requires implementation of three aims, the so called “Triple Aim”.

  1. Improve the care experience

  2. Improve population health

  3. Reduce cost

According to Berwick, 3 preconditions are required: the enrollment of an identified population, a commitment to universality for its members, the existence of an organization (an “integrator”) that accepts responsibility for all three aims for that population. The “integrator” must possess 5 components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.

There must be a balanced pursuit of the 3 aims.


Fragmentation of care has created a need to better measure costs and care. Systems knowledge such as lean is required. Lean thinking involves process improvement through the elimination of waste so that all work adds value. This involves culture change at the organization level. The IHI offers many examples of lean thinking in healthcare.

Value-Based Healthcare

Dr. Michael Porter, Bishop William Lawrence University Professor at The Institute for Strategy and Competitiveness, based at the Harvard Business School, pioneered the concept of value-based care. According to Porter, the core purpose of health care is value for patients. The value formula is based on health outcomes that matter to patients and the costs of delivering those outcomes. To deliver high value, heath care delivery must shift from volume to value.

Porter describes 6 steps to create a value-based healthcare delivery organization.

Lessons for Pathology

Pathologists are important members of the care team. The laboratory sits at the intersection of all medical specialties and touches every patient. What can pathologists do to deliver value?

Pathologists can impact each of the three components of the Triple Aim. Through initiatives such as improving test utilization, pathologists can lower costs, improve outcomes and increase value. Other examples can be found in these recent articles.

Dr. Eleanor Herriman, Senior Fellow at Harvard Business School, has proposed innovative practice models for pathologists to deliver value. At the heart of much of the problems with healthcare are complexity and performance gaps in clinical decision making. Herriman makes the case for pathology supported decision making strategies to deliver value.

Utilizing lean and six sigma principles in the laboratory, pathologists can help transform healthcare. Through implementation of the value framework and a pursuit of the Triple Aim, successful healthcare reform can be realized. As integral members of the care team, it is essential that pathologists embrace these concepts.

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