Ready… aim, aim, aim…

Boston is a city of revolutions past–and maybe future. Sometimes revolutions are simply things that just need to happen and are overdue. This is certainly the case with the “triple aim.”

Among health wonks nothing is more obviously righteous as “the triple aim”– lowering cost, improving quality and improving population health. Originally advanced by the Institute for Healthcare Improvement under Dr. Don Berwick, the triple aim is embedded at the very root of the current federal health care reform legislation. It also pops up at state levels such as Oregon (

Just beyond the water over yonder is Bunker Hill; to the left behind the glass towers, Boston Commons. A more wonkish revolution is under way now, which is why a group from Memphis was here for a couple days. We were drinking deeply of the IHI / triple aim cup along with a hundred or more other folks from around the country. Representing both major hospitals in Memphis, the Med and The Church Health Center we listened to how these goals were being reached at large scale in upper Wisconsin and Oregon.

Of course the new triple aim is a footnote to the original one in Micah 6: “you know what the Lord requires already (some 2,600 years ago): do justice, love mercy and walk humbly.” If we had done that, we would not need the new triple aim. The new triple aim is related to Micah a bit like the plumbing is related to Amos’ prophecy that justice will role down like mighty river. Don’t take plumbing lightly. Just because it depends on gravity, doesn’t mean it is easy or obvious to get it to work. Same with health care.

We learned about CareOregon, a managed care organization for the poor that actually manages and actually cares. With tenacious decency, they use data like a righteous sword to carve waste and silliness from the lives of their members and providers. The result is dramatically more efficient services that are proactive, comprehensive, quick and responsive to what people really need. It passes for brilliance these days to notice that the most expensive patients needing the most medical services can be predicted by asking simple questions about substance use and family problems. And it passes for innovation when you do something non-medical about non-medical issues. Micah knew that would help, but did not need the cost savings to justify it.

Rebecca Ramsey, of CareOregon, shared how the basic revolutionary idea came from the SouthCentral Foundation in Alaska, which has built a large health services network on the highly participatory wisdom of the Native people. They (the people!) turn out to be pretty smart about the way people’s health is connected to their families, community, decency and … spirituality. The Native spirituality got left out of the story but the moral commitment to decency sure didn’t. The key is that the embrace of those with the most complex conditions (almost often involving the snarly mix of substances, interpersonal violence and mental issues) is way cheaper than pretending the complexity isn’t there. Mercy is cheaper; justice even more so.

These lessons are crucial for Memphis where we sit on a never-ending well of wicked disparities and poverty. We could be tempted to think we can’t face the inherent complexity of multi-generational cascade of race and class. “We’ll just do what we can; we can’t afford world peace.” Actually, IHI, Oregon and Wisconsin seem to say that world peace–taking it all on–is cheaper and more managing than trying to operate a hospital blind to the quiet violence of our patients’ lives. We are way off the national curve for unneeded hospitalization that can be effectively managed only by getting involved in the complexity of those who have no real alternative. We are even further off the curve for expensive and futile care at the last months of life; that can be managed not by harshness, but by the gentle-kindness Micah aimed at. We’re in a world war; why not work on world peace?

In the meantime, we can at least do a lot better. Micah thought he was only asking for what was obvious and doable: “you already know what God asks…..”. IHI lives on the wonk-ish side, finding a buzz from the data and flowcharts. But they are talking about the same mercy, same justice and, ironically, the same humble seeking for what is possible on this earth.

– Posted on the journey

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Professor, Faith and the Health of the Public, Wake Forest University School of Divinity. NC Certified Beekeeper Author, Leading Causes of Life, Deeply Woven Roots, Boundary Leaders, Religion and the Heath of the Public, Speak Life and God and the People. God and the People: Prayers for a Newer New Awakening. Secretary Stakeholder Health. Founder, Leading Causes of Life Initiative

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