Healthcare Needs the Quintuple Aim

Covid-19 shined a global spotlight on health equity. Racial and ethnic marginalized groups, the elderly and individuals living in poverty experienced higher rates of infection, morbidity and mortality from Covid-19. Far from an anomaly, the pandemic only magnified the disparities in maternal, child, preventive and chronic care that socially marginalized communities face on an ongoing basis. To address these challenges, we must make advancing health equity a central aim of healthcare.

What about the triple and quadruple aims?

The Triple Aim, first defined in 2007 by the Institute for Healthcare Improvement, included enhancing patient experience, improving population health and reducing costs. Seven years later, in acknowledgement of widespread burnout, a fourth aim was added, improving the satisfaction of physicians and healthcare professionals. Since then, the Triple and Quadruple Aims have been widely adopted as a North Star for healthcare improvement.

Introducing the quintuple aim

However, improving the quality of healthcare without health equity would be a hollow victory.

Health disparities have been recognized in healthcare for decades, yet measurable progress has been limited. One reason is that many innovations and improvements are not designed with a health equity lens from the start. Consider efforts to improve colon cancer screening. Often these initiatives start and end in the clinic—with patient reminders, staff training and enhancements to the electronic health record.

While these efforts are laudable, by definition, they do not reach the 25% of Americans who do not have a regular physician. Because individuals without access to care are disproportionately from socially marginalized groups, these quality improvement efforts, which have been a staple in healthcare innovation and improvement efforts, risk exacerbating health disparities.

A health equity-first approach to improving colon cancer screening may instead include canvassing marginalized neighborhoods, partnering with local churches or community groups or deploying community health workers—all utilizing people, places and organizations that people trust.

To put health equity first, we call for the widespread adoption of the Quintuple Aim (JAMA), which has the potential to shift quality improvement efforts in a meaningful way by making health equity an explicit aim.

The U.S. cannot afford to ignore health equity

Current inequities are costing the U.S. health system $320 billion and could eclipse to $1 trillion in annual spending by 2040 if unaddressed. Additionally, social, economic and environmental factors known as social determinants of health affect up to 80% of health outcomes. This includes factors such as a person or community’s physical environment, access to food, infrastructure (like mass transit), income, employment opportunities, education level, social connections and safety. There is extensive evidence that these nonmedical factors can have a negative impact on health.

Who are the change agents?

Every person’s opportunity to live their healthiest life and receive equitable access to healthcare is a need that has not previously been prioritized within many healthcare organizations as an explicit aim; in fact, only 58% of health systems identified equity as a top priority in 2021. Just as consumer-centric innovation and change in healthcare is happening both within and outside of the traditional system through public and private entities, we can thread the health equity needle by making the Quintuple Aim a call to action for healthcare providers, government officials and nontraditional stakeholders such as employers and healthcare startups.

Traditional healthcare delivery: By adopting the Quintuple Aim, healthcare leaders and practitioners could step up efforts to identify disparities at an individual patient level and incentivize physicians in collecting the data, designing and implementing evidence-based interventions to reduce barriers and investing at a healthcare system level in measuring progress towards defined health equity goals for the populations they serve.

Healthcare start-ups & investors: Often, start-ups develop a best-in-class innovation that addresses a specific health system challenge or health issue. Through a focus on the Quintuple Aim, there exists a compelling call to action for entrepreneurs to find new and innovative models and solutions to address health equity challenges, such as how Icario is addressing digital literacy and broadband access gaps. The Quintuple Aim provides the investor community with a North Star in prioritizing and funding new solutions that address social determinants of health and meet the socio-cultural needs and preferences of marginalized communities.

Employers: Through workplace benefits, such as employee health plans, income and other financial contributions, employers can make a direct impact on closing health equity gaps in support of the Quintuple Aim. Often, companies provide additional benefits that affect social determinants of health, such as tuition reimbursement for ongoing learning and employee discounts at retailers for items such as mobile phones or gym memberships. Employers may also identify ways to close equity gaps in employee access to care — such as expansion of virtual primary care and mental health and navigation services — to further their mission in support of health equity while also contributing to talent retention and acquisition goals.

Public Sector: At the policy level, lawmakers and government leaders should focus on interventions that help close gaps, integrate health equity into broader initiatives, develop a person-centric and technology-agnostic policy vision and view virtual equitable access for all as a necessity, instead of a supplemental component of comprehensive healthcare strategies. A recent example of how the government could organize cross-sector transformation would be the Biden administration’s Conference on Hunger, Nutrition and Health. The conference brought together the private and public sectors to unite around a common vision and commitment to ending hunger and reducing diet-related disease by 2030, while closing disparities in marginalized communities.

We’ve got this, together

Covid-19 has forced us to face inequities present in health outcomes head-on and to recognize the systemic nature of health inequality that goes beyond the limits of what the healthcare system alone can change. The Quintuple Aim is a new framework for addressing these health inequities and centering our innovation and improvement efforts on marginalized communities and populations. Let’s make it a rallying cry to all parts of our health and healthcare ecosystem to put communities and individuals with the most needs first.

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