Pursuing the Triple Aim: A three-dimensional outcome evaluation of the Integrated Care Project “Gesundes Kinzigtal”?

Purpose: “Triple Aim” is the buzzword for the initiatives of the Obama administration in the US and refers to a famous article of Don Berwick et al, asking for better health (quality), better health care (patient experience), and lower per capita costs (efficiency) [1]. The population based integrated care system “Gesundes Kinzigtal” in Germany is also pursuing this Triple Aim [2]. The objective of this study is to evaluate the performance of Gesundes Kinzigtal in these three dimensions. Methods: The concept of this evaluation is oriented on a comparison of insurants, who are enrolled at Ge-sundes Kinzigtal (years 2006-2009) and non-participants. Via a quasi-experimental study design (propensity score matching), which is based on routine data of the two participating health insurers AOK and LKK Baden-Wurttemberg, the bias caused by the non-randomised group assignment is to be eliminated. The outcome measures that are evaluated are mortality (dimension: quality), margin (dimension efficiency) and the rate of insurants turnover (dimension: patient experience/member loyalty). Results: The comparison of standardized differences before and after the propensity score matching confirms the requested equalisation between the intervention group (enrolled insurants = IV; n=4.596) and the control group (non-participants = NIV; n= 4.596). The evaluation shows positive results in all three dimensions. Mortality rates are significantly lower in the time frame of 10 months after enrolment (IV:1,76% vs. NIV:3,74%; chi-square: 0,000*). Also after exclusion of the first two months after enrolment (an adjustment to avoid an indirect immortal time bias) the results remain stable (IV:1,58% vs. NIV:2,94%; chi-square: 0,000*). After the intervention start the margin improved more, but not significantly, in the IV than in the NIV too (margin difference: ca. 151 €, t-test: p<0,05: not significant). In the last dimension (patient experience/member loyalty) the IV also shows significantly better results as the NIV (insurants turnover: IV: 2,8% vs. NIV: 4.4%; chi-square: 0,000*). Conclusions: The study indicates that integrated care systems may improve quality, efficiency and member loyalty at the same time. It suggests three outcome measures for these Triple Aim dimensions. Further research on the “right” measures should be motivated. In addition: Even though the propensity score matching seems to allow a scientifically sound outcome evaluation (on the basis of routine data of health insurers), further possible biases may be explored.