The Quadruple Aim as a Framework for Integrative Group Medical Visits

Editor's Note: In July 2019, we proudly published the JACM Special Focus Issue on Innovation in Group-Delivered Services, with Paula Gardiner, MD, MPH and Maria Chao, DrPH, MHA as Guest Editors. We engaged the project out of clarity that there is a strong concordance between the values in the movement for integrative health and medicine and those imbued in and experienced through the group delivered service models while yet there remains a pervasive under-utilization. A submission for that issue provoked this Invited Commentary. It looks at these group values through the lens of another movement: to shift the US medical industry from a focus on production of services and “volume” toward what is called “value-based medicine”. The “Quadruple Aim” has become a go-to method for capturing this mission. In the Commentary, the authors affirm the multiple ways that group-delivered services move the dial positively on this quartet of values. In so doing, they provide evidence on how the movements for integrative health and that for realizing the Quadruple Aim are in multiple respects parallel play toward transformation of the volume-based industry. – John Weeks, Editor-in-Chief (johnweeks-integrator.com)

Integrative group medical visits (IGMVs) are a compelling health service delivery innovation for complementary and integrative health care (CIH). As explored in the recent JACM special issue on group-delivered services, IGMVs create an opportunity to expand access to CIH. Group medical visits (GMVs) emerged at the intersection of several concerns in U.S. health care: rising prevalence of chronic health conditions, with notable disparities by race/ethnicity and socioeconomic status^1,2; extremely high health care costs compared with other industrialized countries,³ and high rates of clinician burnout.⁴ GMVs combine medical care, health education, and peer support to treat a wide variety of health conditions.^5,6 Although billable medical care in GMVs does not differ substantially from standard individual care, the presence of peers appears to provide additional benefits.^7–10 IGMVs add CIH to existing GMV models,¹¹ in response to CIH's inaccessibility to many people due to limited insurance coverage and high out-of-pocket costs.¹²

Although IGMV programs and GMVs more broadly vary in structure, duration, frequency, and staffing, researchers and practitioners have identified benefits to patients, health care staff, and organizations that are present across IGMV models. Having identified a need for a framework to support IGMV implementation and research, the authors propose the Quadruple Aim Framework as described by Bodenheimer and Sinsky.¹³

The Quadruple Aim was developed as an expansion from the Institute for Health Improvement's Triple Aim Framework, which focused on cost-effectiveness, patient experience, and population health outcomes.¹⁴ The fourth aim added practitioner satisfaction, and was first noted in the literature by Spinelli as the “phantom limb” needing attention as rates of burnout increased among clinicians.¹⁵ The Quadruple Aim has been used to frame reforms on a wide range of health care issues, including efforts to address the current opioid crisis and improve prenatal care.^16,17 Researchers suggest that GMVs can meet the goals of the Quadruple Aim by (1) improving patient experience through extended time with the clinician, peer support, and engagement in care; (2) improving population health through better patient health outcomes; (3) lowering health care costs, as demonstrated in studies of GMV cost-effectiveness; and (4) improving practitioner experience, described in qualitative research with GMV practitioners.¹⁶ The authors recommend that the Quadruple Aim be used as a framework to guide the future of both group-delivered services and research, to measure the potential impact of these programs on advancing health equity.

Improving Population Health Outcomes

Researchers focused on IGMVs have demonstrated positive health outcomes for diverse patient populations, although few studies have been powered to determine efficacy or effectiveness.^18–22 Notably, most of the CIH modalities used are commonly provided in groups but not typically reimbursed by insurance, despite substantial evidence supporting their efficacy (e.g., acupuncture and other mind–body practices). There is a tremendous variation in frequency of IGMV meetings, program duration, and integrative modalities offered. Although further research is needed to determine optimal structure and content of these interventions, there may be benefit from a range of models. Findings point to the potential for improving population health outcomes if IGMVs can be implemented at scale.

Improving Patient Experience

Common qualitative findings across IGMV research align with existing qualitative literature on GMVs, which emphasizes patient satisfaction, decreased isolation, and the benefits of peer support.²³ Shifts in patient–practitioner power dynamics and multiple forms of peer engagement in one another's care were noted in a study of patient experience across four IGMV sites.¹⁰ The mechanisms of positive patient experience in IGMVs are particularly worth exploring among minority patients likely to experience discrimination in health care, as has been shown in qualitative literature on the benefits of multiple GMV models.^8,24

Reducing Cost of Care

Prior research on GMVs has found reductions in the cost of care for both prenatal care and diabetes care,^25–27 increasing access to care. This is particularly important in settings with primary care provider shortages or for patients affected by Medicare mandates for more frequent visits. The recent JACM special issue included some of the first articles to explore cost-effectiveness of IGMVs, with promising findings.^28–30 Lack of public and private insurance reimbursement for CIH has been a major barrier to expansion, but as these and other articles demonstrate, certain kinds of programs are feasible even within current reimbursement structures. As more payers shift from fee-for-service to value-based care and capitated payment models, options for including a wider range of treatment modalities and practitioners (e.g., acupuncturists, naturopathic doctors, holistic nurses, and yoga therapists) in IGMVs may become more feasible.

Improve Practitioner Experience

Practitioner experience is closely connected with patient health; recent research shows that clinician burnout is associated with unsafe care and lower patient satisfaction,³¹ and that changes in working conditions can reduce clinician burnout.³² IGMVs, then, may be a key organizational reform. Few researchers address practitioner experience in their publications on IGMVs, although qualitative research has indicated high levels of practitioner satisfaction with GMVs more broadly.^23,33,34 As payment models shift in the United States, staff such as registered nurses, health coaches, and community health workers should be able to take on expanded roles within IGMVs, alongside licensed clinicians of all kinds. A key area of future research would be to investigate if IGMV practitioners reflect the diversity of patient populations and are trained appropriately to provide patients' preferred CIH modalities. IGMVs connect broader issues of clinician diversity, reimbursement for CIH, and interprofessional practice.³⁵

Concluding Remarks

IGMVs have been frequently, although not exclusively, implemented in safety-net care settings, with the goals of increasing access to both biomedical care and CIH for chronic physical and mental health conditions. IGMVs have the potential to make CIH services available to people who would otherwise not have access, while meeting the goals of the Quadruple Aim. In the future, the authors hope to see rigorous quantitative, qualitative, and mixed-methods research on IGMVs that evaluates the promise of these interventions through all elements of the Quadruple Aim. Eventually, they hope that innovations such as these will lead to widespread uptake and sustainment of CIH interventions across the socioeconomic spectrum.

Disclaimer

The views expressed in this publication do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

I.R. and A.T.-L. contributions were partially supported by T32 Fellowships from the National Center for Complementary and Integrative Health (I.R.: 5T32AT00378-12, A.T.-L.: #2T32 AT003997). Funding for A.U.T. contribution was made possible in part by SAMHSA grant #5T06SM060559-07.