Question

1. Explain the concept of the iron triangle as it applies to healthcare.

Answer 1

In the year 1994 William Kissick developed the concept of "The Iron Triangle of Health Care" which emphasized on th three health care issues which are the primary concerns of all health care systems: Cost, Quality, and Access.

The Triangle is Iron because it is generally difficult to have a low-cost, high quality, wide access health care system. It is generally assumed that if quality increases, then costs must increase as well.

Cost

The most simple of the corners to understand. This is merely a question of how much does health care cost. The goal is always to reduce cost as much as possible because that allows more people to afford health care which leads to a more healthy and productive population. When the Healthcare prices are set by the national or state authorities so the cost gets control.

An even more recent innovation has occurred in the US under Medicare and EPO plans. This cost control mechanism is capitation. Under capitation, when a patient is assigned to a doctor, that doctor will receive a flat annual or monthly fee for that patient no matter how many times that patient sees the doctor. This creates a predictable price for health care services and incentivizes doctors to figure out how to deliver higher quality health care (so they don’t have to see their patient as often) at a flat price.

Cost is the corner which demands compromise on all of the other corners of the Iron triangle. Cost considerations drive down potential quality, and limit access and choice. Innovations in managing cost are important, but these innovations are driven by how they interact with one or more of the other corners.

Quality

Quality is also one of the seemingly more simple corners. This is a measure of how good of health care is being delivered to patients. But health care is a broad thing, and many different aspects of it are subject to quality measures.

Quality measures include

• how good are the surgeons
• how good are the primary care docs
• how good of drugs
• do you have the latest surgical robots
• how sensitive are your MRI machines
• how meticulous are your pathologists

So,to provide a more balanced measure of health care quality, various groups have been developing health-related quality of life (HRQoL) assessments with the goal of measuring how different treatments affect patients’ quality of life (e.g., Health-related quality of life and cancer clinical trials).

Quality can be difficult to measure, but you generally get what you pay for and high quality is generally expensive (but yes there are exceptions too).

Access

Access is the most nebulous of the corners because access means a lot of things. At its most simple, access asks whether you can access the type of health care that you need.There a lot of doctors in urban areas, but patients in rural areas often need to travel a long distance to see specialists. Patients in rural areas then don’t have reasonable access to specialty care.

But access is not just the single question of do you have a doctor nearby. Cost plays a major role in access. If health care is too expensive to afford, then people lack access due to affordability. If health care is so low quality as to be ineffective, then people lack access to effective health care and if the only doctor you can see with reasonable travel is one that you do not like, then you are unlikely to access that doctor.

In the United States, health care has been heavily regulated, by the Patient Protection and Affordable Care Act (ACA) whose main goal of the ACA has been to broaden access through the individual to be covered by insurance, while managing costs through private insurance and some limits on choice, while maintaining the high quality health care that America is renowned for.

But maintaining high quality health care at a reasonable cost is a difficult task. That is why the core driver of health care innovation in the US, and around the world, is to develop new tools to improve quality, access and choice at minimal additional cost.