Welcome to the Quadruple Aim

Welcome to the Quadruple Aim
Logane Kiehnau, Pharm.D., Allina Health 

Quadruple Aim
The Triple Aim of improving patient experience, population health, and reducing cost have been the guiding principles of healthcare professionals and institutions for decades. More recently however, the need for a fourth, additional aim has become increasingly apparent. The Quadruple Aim retains the original three ideals, but adds caregiver health and wellness. It’s a well-known fact that caregiver burnout can decrease patient satisfaction, decrease quality of care, and increase cost, jeopardizing all three original aims. Professional burnout is characterized as feelings of cynicism, low sense of accomplishment, and loss of enthusiasm for work. These feelings are associated with early retirement, depression, and substance abuse.Unfortunately burnout does not discriminate against health care location or specialty of practice. Approximately 46% of physicians report at least one symptom of burnout. Even more upsetting is that in a 2014 survey, 68% of family physicians and 73% of general internists would not choose the same specialty if they could start their careers anew. 

Costs of Burnout
Provider burnout is a major contributor to turnover and is one of the largest factors when deciding to leave a position. All this turnover results in both direct and indirect costs including lost revenue while recruiting and onboarding, and lag time before the provider is efficient in their role. It is estimated that the cost of replacing a physician is about 2-3 times their annual salary.Additionally, the lost billing revenue from an unfilled provider role can be upwards of $990,000. While institutions are aware of these potential losses of revenue, they often overlook them, relying on a new pool of residents and fellows that will command a junior level faculty salary. The largest financial impact is the impact that burnout has on provider productivity. In a study of 2,500 physicians at Mayo Clinic, increases in provider burnout resulted in a 30-50% decrease in work effort over the following 2 years. 

Addressing Burnout Return on Investment (ROI)
Efforts to reduce burnout can positively impact the financial bottom line. If an organization employs 450 physicians with an annual turnover of 7.5%, where typical replacement costs are $500,000 per provider, this results in $16.9 million annually on replacing physicians. Not all turnover is related to burnout, but burned-out providers are 50% more likely to quit and have a burnout prevalence of 50%. Therefore, burnout is likely contributing 2.5% to the total 7.5% turnover rate. Potentially, if burnout was addressed, this institution would experience an overall 5% annual turnover. The organization could dedicate one million dollars towards an intervention to reduce burnout from 50% to 40% (20% RRR) of providers, which would be expected to reduce turnover by 0.5% (20% RRR). The result is an ROI of $1.125 million or 12.5% on the initial expenditure. Even more promising is that this ROI does not account for revenue loss from reduced productivity among burned out physicians that don’t leave their role. With a growing body of evidence regarding the cost of provider burnout it may become difficult for even the most business-minded to deny that there is real money in reducing burnout, and improving provider satisfaction. As we begin to better understand the ROI from addressing provider burnout, the more the Quadruple Aim is poised to become the new standard.


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