“Quality” is hard to define, but it’s always personal. In purchasing decisions large and small, consumers constantly weigh cost and value, and make trade-offs based on their individual needs, budget, preferences, and priorities. This explains why ratings for the same product or service can be all over the map, and why price alone doesn’t always correlate with quality.
For some people, three-star restaurants will always be the “best” (though they can certainly fall short on experience). For others—even those who can afford pricier options—the local hole-in-the-wall or fast-food chain can be just what the doctor ordered. Warren Buffett famously eats breakfast at McDonald’s every day.
The calculations we all make to maximize quality on our terms have shaped our behavior and decision-making in just about every aspect of life, from housing and travel to what we’ll pay for eggs at the supermarket. The glaring exception? Healthcare. That’s where our built-in quality sensors fail.
A PROBLEM FOR THE WHOLE SYSTEM
Healthcare doesn’t work like other markets. It’s too complicated, and people lack the data and context they need to make informed decisions. They’re overwhelmed by countless (and conflicting) physician and hospital ratings. They struggle to assess whether a provider or procedure is suitable for their specific needs. And the true cost of care often isn’t clear until the bill arrives. Not surprisingly, people still rely on word of mouth and less-than-perfect sources like U.S. News & World Report and (increasingly) ChatGPT.
This isn’t just a consumer problem. When people unknowingly see low-quality doctors, they have worse short- and long-term outcomes, ranging from delayed or missed diagnoses to repeat surgeries. Meanwhile, people who believe fancier is always better may see a pricey specialist (or three) at a brand-name hospital, when they really just need high-quality, cost-effective primary care.
When this becomes a trend—and it has—health outcomes decline and costs rise, for individuals and families, as well as for the employers and insurers funding a significant chunk of their care. The entire system suffers, and we all pay more for less.
WHERE DID WE GO WRONG?
Healthcare quality has been a moving target for decades, but we’ve been working on it. The industry has long rallied around the Triple Aim framework. The core idea is simple: Improving healthcare requires the “simultaneous pursuit” of better outcomes, better experience, and lower costs.
It was—and still is—the right idea. And yet, as the Triple Aim nears its 20th birthday, confidence in U.S. healthcare system quality has hit a historic low. With such a clear target, how did we miss the mark?
First, we skipped over the “simultaneous” part. Doctors and hospitals, optimizing for outcomes, have developed groundbreaking, hyperspecialized treatments—a good thing, in some ways, but also a main cost driver. Insurers, optimizing for cost, responded by ramping up prior authorization and Byzantine billing practices, which have become a major sore spot in the U.S. healthcare experience. And while digital-first health companies and other new entrants have optimized the patient experience, many have failed to generate better outcomes and cost savings at scale.
Second—closely related—is that quality was never truly defined through patients’ and consumers’ eyes. By focusing on their leg of the tripod without considering the others, the stakeholders previously mentioned weren’t serving and supporting the whole person. Instead of optimizing all three quality dimensions, they inadvertently made the system more fragmented, impersonal, and difficult to navigate.
Third, and arguably most important, we haven’t had the tools we needed. Balancing outcomes, experience, and costs in real time, as people make decisions about their care, requires deep connections across the clinical, financial, and administrative aspects of healthcare. The technology, data plumbing, and integration needed for those connections simply havn’t existed. Until now.
PUT THE PIECES TOGETHER
Several related breakthroughs are finally empowering healthcare innovators to optimize all three dimensions of quality at once.
AI is a big one, of course. Building a patient-centered view of quality requires combining and interpreting data about doctors and hospitals, health insurance claims, population health trends, and patient satisfaction and preferences (to name a few key domains). Even the most sophisticated consumer—or expert—can’t calibrate all these inputs on their own.
But AI can. Specifically, intelligent AI healthcare assistants that fit in your pocket and deliver a highly personalized and engaging concierge experience. Unlike mass-market chatbots, purpose-built healthcare AI not only provides answers and advice, but is also capable of connecting people to relevant health benefits and human clinicians when needed. Leaving healthcare consumers to their own devices has suddenly become a positive thing.
Equally important is the rise of AI-first, quality-led alternative health plans. These consumer-friendly plans are designed to solve the biggest sticking points in the current healthcare experience: confusing deductibles and coinsurance, surprise billing (and subsequent medical debt), physician networks that limit access, fragmentation across providers, and point solutions. With AI in their DNA, these innovative plans use cost transparency and dynamic networks to continually guide people to quality while limiting inappropriate or unnecessary care. These “alternative” plans—which lower costs for consumers, employers, and other healthcare purchasers—are quickly becoming the new standard.
The final piece of the puzzle is who delivers all of the above. The Triple Aim originators identified the need for an “integrator” with the capabilities and incentives to assume responsibility for all three dimensions and drive system-wide quality improvement. Health systems, insurers, and other industry incumbents have been slow to heed the call. But as I look at my own team, and my like-minded partners and peers, I see a new generation rushing to fill the gap.
Finding quality healthcare will always be more complicated than choosing a restaurant. But we’re taking a big leap forward in making quality a given rather than a shot in the dark.
Owen Tripp is the cofounder and CEO of Included Health.