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The last 2 columns in Figure 3.5 (control knobs) represent “big, hairy, audacious goals” (BHAGs). Bill Hsiao, the author of this framework, likened them to the pursuit of efficiency (the intermediate outcomes) and effectiveness (the ultimate ends). They are more widely known today under different labels.

The first of these 2 columns constitutes one set of tripartite BHAGs known as “the iron triangle”: access, quality, and cost. Within the past decade or so, that triangle has been supplanted by a new set of tripartite BHAGs (that parallel the second of these columns) known as “the triple aim”: patient experience of care, population health, and cost per capita. Although there is nothing wrong with either set, it reinforces the observation made at the beginning of this book (“The Intro and the Outro” in Chapter 1): We have not only witnessed the continued introduction of new players, but we are also now witnessing the introduction of new goals. It raises the important question of whether or not these 2 sets of tripartite goals are synonymous and reinforcing, contradictory, or orthogonal. It also poses a dilemma for providers and the healthcare industry as a whole as to what they should focus on achieving. In business parlance, is this an instance of goal congruence, goal conflict, goal overload, or goal ambiguity?


Nothing better illustrates the opportunities and challenges we face than meeting the 3 goals of healthcare pursued by every country for decades: increase access, improve quality, and contain rising costs.1 Public surveys frequently assess consumer satisfaction with achieving these 3 goals.2 Attainment of these 3 goals is also baked into global frameworks of the functioning of every country’s healthcare system.3 They also define the strategic aim of major foundations like the Commonwealth Fund: Affordable, quality health care. For everyone. These tripartite goals have been widely acknowledged and studied for decades.

The 3 goals became embedded and embodied in geometric logic by Dr. William Kissick as “the iron triangle,” depicted in Figure 5-1.4 The logic of this triangle is that there are inevitable societal trade-offs in pursuing any of the goals (vertices) in the triangle. Often, these trade-offs are described as the tension between promoting access to care for everyone versus using price as a tool to ration healthcare services, or the tension between balancing equitable access and efficiency in the provision of services. If the triangle is an equilateral triangle, and thus each angle is 60 degrees, policy initiatives that expand 1 angle beyond 60 degrees force 1 or both of the other 2 angles to contract below 60 degrees. Thus, efforts to promote access to care (eg, via insurance coverage) will lead to higher demand for care, rising utilization, and higher costs. Similarly, efforts to promote quality by virtue of enabling access to modern ...

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