A dual aim would elevate the priority of health equity and facilitate alignment of delivery models, payment models, and measurement with improving health equity (and value). Instead of being an add-on, health equity would be one of two twin aims. A new dual aim would explicitly focus on advancing improvement in health per dollar spent (value) and mitigating health inequities. One solution is to rethink the original "Triple Aim." Rather than moving from a triple to quadruple to quintuple aims, perhaps we should reduce the number of aims and focus on the core problems in the US health care system: poor value and persistent health inequities. Adding health equity as a quintuple aim could have the unintended consequence of preserving the status quo in which only selected, highly motivated health care systems prioritize health equity, leaving health equity too often marginalized from mainstream quality improvement and alternative payment and delivery models. The problem is that health equity simply has not been sufficiently prioritized for it to be systematically incorporated into health care quality measurement and improvement, much less integrated into current payment and models. Despite these endorsements, progress in mitigating health care inequities has been painfully slow. Health equity has subsequently been endorsed by CMS, the Joint Commission, the National Committee for Quality Assurance, the National Quality Forum, and other important stakeholders. Health equity has been recognized as a core dimension of quality for more than two decades, beginning with the Institute of Medicine Report (Crossing the Quality Chasm, 2001). However, adding health equity as a quintuple aim is too much in terms of aims and too little in terms of priority. The preceding paper by Dzau et al offers further support for health equity being a national priority. The authors articulate cogent arguments for health equity improvement being a national aim. Adding health equity as the quintuple aim, with its linkage to measurement, transparency, and reimbursement, will help sustain attention to persistent inequities plaguing our health systems and communities. We are coupling that approach with the training and engagement of trusted community voices such as Black church leaders, hair-dressers and barbers, and community-based pharmacists. At the Center for Sustainable Health Care Quality and Equity (SHC) we are implementing quality improvement education programs for clinical teams serving people of color, helping them close gaps in vaccination, diabetes management, evidence-based heart failure treatment, and other conditions characterized by disparities in care and outcomes. Strategies that helped make vaccines more available, such as true community engagement, delivery of services in the community, and attention to social determinants of health, will not continue. But my colleagues and I fear that the urgency to address equity will fade as the pandemic recedes. COVID certainly spotlighted health inequities. I applaud the authors' call for making health equity the fifth rail of the "quintuple" aim, including measurable and transparent reporting, consideration of systemic contributing factors, and tying it to reimbursement.
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