What is the Iron Triangle of Health Care?

By on March 3, 2012

William Kissick MD

OK. I’m going to turn you all into Health Care analysts by introducing the concept of The Iron Triangle of Health Care. The Iron Triangle is a mechanism used to assess health care systems of all kinds. It is helpful if you think of the Iron Triangle three-dimensionally, as a tripod on which the health care delivery system itself rests. This concept was employed by those who devised the recent reform measures passed by Congress in 2010.

What are the three legs?

Quality, Access and Cost. We have made informal reference to all three in past postings, but it will be useful to go over each again.

Quality is the value, efficacy, reliability, and outcome of the care being delivered. This may sound like a no-brainer, but it is not. Quality to the average patient usually suggests the quality of service. It may also suggest competency.

We know patients forgive disappointing outcomes if the quality of service has satisfied. Fine, but that is not what health policy experts are looking for. They want reliable, measurable, verifiable outcomes like the number of patients in a practice getting required childhood vaccinations, the number of diabetics having tests showing good blood sugar control, the number of post-operative complications and so on. Numbers attach easily to these measures. So does monetary reward.

Doctors often push back against this. They argue that patients are not interchangeable parts. Some are more complicated than others. Some are sicker; some have other confounding problems. Some are non-compliant. Some have economic issues. We are not manufacturing widgets here, but treating individual human personalities.

Access also is not as straightforward as it seems. Wonks look at who can get the care when it is needed, not how long it took to get an appointment or how long you spent in the waiting room with a cold. Of course they are appalled when any patient waits six months for routine gall bladder surgery or a truss. But, remember experts are measuring systems, not personal experiences. The Health Reform Bill of 2010 largely tried to improve access to care for Americans by opening the doors to insurance coverage for more of them. The Obama Administration failed to make this clear, and has paid a price.

Lastly is Cost. That is straightforward. Systems need to make costs affordable for patients and those who pay, whether that be employers in the US, government agencies, or insurance providers. Powerful forces are driving costs up as we have noted before. The Reform Act did not fully address this leg of the triangle.  It worked hard to  provide a way to pay for the improved access uninsured Americans would receive under the Bill. It trimmed the fat out of some programs and encouraged innovative ideas. It satisfied Congressional Budget Office measures of being cost-effective, but it does not solve the money problem.

Like a tripod, if one leg is moved, the whole system is affected. When attempting any reform, a balancing approach must be taken. Those who can afford current costs and have good access to care, read many Republicans, worry tampering with the current system will either erode high quality or saddle them with additional cost. Democrats are addressing current access issues caused by increasing costs. Without access there is no quality. The social safety net financed through state Medicaid programs has been shredded in recent years.

The system left alone is not inert. Cost is most dynamic. It is changing faster than any other leg of the triangle. Rapidly rising costs are affecting access, access impacts quality. There is a fear quality will move further from reach for working Americans, as new costly technology makes high quality care a luxury. Where to intervene?

The Affordable Care Act of 2010 pinned a lot of hope to controlling costs through IT, innovation and obliging best practices. As death and ‘wearing out’ are not, after all, optional for Americans, that alone is likely to be insufficient. How this challenge going forward is met will require careful attention. Health Policy must be crafted so that the three Iron Triangle legs holding up our Health Care Delivery System do not topple over and cast us into the great abyss.


The Iron Triangle concept originated with William Kissick MD, a professor of medicine from University of Pennsylvania, who worked on the original Medicare proposal. He studied systems worldwide, served the Public Health service as a planner and later wrote the important book Medicine’s Dilemmas: Infinite Needs Versus Finite Resources (Yale University Press, 1994.)

In the 1990’s, after a successful career he observed,

“The forecast for the year 2000 is that we will spend between 15 and 18 percent of gross national product on health and medical care, and I am certain 6 percent on education.  If that is true, early in the 21st century the United States will have a very well medicated, illiterate labor force busily selling french fries to each other under golden arches….

“The culture of health care like its societal context has changed. What was perceived as a threat to the practice of medicine in 1965 looks to me like a lifeline in the decades ahead….  For every health policy action, there will be a reciprocal over-reaction.”

French fry, anyone?





Tom Godfrey

(rev. 8/31/12)

About Tom Godfrey

Leave a Reply

Your email address will not be published. Required fields are marked *


HTML tags are not allowed.