Melting The Iron Triangle: Prioritizing Health Equity In Dynamic, Innovative Health Care Landscapes

As a master of health administration (MHA) student completing my administrative residency in the health technology industry, I chose to dedicate my capstone project to a topic positioned at the intersection of what I had learned in graduate school and what I had learned during my residency. While administrative residencies are typically in a hospital or consulting setting, I matched with a primary-care-focused electronic health record company as the organization’s first administrative resident. During my residency, I gained an even greater understanding of the complexities of the U.S. health care system while taking advantage of the flexibility and independence afforded me to pursue my passions and ideas as an early careerist. As it turns out, health technology is the perfect realm for leveraging administrative health care knowledge in the pursuit of health care innovations.

Having completed my graduate degree in a remote setting during the pandemic, I recognize how privileged I am to have the tools and resources needed to achieve academic success digitally and maintain my physical and mental health digitally via telehealth. Studying the recent, multifaceted advancements in health technology and health disparities that existed long before COVID-19, I quickly became interested in examining the relationship between health innovation and health equity.

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The theory of the iron triangle

Pandemics have long catalyzed robust, rapid changes to health care status quo. Though the devastation and pain caused by the COVID-19 pandemic persist, it is through public health crises that the most impactful advancements are made to the health care system as a whole. Though systematically flawed, America’s health care landscape continues to represent a hub of medical and technological innovation, rapidly adapting to meet evolving demands. As health care leaders continue to meet the challenges of the rapidly evolving health care environment, a major obstacle remains: the iron triangle.

The theory of the iron triangle, first introduced in Medicine’s Dilemmas: Infinite Needs Versus Finite Resources by William Kissick in 1994, asserts that the elements of cost, quality, and access in health care cannot be simultaneously improved without worsening at least one of the other elements. In this new era of digital health technologies, the iron triangle is more relevant than ever, with advancements widely embraced during the pandemic – such as telehealth – filling the immediate need for access to health. But are the populations at greatest risk in terms of access, quality, and cost of health care the ones truly benefiting from these innovations?

As it turns out, despite digital health technologies showing promise for the future of health care, vulnerable populations are often left with an even larger health disparity gap. Because of this unintended consequence of health innovation, disparities resulting from the digital divide combine with existing, multi-factor inequities in health care.

The biggest revolution in patient experience

While the technological boom in the health care field is not a circumstance of the pandemic, the accelerated roll-out and adoption of digital features certainly are. And rapid innovation in the health care technology field is not a bad thing in itself. Health care technology discoveries improve health care access, quality of life, patient safety, and even save lives – for example, remote patient monitoring devices and robotic surgery. Although digital health innovations have significantly impacted patient engagement by empowering individuals’ autonomy over their own health, these modern health tools could yield a much greater impact if they were not primarily utilized by populations already advantaged in terms of cost, access, and quality of care.

In contradiction to the iron triangle, some argue that “digital communications and telepresence facilitate keeping patients away from the physical facility – ideally, at home – thereby increasing access and reducing costs, and appears to be doing so without a decrease in quality.” However, the developments in digital health care themselves haven’t resulted in a profound impact on vulnerable populations and health equity. Without predetermined strategies for leveraging digital health innovations through a health equity lens, cost, access, and quality may not improve for those who need it the most.

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