Testing Kissick’s Iron Triangle—Structural Equation Modeling Analysis of a Practical Theory




Beauvais, Bradley
Kruse, Clemens S.
Fulton, Lawrence V.
Brooks, Matthew
Mileski, Michael
Lee, Kimberly
Ramamonjiarivelo, Zo
Shanmugam, Ramalingam

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Multidisciplinary Digital Publishing Institute


Background/Purpose: The purpose of this research is to determine if the tradeoffs that Kissick proposed among cost containment, quality, and access remain as rigidly interconnected as originally conceived in the contemporary health care context. Although many have relied on the Kissick model to advocate for health policy decisions, to our knowledge the model has never been empirically tested. Some have called for policy makers to come to terms with the premise of the Kissick model tradeoffs, while others have questioned the model, given the proliferation of quality-enhancing initiatives, automation, and information technology in the health care industry. One wonders whether these evolutionary changes alter or disrupt the originality of the Kissick paradigms themselves. Methods: Structural equation modeling (SEM) was used to evaluate the Kissick hypothetical relationships among the unobserved constructs of cost, quality, and access in hospitals for the year 2018. Hospital data were obtained from Definitive Healthcare, a subscription site that contains Medicare data as well as non-Medicare data for networks, hospitals, and clinics (final n = 2766). Results: Reporting significant net effects as defined by our chosen study variables, we find that as quality increases, costs increase, as access increases, quality increases, and as access increases, costs increase. Policy and Practice Implications: Our findings lend continued relevance to a balanced approach to health care policy reform efforts. Simultaneously bending the health care cost curve, increasing access to care, and advancing quality of care is as challenging now as it was when the Kissick model was originally conceived.



cost containment, quality, access, Health Administration


Beauvais, B., Kruse, C.S., Fulton, L., Brooks, M., Mileski, M., Lee, K., Ramamonjiarivelo, Z., & Shanmugam, R. (2021). Testing Kissick’s Iron Triangle—Structural equation modeling analysis of a practical theory. Healthcare, 9(12), 1753.


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