Beyond the Triple Aim Paradox: Unraveling Investor Influence in the Quintuple Aim Era

Abstract

Globally, healthcare systems face increasing pressure to deliver high-quality care while reducing costs to remain sustainable. The Triple Aim of Healthcare framework addresses this tension between quality and costs. It does so by introducing three key objectives that should be central in a well-functioning healthcare system: improving population health, enhancing patient experiences and reducing per capita healthcare costs. This framework later evolved into the Quadruple and Quintuple Aim, adding the well-being of healthcare workers and the pursuit of health equity. Many international healthcare policies implemented measures to promote Quintuple Aim achievement by different healthcare actors. Despite this policy focus, only very few medical startups fulfill multiple, let alone all five aims of the Quintuple Aim framework. This discrepancy is commonly referred to as the Triple Aim paradox (as the Quadruple and Quintuple Aim are relatively new). This thesis explores whether investors influence a medical startup’s ability to achieve the Quintuple Aim. Drawing on social enterprise literature, it examines the impact of investor’s finance/impact orientation on Quintuple Aim pursuit by medical startups. Specifically, it investigates the effects of individual investors, investor diversity, and investor mixes using a quantitative approach. This fills a gap in existing Quintuple Aim research, which is often qualitative and focuses on clinical rather than business contexts. It also contributes to social enterprise literature by addressing the understudied role of investors in shaping mission driven startups. The findings reveal that impact-led investors do not consistently drive higher Quintuple Aim performance. Surprisingly, finance-first investors, especially venture capitalists, can also support positive Quintuple Aim outcomes. Furthermore, investor diversity appears beneficial for Quintuple Aim outcomes, with no diminishing effect as diversity increases. Finally, both investor mixes dominated by impact-led or finance-first investors were found to positively affect Quintuple Aim performance. These findings have important policy and scientific implications as they challenge the belief that only impact focused investors foster socially beneficial outcomes.