MMHA 6050 Week 11 Full Delivery System Analysis Example

Three Delivery Models Compared on Access, Cost and Quality, With Recommendations for a Regional Health System

Student Name

Walden University

MMHA 6050: Delivery of Healthcare

Instructor Name

Month Day, Year

Three Delivery Models Compared on Access, Cost and Quality, With Recommendations for a Regional Health System

Introduction

Three organizations that answer fragmentation in very different ways, a plan-owning integrated system, a community health center and the national veterans' system, are compared here on access, cost and quality. The paper argues that Riverside Regional Health, an invented regional system of two hospitals and forty primary care practices, should adopt specific features from each rather than any whole model. Its recommendations are addressed to Riverside's chief executive and checked against the Triple Aim (Berwick et al., 2008).

The Three Models in Brief

The integrated delivery system owns hospitals, a salaried medical group and a health plan, and is paid premiums to cover its members' total care, so it bears financial risk for their total cost (Shi & Singh, 2022). The federally qualified health center is a community-governed nonprofit that serves everyone in its area regardless of ability to pay, financed by Medicaid, Medicare, private insurance, federal grants and sliding-scale fees, with a patient-majority board (42 U.S.C. § 254b). The Veterans Health Administration is a federally owned national system financed by appropriations, serving veterans who meet eligibility rules that prioritize service-connected disability and lower income (38 U.S.C. § 1710).

Access

On access, judged by who is covered, what care costs them at the point of use and how quickly they are seen, each model does well for its own population and leaves others outside. The integrated system offers members coordinated access across primary, specialty and hospital care, but only to those enrolled in its plan. The health center offers access to everyone in its area, including the uninsured, through sliding-scale fees, which removes cost barriers to primary care for those most likely to face them; its limit is that specialty and hospital care must be found elsewhere. The VA offers comprehensive access at little cost to eligible veterans, but eligibility is restricted, and timeliness has been a recurring concern. For a regional system, the health center's model of access without regard to ability to pay addresses the U.S. system's sharpest access problem, cost, more directly than the others.

Cost

On cost, the integrated system and the VA share a structural advantage: each is responsible for its population's total cost of care, rather than being paid per service, which gives it reason to prevent avoidable hospital use. The health center is paid mostly per visit, but its lower-cost primary care, using nurse practitioners and physician assistants whose care has been found largely comparable to physicians' on most outcomes studied in health centers (Kurtzman & Barnow, 2017), can reduce more expensive care elsewhere. Medicare's shared-savings experience suggests that holding responsibility for total cost can save money, but that who holds it matters: by the third year, McWilliams and colleagues found meaningful savings among physician-led organizations and, on average, none among hospital-integrated ones (McWilliams et al., 2018). That finding matters for Riverside, which is hospital-centered.

Quality

On quality, the strongest comparative evidence concerns the VA. Across the 69 studies O'Hanlon and colleagues reviewed, VA care usually matched or exceeded other systems on safety and effectiveness, though not in every study, while timeliness, efficiency, equity and patient-centeredness had been studied too rarely to judge (O'Hanlon et al., 2017). Health centers deliver primary care whose quality, in the dimensions measured, is comparable across clinician types (Kurtzman & Barnow, 2017). Integrated systems are often cited for coordinated care, but the published evidence is less systematic. All three models address the quality failure at the seams between components, documented in the gaps in information at hospital discharge (Kripalani et al., 2007), more directly than fragmented arrangements do, because one organization is responsible across more of the patient's care.

Summary Matrix

Table 1 summarizes the comparison.

Table 1

Summary of the Comparison

Recommendations

Recommendation 1: Build team-based primary care with expanded roles for nurse practitioners and physician assistants, starting in practices serving low-income patients. This follows the health center finding on comparable quality and addresses Riverside's access gap. The chief operating officer would lead it, beginning with five practices.

Recommendation 2: Take on shared-savings responsibility for a defined population, led by Riverside's physician group rather than its hospitals. This follows the integrated system and VA advantage in managing total cost, and the Shared Savings Program finding that physician-led arrangements produced savings where hospital-led ones did not. The chief medical officer would lead it.

Recommendation 3: Make the discharge handoff a measured responsibility. This follows the evidence on information loss at discharge and the coordination advantage all three models share. The chief nursing officer would lead it, with a target for the share of discharges with a summary sent to the primary care clinician before the first follow-up visit.

Testing the Recommendations Against the Triple Aim

Berwick and colleagues argued that a system should pursue the patient's experience, the health of the population and per capita cost at the same time, without buying gains in one with losses in another (Berwick et al., 2008). Recommendation 1 improves experience and population health by expanding access, and may lower cost by preventing avoidable emergency use, though it adds staff cost. Recommendation 2 targets cost directly, and should improve population health if savings come from prevention rather than withheld care; quality measures must be monitored to confirm that. Recommendation 3 improves experience and safety, and lowers cost by reducing readmissions. None trades one aim for another outright, though Recommendation 2 carries that risk and needs the monitoring described.

Limitations and Conclusion

The three models serve different populations: the VA's is older and mostly male, the health center's lower-income and the integrated system's mostly insured. Their results cannot be transferred directly to Riverside's population. The recommendations therefore borrow features rather than models, and each is scaled to be tested before it is expanded. The comparison's main lesson is that responsibility across the patient's care, whether through ownership, community mission or a national system, is what each model has and the fragmented arrangement lacks, and that Riverside can build pieces of that responsibility without becoming any of the three.

References

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759-769. https://doi.org/10.1377/hlthaff.27.3.759

Eligibility for hospital, nursing home, and domiciliary care, 38 U.S.C. § 1710 (2023).

Health centers, 42 U.S.C. § 254b (2023).

Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831

Kurtzman, E. T., & Barnow, B. S. (2017). A comparison of nurse practitioners, physician assistants, and primary care physicians' patterns of practice and quality of care in health centers. Medical Care, 55(6), 615-622. https://doi.org/10.1097/MLR.0000000000000689

McWilliams, J. M., Hatfield, L. A., Landon, B. E., Hamed, P., & Chernew, M. E. (2018). Medicare spending after 3 years of the Medicare Shared Savings Program. New England Journal of Medicine, 379(12), 1139-1149. https://doi.org/10.1056/NEJMsa1803388

O'Hanlon, C., Huang, C., Sloss, E., Anhang Price, R., Hussey, P., Farmer, C., & Gidengil, C. (2017). Comparing VA and non-VA quality of care: A systematic review. Journal of General Internal Medicine, 32(1), 105-121. https://doi.org/10.1007/s11606-016-3775-2

Shi, L., & Singh, D. A. (2022). Delivering health care in America: A systems approach (8th ed.). Jones & Bartlett Learning.