MMHA 6050 Week 8 Emerging Delivery Models Post Example

Week 8 Discussion: Initial Post and Replies

Where Delivery Is Heading: Risk Moves to Groups, the Encounter Moves Home and First Contact Moves to the Pharmacy Aisle

My forecast is that over the next decade, more financial risk will shift from payers to physician-led groups, more routine encounters will happen outside clinical buildings and more first contacts will be handled by nurse practitioners and physician assistants in retail settings, with each change helping some patients and costs while leaving others untouched. Three models already operating show the direction.

Accountable care organizations change who holds financial risk. A group of clinicians, sometimes with hospitals, answers for both the spending and the quality of care across a defined group of patients, rather than being paid only per service. After three years of Medicare's Shared Savings Program, physician-group organizations were associated with savings that grew over time, while hospital-integrated organizations did not produce savings on average (McWilliams et al., 2018). The limit is that savings have been modest and concentrated in physician-led groups, which suggests the model works best where the group has reason to reduce hospital use.

Telehealth changes where care takes place. It suits conditions that can be assessed by conversation and visual inspection, such as many minor respiratory illnesses and follow-up visits, and suits poorly anything needing a physical examination or test. One study of direct-to-consumer telehealth for respiratory illness estimated that only about one visit in eight substituted for another kind of visit, so access rose but net spending also rose (Ashwood et al., 2017). The limit is that convenience can add cost without replacing more expensive care.

Retail clinics change who staffs the first contact, usually nurse practitioners and physician assistants, with a narrow scope of minor acute care. For three common illnesses, care starting at retail clinics cost less than at physician offices, urgent care or emergency departments, with similar quality to offices and urgent care (Mehrotra et al., 2009). The limit is scope: retail clinics do not provide the ongoing management chronic disease requires. For a regional health system, the three models point in one direction: the system will have less control over where its patients make first contact, and more reason to coordinate with whoever does, because under shared-savings contracts it is accountable for the total cost of care wherever that care happens.

Reply to Olivia

Olivia, your forecast that hospital-at-home programs will grow is plausible, but your post describes only the benefits. What is one sourced finding about outcomes or cost, and one limit, such as which patients are not suitable or what happens if a patient deteriorates at night? Naming the limit would make the forecast easier to judge.

Reply to Ethan

Ethan, you describe direct primary care, a monthly membership fee for unlimited primary care, as the future. Which of the three changes does it make: who holds risk, where care happens or who staffs it? It seems to shift some financial risk to the practice for primary care only, while leaving hospital and specialty costs with the patient's insurer. That might limit how much it changes total spending.

References

Ashwood, J. S., Mehrotra, A., Cowling, D., & Uscher-Pines, L. (2017). Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs, 36(3), 485-491. https://doi.org/10.1377/hlthaff.2016.1130

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

Mehrotra, A., Liu, H., Adams, J. L., Wang, M. C., Lave, J. R., Thygeson, N. M., Solberg, L. I., & McGlynn, E. A. (2009). Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Annals of Internal Medicine, 151(5), 321-328. https://doi.org/10.7326/0003-4819-151-5-200909010-00006