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Identify 3 constituents of integrated health care delivery systems (IDS) and describe its development. What benefits directly apply to the provision of allied health care services? What limitations exist at present that could be improved, and how so?
The U.S. healthcare delivery system is a complex, mixed model that relies on a fragmented patchwork of public and private financing and delivery methods. The major reform models seek to shift the focus from the quantity of services provided to the overall value, coordination, and population health.
The current system can be characterized by four core elements, often found operating simultaneously:
Private/Employer-Sponsored Insurance: The dominant system, based on the Bismarck Model, where employers and employees pay premiums to private insurance companies (e.g., HMOs, PPOs), and care is delivered by private providers. This system emphasizes choice but can lead to high administrative costs and variable coverage.
Public Insurance Programs:
Medicare (National Health Insurance Model): A federally funded program for the elderly (65+) and disabled. The government is the primary payer, but care is mostly delivered by private providers.
Medicaid (Beveridge/National Insurance Hybrid): A joint federal-state program for low-income and vulnerable populations. It varies significantly by state regarding eligibility and benefits.
Managed Care Organizations (MCOs): Structures like HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations) are designed to control costs by restricting patient choice, requiring referrals, or providing financial incentives to use in-network providers.
Fee-for-Service (FFS): The traditional payment mechanism where providers are paid a separate fee for each service provided (e.g., a test, a visit, a procedure). This system is widely criticized as it rewards volume over value and drives up costs.
The primary contrast between the current FFS-driven system and reform models centers on the incentive structure and the scope of accountability.
| Current Status (FFS Dominance) | Proposed Reform Models (Value-Based Care) |
| Incentive: Maximize the number of services and procedures. | Incentive: Maximize patient outcomes and overall efficiency (value). |
| Accountability: Fragmented care; each provider is accountable for their single service. | Accountability: Population-based care; an organization is accountable for the total cost and quality for a defined patient group. |
| Payment Model: FFS, with billing for every item and service. | Payment Model: Alternative Payment Models (APMs), such as Accountable Care Organizations (ACOs), Bundled Payments, and Global Budgets. |
| Focus: Treating acute illness in a hospital/clinic setting. | Focus: Prevention, primary care investment, and addressing social determinants of health (SDoH). |
The key reform vision is to move away from the volume-based FFS model toward Value-Based Care (VBC). VBC models like ACOs aim to improve coordination among all providers—physicians, specialists, and allied health—by sharing the financial risk and reward. If the team keeps the patient healthy and avoids unnecessary hospitalizations, they share in the savings.
One area where reform to the current system could dramatically improve the delivery of allied health care is through the Full Integration of Allied Health Professionals into Primary Care Teams.
Under the FFS model, access to allied health services like Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) is often:
Delayed: Access requires a physician referral and often complex pre-authorization from the insurer, delaying preventative or early-stage intervention.
Siloed: Allied health services are treated as separate, episodic treatments, usually in a specialized, off-site clinic, rather than as an integral part of holistic primary care management.
Uncompensated for Coordination: PTs/OTs are typically only reimbursed for direct, face-to-face patient time, not for team consultation, developing home exercise programs, or follow-up with the primary care provider (PCP), which are crucial for coordination.
A reform model based on Capitated/Global Budgets for Primary Care (e.g., the Patient-Centered Medical Home approach) would provide a fixed, prospective payment to the primary care practice to manage all the patient's needs for a period of time. This should include:
Unrestricted Access to Allied Health: The global budget should be large enough to embed or co-locate a PT, OT, or SLP directly within the primary care clinic. This would eliminate the need for costly referrals and pre-authorizations, allowing the allied professional to provide triage, early intervention, and same-day consultations.