BUSI 511 Week 7 Discussion Board Forum 7 Example

Discussion Board Forum 7: Special Populations and Cost, Access and Quality

BUSI 511 Healthcare Administration, Discussion Board Forum 7

Thread by [Student Name]

The hospital, its county, its veterans and the classmates are composites; the textbook, Scripture and the peer-reviewed sources cited are real.

The board of our 40-bed hospital met last month to decide whether to join the Veterans Affairs community care network, which would let the VA pay us to see veterans in our county. About 1,900 veterans live here, many of them older men who served in Vietnam or the Gulf War, and the nearest VA medical center is ninety miles away over two-lane roads. Our family medicine clinic already sees some of them as private-pay or Medicare patients, and our emergency department sees others when chronic conditions go unmanaged. Some board members saw a chance to serve neighbors and add revenue. Others worried about payment delays, extra paperwork and the risk of splitting a veteran's care between two systems that do not share records. As the administrator, I was asked to frame the decision.

Shi and Singh (2019) describe veterans as a population with distinctive health needs, including service-connected injuries, chronic pain, post-traumatic stress and higher rates of some chronic diseases, served by the Veterans Health Administration, one of the largest integrated delivery systems in the country. They also frame health care decisions around three linked concerns, cost, access and quality, observing that improving one often strains another. For our county, joining the network would clearly improve access, since a veteran could see a local clinician rather than drive three hours round trip. The questions were whether it would raise costs or lower quality, and whether it would fragment the care that the integrated VA system was designed to coordinate.

The national evidence is mixed in instructive ways. Saffar et al. (2026) examined monthly referrals to 24 specialties across the VA from 2018 to 2024 and found that total specialty referrals rose 42.5%, from about 1.16 million to 1.66 million a month, while the share sent to community providers rose from 16.1% to 21.5%, with surgical referrals to the community climbing from 17.1% to 26.4%. Yet mean wait times for new patients did not improve, which suggests that sending more care outside the VA has not by itself solved the access problem. Quality appears to favor the VA in at least one major area. Blegen et al. (2023) systematically reviewed studies comparing surgical care inside and outside the VA and found that 11 of 13 studies on quality and safety reported VA care as good as or better than community care, while all four studies of cost and efficiency favored non-VA care. Access studies showed no clear advantage either way.

Based on that evidence, I recommended that we join the network for primary care, behavioral health counseling, physical therapy and common diagnostic imaging, where local access matters most and the quality risk is lowest, while continuing to refer complex surgery to the VA medical center. We would also hire a part-time care coordinator to send visit notes and test results to each veteran's VA primary care team within a week, so the VA remains the veteran's medical home. We would track wait times for veterans' first appointments, the share of visit records received by the VA and veterans' satisfaction, and review the decision after a year.

When some of David's men were too exhausted to cross a ravine and stayed behind with the supplies, others argued they should receive nothing from the victory. David ruled instead that the share of the one who stays by the baggage would be the same as the share of the one who goes into battle (English Standard Version Bible, 2001/2016, 1 Samuel 30:21-25). A veteran who lives ninety miles from the nearest VA hospital served the same country as one who lives across the street from it. Equal honor for equal service means organizing care so that geography does not decide who receives it.

Reply to Naomi

Naomi, your thread argued that community care could widen racial gaps among veterans because it depends on whether a veteran can locate a willing outside provider and work through the scheduling on his own, and you described Black veterans in your city waiting longer for appointments. Two national studies support your concern. Gurewich et al. (2023) examined new outpatient cardiology and orthopedic consultations for more than 1.16 million veterans from 2018 to 2021 and found that Black veterans already waited about two days longer than White veterans for orthopedic care before the COVID-19 pandemic, and that during the pandemic the gaps grew to about four days for both Black and Hispanic veterans compared with White veterans. Rosen et al. (2024) then studied more than 5 million veterans who used primary care in fiscal years 2021 and 2022 and found that Black and Hispanic veterans were less likely than White veterans to use community care for primary care. Overall wait times averaged 33.3 days and remained longer in community care than inside the VA. Black veterans had longer waits than White veterans when they used community care, but shorter waits inside VA facilities, regardless of whether they lived in rural or urban areas.

That last finding is striking, because it suggests the VA's own clinics may be more equitable than the community providers the program pays. Shi and Singh (2019) describe integrated systems as better able to coordinate and standardize care, and the VA's internal scheduling may simply be more consistent than the many outside offices veterans must call on their own. Community providers may also be concentrated in neighborhoods with fewer Black and Hispanic residents, which would lengthen travel and waiting for those veterans.

For your facility, I would suggest reporting wait times for community care referrals by race, ethnicity and rurality each quarter, using the same measures these studies used, so leaders can see whether the gaps you described appear locally. Community care coordinators could also call veterans who have not scheduled within ten days of referral, since a referral that sits unscheduled is where disparities often begin. A third step would be to recruit community providers in the neighborhoods where minority veterans live, rather than relying on whichever practices volunteer for the network. These steps cost little compared with the harm of a delayed diagnosis. A veteran who waits an extra week for an orthopedic or cardiology appointment may lose function or suffer a preventable event, and when those delays fall more heavily on Black and Hispanic veterans, they compound gaps in health that already exist. The VA has stated that equity is a priority, so data showing local gaps would give your facility a strong case for added coordinator positions or targeted outreach. Does your VA facility already break down community care waits that way?

Reply to Isaac

Isaac, your thread described patients experiencing homelessness who are discharged from your hospital with wound care instructions and no place to follow them, and you proposed that your hospital fund a medical respite program. Shi and Singh (2019) list people experiencing homelessness among the populations with special health needs, facing higher rates of chronic illness, mental illness and substance use along with barriers to every kind of care. Your proposal fits that description, and the evidence on readmissions supports it.

Racine et al. (2020) analyzed 1,269 hospitalizations among 458 homeless Medicaid members in Massachusetts and found that 27% of those stays ended with the patient back in a hospital within a month, more than double the average national Medicaid rate. Leaving against medical advice raised the risk of readmission, while having a primary care clinician at a health care for the homeless program lowered it. Among the most frequently admitted patients, discharge to medical respite care was associated with fewer readmissions. Biederman et al. (2019) evaluated a medical respite pilot in the southeastern United States that gave 29 patients housing and nurse case management after discharge. In the following year, hospital admissions fell 36.7%, inpatient days fell 70.2%, outpatient visits nearly tripled and health care charges dropped 48.6%, while participants' housing and income improved. The pilot was small and lacked a comparison group, so its numbers should be treated as encouraging rather than proof.

Viewed through the textbook's cost, access and quality framework, medical respite improves access to follow-up care, likely improves quality by allowing wounds and infections to heal and may lower total cost if it prevents readmissions. The question for your hospital's finance committee is who captures those savings. Under fixed payments per admission, readmissions carry penalties and costs the hospital bears, so preventing them helps the hospital directly. A modest program of a few beds, run with a local shelter or nonprofit and staffed by a nurse case manager, could test the idea before larger investment. Your hospital could also partner with a Medicaid managed care plan that shares in reduced hospital spending. Two cautions would strengthen the proposal. First, respite works best when it is tied to housing, since a patient who heals in a respite bed and then returns to the street often comes back within months. Partnering with the local continuum of care, the network that coordinates housing for people experiencing homelessness, would give respite patients a path out. Second, the program should collect its own outcome data from the start, including readmissions, emergency visits and housing placements, because the published studies are small and the finance committee will want local proof before expanding. Has your hospital calculated how many of its 30-day readmissions involve patients with no stable address?

References

Biederman, D. J., Gamble, J., Wilson, S., Douglas, C., & Feigal, J. (2019). Health care utilization following a homeless medical respite pilot program. Public Health Nursing, 36(3), 296-302. https://doi.org/10.1111/phn.12589

Blegen, M., Ko, J., Salzman, G., Begashaw, M. M., Ulloa, J. G., Girgis, M., Shekelle, P., & Maggard-Gibbons, M. (2023). Comparing quality of surgical care between the US Department of Veterans Affairs and non-Veterans Affairs settings: A systematic review. Journal of the American College of Surgeons, 237(2), 352-361. https://doi.org/10.1097/XCS.0000000000000720

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Gurewich, D., Beilstein-Wedel, E., Shwartz, M., Davila, H., & Rosen, A. K. (2023). Disparities in wait times for care among US veterans by race and ethnicity. JAMA Network Open, 6(1), e2252061. https://doi.org/10.1001/jamanetworkopen.2022.52061

Racine, M. W., Munson, D., Gaeta, J. M., & Baggett, T. P. (2020). Thirty-day hospital readmission among homeless individuals with Medicaid in Massachusetts. Medical Care, 58(1), 27-32. https://doi.org/10.1097/MLR.0000000000001234

Rosen, A. K., Beilstein-Wedel, E., Shwartz, M., Davila, H., & Gurewich, D. (2024). Racial and ethnic and rural variations in access to primary care for veterans following the MISSION Act. JAMA Health Forum, 5(6), e241568. https://doi.org/10.1001/jamahealthforum.2024.1568

Saffar, D., Rose, L., Gao, Y., Hofer, T. P., Kerr, E. A., Saini, S. D., & Adams, M. A. (2026). Trends in outpatient specialty care referrals and specialty clinic wait times in the Veterans Affairs health system before and after VA community care expansion. Journal of General Internal Medicine. Advance online publication. https://doi.org/10.1007/s11606-026-10729-4

Shi, L., & Singh, D. A. (2019). Essentials of the U.S. health care system (5th ed.). Jones & Bartlett Learning.