BUSI 511 Week 8 Discussion Board Forum 8 Example

Discussion Board Forum 8: Health Policy and the Future of Health Services Delivery

BUSI 511 Healthcare Administration, Discussion Board Forum 8

Thread by [Student Name]

The health system, its region and the classmates are composites; the textbook, Scripture and the peer-reviewed sources cited are real.

Our regional health system runs three critical access hospitals and eleven rural clinics across four counties, and for six years we have tried to recruit family physicians from outside the region. We have paid recruiting firms, offered signing bonuses above $100,000 and promised loan repayment, and we have still lost most of the physicians we hired within three years, usually to suburbs where their spouses could find work and their children could attend larger schools. Two clinics now rely almost entirely on nurse practitioners and rotating locum physicians, whose daily rates strain our budget. Last month the board asked a different question: instead of buying physicians trained elsewhere, should we train our own by sponsoring a rural family medicine residency? As the administrator charged with the analysis, I found that the answer depends heavily on federal policy.

Shi and Singh (2019) describe American health policy as made incrementally through a fragmented process involving Congress, federal agencies, states and powerful interest groups, which tends to produce gradual adjustments rather than sweeping redesign. Graduate medical education illustrates that pattern. Medicare is the largest public funder of residency training, paying teaching hospitals for residents' salaries and the added costs of teaching, and Congress capped the number of Medicare-funded positions at most hospitals in 1997, a limit that has changed only modestly since. The authors also anticipate continued pressure on the physician workforce as the population ages, with primary care and rural areas facing the greatest shortages. For our region, the cap matters less than one might expect, because hospitals that have never trained residents can establish new caps when they start a program, and rural hospitals receive more favorable treatment. The challenge is less permission than the cost and capacity to build a program.

The research supports the idea that where physicians train shapes where they stay. Bray et al. (2026) followed 87 graduates of three family medicine residencies based in tribal health systems in Oklahoma from 2013 to 2024 and found that 66.7% remained in the state, 65.5% practiced in rural areas, 79.3% practiced in primary care shortage areas and 57.5% began practice in medically underserved areas. Graduates who had also attended medical school in the state were even more likely to stay. Quezada et al. (2026) examined 15,851 family physicians certified from 2017 to 2022 and found that those who trained in teaching health centers or rural training tracks had higher odds of practicing in communities with high health-related social needs, while a broader definition of community-based training showed no such association. The lesson is that training must be truly rural or community based to change practice patterns, not simply located outside a large academic center.

I recommended that we partner with an established urban family medicine residency to create a rural training track, in which residents spend their first year at the urban program and their second and third years in our hospitals and clinics. That model lets us use the partner's accreditation experience and faculty while we build our own, recruit residents from our region's medical students and make use of federal start-up grants for rural residency planning. We would measure how many graduates remain in our four counties three and five years after graduation, compared with the retention of physicians we recruited from outside.

When Israel built the tabernacle, Moses told the people that the Lord had filled Bezalel with skill and understanding in every craft and had also inspired him and Oholiab to teach others (English Standard Version Bible, 2001/2016, Exodus 35:30-35). The work required more than two gifted craftsmen; it required skill passed on to many hands. A health system that only buys talent will always be competing for it, but a system that teaches can grow the workforce its communities need. Stewardship of our region's health means investing in the next generation of physicians as well as in today's care.

Reply to Rebecca

Rebecca, your thread predicted that telehealth will define the future of health care delivery and argued that it will lower costs by replacing many in-person visits, especially for rural patients. Shi and Singh (2019) expect technology to keep reshaping where and how care is delivered, and telehealth expanded dramatically during the pandemic, so your forecast has a strong basis. The evidence on cost and rural access, however, is more mixed than your thread suggested.

Mafi et al. (2026) studied 3.04 million commercially insured, Medicare Advantage and Medicaid members, with 120 million visits and $178.4 billion in spending from 2019 to 2023, and compared regions that adopted telemedicine heavily with regions that adopted it lightly. High-adopting regions showed about 2.4% fewer total visits and 0.5% lower spending, but neither difference was statistically significant, and no subgroup, whether urban, Medicaid, dual-eligible or socially vulnerable, showed a significant change. In other words, telemedicine did not clearly raise or lower total use and spending. That finding answers a fear payers once had, that telehealth would simply add visits, but it also challenges the hope that it would reduce costs.

Rural access is the second concern. Mackwood et al. (2026) examined 355,868 Medicare patients with lung or colon cancer and found that in 2020, patients living in small towns and rural areas used telemedicine far less than metropolitan patients, about 1.28 visits per year compared with 2.34, had fewer in-person outpatient visits and had more emergency department visits, 0.85 per year compared with 0.48. Lower rural telemedicine use continued in 2021. The authors concluded that telemedicine expansion did not improve overall access for rural patients with cancer, likely because of broadband gaps, older patients' comfort with technology and the need for in-person treatment.

None of this means telehealth lacks a future. It suggests that its value lies in convenience and continuity for patients who can use it, not in automatic savings, and that rural patients need broadband, devices and support before telehealth closes their access gap. For your organization, tracking telehealth use by rurality and age, and offering assisted telehealth visits at local clinics or libraries, could test whether the technology reaches the patients you most want it to serve. Payment policy will also decide telehealth's future more than technology will. Medicare's pandemic-era flexibilities, such as allowing patients to receive video visits at home and paying for audio-only care, have been extended repeatedly by Congress for short periods rather than made permanent, which leaves organizations uncertain whether to invest in telehealth staff and equipment. Shi and Singh's description of incremental policymaking fits that pattern exactly. An organization planning for the future might build telehealth into services that remain payable under any likely rule, such as behavioral health and chronic disease follow-up, while treating other uses as experiments. Does your organization know which of its patients have never used a video visit, and why?

Reply to Miguel

Miguel, your thread warned that rural hospitals are losing general surgeons faster than primary care physicians and that the future of rural obstetric and emergency services depends on keeping surgeons in small towns. Shi and Singh (2019) note that specialists concentrate in metropolitan areas, and the surgical workforce shows that pattern sharply. The evidence also suggests that the training remedy I proposed for family medicine applies to surgery too, although surgical training is longer, more equipment intensive and harder to move out of large hospitals.

Clark et al. (2025) studied 11,407 general surgery residency graduates from 2011 to 2020 and found that only 6.2% worked in rural communities. Graduates of programs that offered rural training, as listed on residency websites or by the American College of Surgeons, were more likely to work in rural areas, with odds ratios of 1.81 and 2.09, and rurally located programs, rural rotations and programs with a stated rural mission were associated with rural practice. The finding mirrors the family medicine evidence in my thread: exposure to rural practice during training predicts rural practice afterward.

The pipeline may need to begin even earlier. Suwondo et al. (2026) compared 96 graduates of the Columbia-Bassett program, a rural longitudinal integrated clerkship track in medical school, with 1,449 classmates in the traditional curriculum. Eight to ten years after graduation, 20.8% of program graduates were practicing in rural areas compared with 1.2% of their peers, and 54.2% practiced in health professional shortage areas compared with 17.1%. Participation remained strongly associated with rural practice after adjusting for rural upbringing and prior interests, which suggests the training itself, not only the students it attracted, made a difference.

For your hospital, a practical step would be to offer rural rotations to general surgery residents from the nearest academic program, with housing, a dedicated surgeon mentor and a case mix that shows residents the full scope of rural surgery, including endoscopy and cesarean sections. Over time, a rural surgery track with the same partner could follow. The financial case is worth making explicitly to your board. A rural hospital that loses its only general surgeon often loses its obstetric service too, since cesarean deliveries require surgical backup, and it may lose trauma and emergency admissions that keep its beds full. Training partnerships cost money for housing, faculty time and administration, but they are far cheaper than closing a service line or paying locum surgeons indefinitely. Residents who rotate through also give the hospital a recruiting pool of surgeons who already know the community, the staff and the kind of practice it offers. Would the surgeons at your hospital be willing to serve as teaching faculty if the hospital reduced their call burden in return?

References

Bray, N. N., Raischel, M., McGuire, D., Newhardt, R., Nolan, D., Snyder, T., Som, M., VanVolkinburg, L., Landgraf, C., & Wheeler, D. (2026). Addressing physician shortage in medically underserved rural and tribal communities through residency program collaboration. Journal of Osteopathic Medicine, 126(10), 473-480. https://doi.org/10.1515/jom-2025-0086

Clark, N. M., McClure, P., Erickson, A., Andrilla, H. A., Riha, G., Dennis, A., Stewart, B. T., Lynge, D. C., & Patterson, D. G. (2025). Impact of rural exposure during general surgery residency on practice in a rural community. Annals of Surgery, 282(2), 186-192. https://doi.org/10.1097/SLA.0000000000006696

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

Mackwood, M., Wang, Q., Tosteson, T. D., Brooks, G., Smith, R. E., & Tosteson, A. N. A. (2026). Comparing trends in telemedicine use and geographic disparities in utilization among patients with cancer in the United States. JCO Oncology Practice, 22(7), 1331-1340. https://doi.org/10.1200/OP-24-00751

Mafi, J. N., Vangala, S., Cantor, J., Craff, M., Cui, M., Romanov, A., Li, Z., Rockwell, M., Tseng, C. H., Skinner, D., Hadfield, M., Fendrick, A. M., Damberg, C. L., Sarkisian, C., & Kahn, K. L. (2026). Telemedicine adoption, US ambulatory visits, and total medical spending, 2019-2023. JAMA Network Open, 9(5), e2611835. https://doi.org/10.1001/jamanetworkopen.2026.11835

Quezada, F., Manfredonia, P., Fenster, T. L., Topmiller, M., Jabbarpour, Y., & Park, J. (2026). Community-based training and impact on care of socially disadvantaged populations. Journal of Graduate Medical Education, 18(4), 424-431. https://doi.org/10.4300/JGME-D-25-00680.1

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

Suwondo, P., Richards, B., Cunningham, H., & Weil, H. F. C. (2026). Ten-year outcomes from the Columbia-Bassett program: A model for strengthening the underserved health workforce. Academic Medicine. Advance online publication. https://doi.org/10.1093/acamed/wvag203