Health Care Delivery Systems and Organization
Core concepts
Candidates should be able to distinguish the major delivery models - solo and small-group practice, multispecialty groups, hospital-owned practices, accountable care organizations (ACOs), patient-centered medical homes (PCMH), concierge/direct primary care, retail clinics, and telehealth-only entities - and describe the incentives each creates. Understand the continuum of care, levels of care (primary, secondary, tertiary, quaternary), and the difference between vertical and horizontal integration. Know the roles of governing bodies (board, medical staff, credentialing committee) and how medical staff bylaws, department structures, and peer review fit together.
Traps
Questions often blur ownership with control. A physician may be an employee of a hospital yet retain clinical autonomy protected by bylaws. Another trap is conflating an ACO (a payment-and-care coordination structure) with an HMO (an insurance product with restricted networks). Watch for items that assume hospital-employed physicians must follow hospital policies on purely clinical judgment - credentialing and peer review are governed by medical staff processes, not employment contracts alone.
Worked example / rule of thumb
A hospital buys 12 independent primary care practices. This is vertical integration (moving toward the patient-facing front of the care continuum), not horizontal. If those 12 practices instead merged with each other into one group, that would be horizontal. Rule of thumb: horizontal = same level, vertical = different levels of the continuum.
Also remember that the organized medical staff is accountable to the governing board for the quality of care, and the board delegates credentialing and privileging to the medical staff through bylaws - a chain of accountability questions love to test.