One federal payer buys an essential floor through four payment methods matched to cost structure rather than to who owns the building: a reference fee schedule, capacity payment for standby capability, capitation with reinsurance, and hospital global budgets. Delivery stays plural and regional — private practices, nonprofit systems, public hospitals, tribal systems, and a standing public arm of federally chartered Regional Health Authorities, aggregated from entities that already run multi-site operations. Every county is assigned to exactly one Authority, so deserts are attached rather than built. Inside the floor there is no prior authorization, no network denial and no balance billing. A regulated supplemental sits above it, separately priced.
The model is neonatal regionalization: defined capability tiers, defined referral relationships, and organized maternal and neonatal transport. Trauma inherits the same template without loss and keeps its Level I–IV designation.
Perinatal care is the better template because it is a planned event with a low-probability tail. Capability can be sited in advance, risk stratified prenatally, and the patient moved before the emergency. Trauma is a random event with no notice, so its design collapses onto retrieval speed alone.
Presence is not capability. A hospital that says it delivers babies but cannot perform a caesarean has presence. The Rural Emergency Hospital designation illustrates the limit: conversions cluster where another hospital is nearby because of the 24-hour transfer requirement, which makes the mechanism least available in the deepest deserts, and bypass kills converted facilities outright.
Bypass is not always a failure. It is correct when it routes a patient toward capability and destructive when it routes them away from capability that exists. That distinction is why the design purchases capability rather than presence.
Four components fund together or none do.
A capable local site meeting the access threshold — for obstetrics, surgical delivery capability. A staffed retrieval network: ground EMS on capacity payment, with maternal and neonatal air transport as a core funded component. A designated receiving centre under a standing acceptance obligation, crossing state lines where geography requires, with its global budget conditioned on acceptance. Tele-support from the receiving centre, funded inside that centre's budget rather than billed by the rural site.
Catchments cross state lines routinely, which is the operative argument for federal financing: a coverage unit that does not contain the care is not a coverage unit.
Where a local unit cannot be sustained, transport is the funded backstop. Degraded is not the same as absent, and the two should not be described in the same words.
- Access as a distribution
- The bundle moves travel times down; it does not produce a completion percentage.
- Capacity payment
- Retrieval and standby are funded as capability, not per encounter.
Bypass defeats the bundle. A facility can be funded, open and still fail because patients drive past it.
Correct, and the reason the bundle buys capability rather than presence. Capability is expensive and the workforce pipeline is a decade out, so in the interim the retrieval network and the receiving-centre obligation carry catchments that cannot yet sustain a local site.
Honesty about gaps. Distributed Healthcare has more unresolved specification than other Engines because operational complexity is higher; the items below are flagged for v10.2 specification or for outside expert review.
- Air transport capacity has to be sized as a contingency load, not a steady state: when a local unit closes, the receiving centre absorbs volume and the retrieval network absorbs transfers.