JANUARY

UNITED STATES
Administrative mechanisms for paying primary care doctors and specialists: Copayments for doctor visits
are typically paid at the time of service or are billed to the patient afterward. Some insurance plans and
products (including health savings accounts) require patients to submit claims to receive reimbursement.
Providers bill insurers by coding the services rendered; this process can be very time-consuming, as there are
thousands of codes.
After-hours care: After-hours access to primary care is limited (39% of primary care doctors in 2015 reported
having after-hours care arrangements) (Osborn et al., 2015), with such care often being provided by hospital
emergency departments. As of 2007, there were between 12,000 and 20,000 urgent-care centers in the U.S.
providing walk-in after-hours care. Most urgent-care centers are independently owned by physicians, while
about 25 percent are owned by hospitals (Rice et al., 2013). Some insurance companies make after-hours telephone
advice lines available.
Hospitals: Hospitals can be nonprofit (approximately 70% of beds nationally), for-profit (15% of beds), or public
(15% of beds). Public hospitals can serve private patients. Hospitals are paid through a combination of methods,
including per-service or per-diem charges, per-case payments, and bundled payment, in which case the hospital
may be financially accountable for readmissions and services rendered by other providers. Some hospital-based
physicians are salaried hospital employees, but most are paid on some form of fee-for-service basis—physician
payment is not included in Medicare’s diagnosis-related group (DRG) payments. Hospitalists are increasingly
common and now present in a majority of hospitals.
Mental health care: Mental health care is provided by a mix of for-profit and nonprofit providers and
professionals—including psychiatrists, psychologists, social workers, and nurses—and paid for through a variety
of methods that vary by provider type and payer. Most insurance plans cover inpatient hospitalization,
outpatient treatment, emergency care, and prescription drugs; other benefits may include case management
and peer support services.
The Affordable Care Act aimed to improve access to mental health care by establishing it as an essential health
benefit (see above), applying federal parity rules to ensure that coverage is comparable, and increasing access
to health insurance more generally.
Long-term care and social supports: Long-term care is provided by a mix of for-profit and nonprofit providers,
and paid for through a variety of methods that vary by provider type and payer. Medicaid, but not Medicare,
offers the most extensive coverage of long-term care, although it varies from state to state (within federal
eligibility and coverage requirements). Since Medicaid is a means-tested program, patients must often “spend
down” their assets to qualify for long-term care assistance. However, hospice care is included as a Medicare
benefit, as are skilled short-term nursing services and nursing home stays of up to 100 days. Long-term care
insurance that offers comprehensive care is available but rare. Most certified nursing facilities are for-profit
(69%), while 24 percent are nonprofit and 6 percent are government-owned (Henry J. Kaiser Family Foundation,
2015b). Caregiver support programs and personal health budgets—such as cash and counseling programs in
Medicaid—are available in some states to support caregivers and recipients of home-based care. Some of these
programs allow recipients to employ family members. However, most informal and family caregivers do not
receive payment or benefits for their work.
What are the key entities for health system governance?
The Department of Health and Human Services (HHS) is the federal government’s principal agency involved with
health care services. Organizations that fall within HHS include the:
• Centers for Medicare and Medicaid Services:
• Centers for Disease Control and Prevention, which conducts research and programs to protect public health
and safety;
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The Commonwealth Fund