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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; 174 The Commonwealth Fund
UNITED STATES • National Institutes of Health, which is responsible for biomedical and health-related research; • Health Resources and Services Administration, which supports efforts to improve health care access for people who are uninsured, isolated, or medically vulnerable; • Agency for Healthcare Research and Quality, which conducts evidence-based research on practices, outcomes, effectiveness, clinical guidelines, safety, patient experience, health information technology, and health disparities; • Food and Drug Administration, which is responsible for promoting public health through the regulation of food, tobacco products, pharmaceutical drugs, medical devices, and vaccines, among other products; • Center for Medicare and Medicaid Innovation, an agency within CMS that was created by the Affordable Care Act to test and disseminate promising payment and service delivery models designed to reduce spending while preserving or improving quality; and • Patient-Centered Outcomes Research Institute, also created by the ACA, which is tasked with setting national clinical comparative-effectiveness research priorities and managing research on a broad array of topics related to illness and injury. Organization of the Health System in the United States Public Financing Private Financing Federal government State government Privately insured individuals Selected other HHS agencies: • CDC • NIH • HRSA • AHRQ • FDA Department of Health & Human Services (HHS) Centers for Medicare & Medicaid Services Employers Marketplaces Other government insurance programs Medicare Medicaid and CHIP Private insurance Providers (e.g. hospitals, physicians, long term care institutions, mental health institutions, pharmacies) Nongovernmental scientific and professional organizations (IOM, AMA, PCORI, etc.) Provider regulatory organizations (Joint Commission, etc.) Hierarchial Contracts Regulation Source: Adapted from T. Rice, P. Rosenau, L. Y. Unruh et al., “United States of America: Health System Review,” Health Systems in Transition, vol. 15, no. 3, 2013, p. 27. International Profiles of Health Care Systems, 2015 175
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
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AUSTRALIA In 2013, the federal gove
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What is being done to reduce dispar
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References AUSTRALIA Australian Bur
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CANADA What is covered? Services: T
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CANADA funding to 145 not-for-profi
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CANADA Organization of the Health S
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CANADA provides recommendations to
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CANADA Health Council of Canada (20
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CHINA Private health insurance: Com
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CHINA is not substantially more exp
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CHINA Organization of the Health Sy
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CHINA References Chen, X. (2014).
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DENMARK In addition, nearly 1.5 mil
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DENMARK Social psychiatry and care
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DENMARK Quality data for a number o
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DENMARK portion is small, it makes
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48
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ENGLAND immunization, and vaccinati
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ENGLAND Hospitals: Publicly owned h
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ENGLAND Organization of the Health
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ENGLAND How are costs contained? Ra
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ENGLAND Organisation for Economic C
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FRANCE VHI finances 13.8 percent of
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FRANCE The average income of primar
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FRANCE What are the key entities fo
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FRANCE inequities in prevention rel
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FRANCE Nolte, E., C. Knai, and M. M
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GERMANY There were 42 substitutive
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GERMANY The 16 state governments de
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GERMANY management system, by the s
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GERMANY What major innovations and
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INDIA Private health insurance: The
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INDIA provide after-hour care, reim
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INDIA are provided by other ministr
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INDIA How are costs contained? Ther
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ISRAEL Together, these two types of
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ISRAEL Primary care physicians are
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ISRAEL Organization of the Health S
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ISRAEL • Using electronic health
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ITALY during hospitalization (Thoms
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ITALY Some regions are promoting ca
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ITALY Organization of the Health Sy
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ITALY although the degree of evolut
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ITALY The author would like to ackn
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JAPAN What is covered? Services: Al
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JAPAN incentives for providers to c
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JAPAN Organization of the Health Sy
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JAPAN The author would like to ackn
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THE NETHERLANDS receive faster acce
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THE NETHERLANDS Hospital payment ra
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THE NETHERLANDS Organization of the
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THE NETHERLANDS References Organisa
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Page 134 and 135: NORWAY Primary, preventive, and nur
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Page 140 and 141: NORWAY The National System for the
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Page 144 and 145: SINGAPORE Medifund is the governmen
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Page 156 and 157: SWEDEN Hospitals: There are seven u
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Page 162 and 163: SWITZERLAND Insurers offer premiums
Page 164 and 165: SWITZERLAND Hospitals: About 70 per
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Page 172 and 173: UNITED STATES What is covered? Serv
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