HEALTH SYSTEM

Government role

Medicare: age 65+, some disabled; Medicaid: some low-income; for those without employer coverage, state-level insurance exchanges with income-based subsidies; insurance coverage mandated, with some exemptions (10.4% of adults uninsured).

Public system financing

Medicare: payroll tax, premiums, federal tax revenue; Medicaid: federal, state tax revenue.

Private insurance role

Primary private voluntary insurance covers ~66% of population (employer-based and individual); supplementary for Medicare.

Provider ownership

Primary care: Private

Hospitals: Mix of nonprofit (~70% of beds), public (~15%), and for-profit (~15%)

Provider payment

Primary care payment: Most fee-for-service, some capitation with private plans; some incentive payments

Hospital payment: Outpatient care as a fee-for-service

Primary care role

Registration with GP required: No

Gatekeeper: In some insurance programs

HOW IS THE MEDICAL SERVICE ORGANIZED

Primary care

Roughly one-third of all US-physicians work in in primary care. The majority of which work in self-or group owned practices. However there is a trend towards larger group practices. Mostly the patients have freedom of choice at least umong the in-network providers. They are usualy not required to register with a GP and the GP does not have a gatekeeping role to play.
The physician is paid through a combination of methods ranging from negotiated fees with the private insurers to administratively set fees for the public insurance. Mostely the patient is directly responsible for a portion of the payment.

Outpatient specialist care

Outpatient specialists tend to work in both private practices and hospitals. Some plans limit direct access to specialist and require a referral from the GP (e.g. HMOs) other plans such as PPO plans allow for a more direct access. For Medicaid patients or non-insured patients access can be difficult.Private insurance role

Complementary to cover cost-sharing and gaps, as well as better health care quality and/or higher reimbursements. No data on coverage, but growth has been rapid.

Direct payments to providers

Co-payments for doctor visits are typically paid at the time of service or are billed to the patient afterward. Often insurance plans 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 care is limited and is often provided by emergency rooms. Next to this there are also urgent care centers which are mostly independent and owned by physicians. Some insurance companies make after-hours telephone service available and also tele-consulation is becoming more popular.

Hospitals

Hospital can be non-for profit (majority of beds nationally), for-profit or public. Public hospitals can also service private patients.
The hospitals can be financed through a variety of methods such as per case payments, per-service-charges,…
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.

Mental Health Care

Mental health care can be provided by either for-profit and non-for-profit providers. Most insurance plans cover inpatient hospitalization, outpatient treatment emergency care and prescription drugs.

Long-term Care

Long-term care is provided by for-profit and non-fo-profit providers. Hospice care is included is included as medicare benefit.