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Background The United States is considering enacting a national health plan and global health care budget similar to those in other countries. There are few data on the effects of such policies on physicians and patients.
Methods We conducted a telephone survey of 602 physicians in the United States, 507 physicians in Canada, and 519 physicians in the former West Germany from February through May 1991; the response rates were 44 percent, 49 percent, and 41 percent, respectively. Among other topics, the questionnaire included measures of satisfaction with the health care system and with medical practice.
Results In the United States, 23 percent of the physicians surveyed thought the health care system worked well, as compared with 33 percent in Canada and 48 percent in West Germany. Seventy-three percent of U.S. physicians reported that patients' inability to afford necessary treatment was a serious problem, as compared with 25 percent in Canada and 15 percent in West Germany. Seventy-seven percent of West German physicians, 56 percent of Canadian physicians, and 54 percent of U.S. physicians said the shortage of competent nurses was a serious problem. In Canada, 50 percent of the respondents cited the lack of well-equipped medical facilities as a problem, as compared with 14 percent in the United States and 20 percent in West Germany.
Conclusions Programs of universal coverage and cost containment necessitate important trade-offs. In Canada and West Germany, physicians do not report serious problems of access to care for the poor and uninsured. In the United States, doctors do not face the limited access to sophisticated forms of medical technology that was reported in Canada or the diminished quality of some services reported in West Germany.
One element that has been missing from this examination is an assessment by practicing physicians of how well their health care systems function. Physicians are in a unique position to make this assessment because they make professional judgments about when patients require hospitalization and other services. In addition, physicians often serve as advocates for patients who require expensive tests or treatments. Finally, the subjective reactions of physicians are important. The willingness of U.S. physicians to accept a particular reform will be a factor in determining the feasibility of the reform.
In an effort to understand the health care systems of the United States, Canada, and West Germany from the perspective of the physicians who practice in those systems, we designed and conducted a survey focusing on the realities of caring for patients in these diverse environments.
Methods
Sampling and Response Rate
We surveyed 602 physicians from the United States, 507 physicians from Canada, and 519 physicians from West Germany by telephone from February through May 1991; these numbers represented 44 percent of the physicians selected for participation in the United States, 41 percent in West Germany, and 49 percent in Canada. West and East Germany were reunified before the survey period, but our sample was drawn from lists of physicians practicing in the former West Germany, and these respondents are designated as being from West Germany throughout this report. The survey was conducted by telephone by Louis Harris and Associates in the United States and by their subcontractors, Consumer Contacts in Toronto, and EMNID in Ebenhausen, Germany. All interviews in the United States were conducted in English, those in Canada in English or French, and those in West Germany in German.
The physicians were selected randomly from lists of practicing physicians in each country that were available through private or government sources, with the samples controlled to be representative of the distribution of specialists and nonspecialists within each country. In the United States we used the MEDEC file of hospital-based and office-based patient care physicians compiled by Business Mailers, Inc.; in Canada, the Canadian Medical Directory '9011; and in West Germany, the listing of the national physicians' board. Physicians in training were excluded. The physicians selected for participation were notified by letter before the initial telephone contact and were informed at that time that they would be compensated at an average rate (in U.S. dollars) of $40 per interview, with some variation according to location and specialty, after completing the interview. Up to five attempts were made, at different times of the day, to contact each physician by telephone.
The Survey Questionnaire
A single questionnaire was designed to be administered to physicians in all three nations. Questions were included about their views of the health care system, their satisfaction with various aspects of medical practice, their perceptions of the quality of care delivered, their ability to obtain needed services for patients, their perceptions of the overuse and underuse of services within the system, and demographic variables. Thirty-seven questions were asked, of which seven had multiple parts. All questions included a possible response of "not applicable." The questionnaire was reviewed by experts on the health care systems of the three countries and pretested for length and comprehensibility in each country. French and German translations were prepared by the Canadian and West German survey firms and validated by back-translation methods. The average length of the interview was 19 minutes in the United States, 30 minutes in Canada, and 45 minutes in West Germany. The French and German versions of the questionnaire were substantially longer than the English version; this factor probably accounted for much of the variation in the length of the interview among the three nations.
Sources of Error and Bias
The response rate indicates that our results may be subject to a substantial degree of bias due to the nonresponse of a high proportion of the original sample. However, the distribution of physicians in our samples was within ±5 percentage points of the known distributions of practicing physicians in each country according to specialty, sex, and age group (with the exception of West Germany, where the proportions in our sample were 7 percentage points lower for physicians under 40 years old and 9 percentage points higher for physicians at least 40 years old than the known distribution in the country as a whole).
Estimates from samples of 500 to 600 respondents are associated with sampling errors (i.e., 95 percent confidence intervals) on the order of ±4 percent when the responses are evenly divided. The errors are smaller when the responses of study subjects differ substantially. As a general rule, when two uncertain estimates of study groups of this size are compared, the difference between the two needs to be about 6 percent in order to meet a conventional standard of statistical significance (P<0.05). Significance tests, when reported here, are based on likelihood-ratio chi-square analysis and refer to the total responses in the countries compared.
Results
Table 1 shows comparative demographic data for the respondents. The mean age of the West German physicians was lower than that of physicians in the other two nations, and there were more women respondents in Canada and West Germany than in the United States. The proportions of U.S. and Canadian physicians practicing in office or hospital settings were similar, but the West German physicians were much more likely to practice in hospitals. With respect to total hours worked and the proportion of time physicians spent in administrative tasks, there were only minor differences among the three countries. However, the mean number of patients cared for in the week before the survey was substantially higher in West Germany than in the United States or Canada (176 vs. 85 and 102, respectively). The proportion of the physicians surveyed in Canada and West Germany who were in primary care specialties (family or general practice, general internal medicine, and pediatrics) was higher than in the United States.
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Physicians in each country were asked to select one of three statements to describe their view of the overall performance of their health care system. Table 2 shows the statements and the results, stratified according to specialty. The majority of physicians in all three countries thought fundamental change or complete rebuilding was necessary to make their health care system function more effectively. However, both West German and Canadian physicians were more satisfied with their systems than were U.S. physicians. Almost half of the West German physicians (48 percent) said their current system worked well, as compared with less than one quarter (23 percent) of U.S. physicians. In Canada and the United States there were no major variations in the response to this question according to specialty or age; in West Germany, however, 52 percent of physicians 40 years of age or older said that only minor changes were needed, as compared with only 41 percent of physicians under 40 years of age.
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Caring for Patients
The physicians were also asked to rate the severity (very serious, somewhat serious, not very serious, or not a problem at all) of 12 different problems related to patient care. The nine items listed in Table 4 were reported as serious problems (very serious or somewhat serious) by half or more of the physicians in at least one of the countries. Problems that were not ranked as serious by a majority in any of the countries included limitations on when patients could be admitted to the hospital, limitations on the ability to refer a patient to a particular specialist of the physician's choice, and the continuity of the relationship with patients.
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Half of Canadian physicians reported an inadequate supply of well-equipped health care facilities as a serious problem. In both Canada and the United States, a majority of primary care physicians (66 and 60 percent, respectively) said that patients' demands for more services than doctors thought clinically necessary was a serious problem. West German physicians were the only group in which a majority (58 percent) said that difficulty in spending enough time with their patients was a serious problem. Overall, U.S. specialists reported fewer problems with the amount of time they spent with their patients than physicians in Canada or West Germany, whether they were specialists or primary care physicians. In all three countries, but especially in West Germany, a majority of physicians identified the shortage of nurses as a serious problem.
Several items were included to gauge physicians' perceptions of the quality of health care available within their health care systems. In one sequence of questions, we asked the respondents to rate the hospital in which they practiced or in which the majority of their patients were hospitalized in terms of several factors, using a four-point scale (excellent, good, fair, or poor). There were differences in the responses of the West German and U.S. physicians with regard to several factors, including the hospital's success in maintaining an adequate nursing staff (80 percent chose excellent or good in the United States, as compared with 30 percent in West Germany), coordination of patient care services (78 percent in the United States vs. 57 percent in West Germany), and cooperation and communication among health professionals (80 percent in the United States vs. 44 percent in West Germany). There were smaller but still substantial differences regarding the adequacy of response of the nursing staff to patients' requests for pain medication and the availability of accurate and timely laboratory results (the gaps between the two nations in the proportion of physicians choosing excellent or good were 12 percent and 9 percent, with the United States having the higher proportion in both instances). There were differences between the responses of Canadian and U.S. physicians with regard to the coordination of patient care services (68 percent choosing excellent or good vs. 78 percent, respectively) and communication among patient care staff (68 percent vs. 80 percent).
We then asked the respondents to rate certain types of services available in their communities. West German physicians rated as excellent or good the provisions in their system for prenatal care (86 percent) and preventive health services (77 percent); in the United States 66 percent rated prenatal care as excellent or good and 58 percent gave preventive care similar ratings; for the Canadian physicians, these figures were 69 percent for prenatal care and 65 percent for preventive care. The West German physicians were not at all happy with the services available for the frail elderly; only 15 percent rated these services as excellent or good. The comparable percentages among U.S. and Canadian physicians were 44 percent and 36 percent, respectively. A final question in this series asked whether the physicians had referred a patient to another country for medical treatment in the past five years and, if so, for what reason. The majority of physicians in all countries had never sent a patient to another country for medical care, but the frequency of this practice did vary. Nearly one third of Canadian physicians (32 percent) had referred a patient outside their country, as compared with 7 percent of U.S. physicians and 19 percent of West German physicians. In Canada, the two principal reasons for sending a patient abroad were the lack of availability of services in Canada (40 percent) and the length of the wait for certain treatments (19 percent), whereas in West Germany the principal reasons were that higher-quality care was available elsewhere for some services (30 percent) and that the wait was too long (23 percent). In the United States, the two major reasons were that patients lived in another country (27 percent) and that certain services were unavailable in the United States (20 percent).
Discussion
We examined the U.S., Canadian, and West German health care systems from the viewpoint of practicing physicians in order to understand better the national health systems and mechanisms of cost containment. The study provides helpful information but is not without limitations, of which two are of primary concern. First, comparative studies such as this are of limited use in describing underlying cultural differences that could shape perceptions and expectations. For example, are the physicians in one country more optimistic or pessimistic than those in another country? Do the physicians have different views of the role of government? Such questions might be answered with other research, but they are not addressed here. Second, the rate of response in this study was low, although efforts were made, in accordance with standard survey practice, to encourage physicians to respond. Nonresponse bias may be attenuated by the fact that the respondents were representative of practicing physicians within each country in terms of age, sex, and specialty.
A majority of physicians in all three countries thought their systems needed reform. This finding highlights the fact that there is no panacea for the problems that face any nation as it tries to provide affordable, high-quality health care to all its citizens. In addition, the adoption of a national health care system does not necessarily lead to administrative simplicity for physicians, since physicians in all three countries spent similar numbers of hours in administrative activities.
This study also highlights some of the trade-offs the three countries have made while trying to address these common problems. In the United States, the only country of the three without universal coverage or a national cost-containment strategy, physicians pointed to access to care for the indigent as the most important problem in patient care; they were also more likely to report a serious problem with disputes over payment. In Canada, a nation with universal coverage and stringent cost-containment programs, about half the physicians confirmed that access to specialized services and facilities was troublesome, and the most important systemwide problem was seen as the overuse of services by patients. In West Germany, which also has universal coverage and a global health care budget, the central problem for physicians was coping with a shortage of nurses and poor coordination of services for patients in an environment of high demand for services.
On balance, as the United States examines the experience of other nations, it would be prudent to think about the types of trade-offs Canada and West Germany have made to achieve universal access and containment of health care costs. We should recognize, however, that the United States spends substantially more per person for health care ($2,566 in 1990) than Canada ($1,770) or West Germany ($1,486); at this higher spending level, our nation would not necessarily face the same difficulties with access to services or quality of care12.
These results demonstrate that although the majority of physicians in each country thought their health care system needed reform, U.S. physicians were less satisfied with their system than those in Canada and West Germany. The nature of the trade-offs made in achieving universal coverage and cost containment in Canada and West Germany appears to be more acceptable to physicians in those countries than is the limited access to care for the poor to physicians in the United States.
Supported jointly by the Robert Wood Johnson Foundation, the Commonwealth Fund, and the Pew Charitable Trusts. The views expressed are solely those of the authors, and no official endorsement by any of the sponsors is intended or should be inferred.
We are indebted to the following, who reviewed and commented on early versions of the survey questionnaire: Michael Arnold, M.D., Cathy Charles, Ph.D., Gregory Curfman, M.D., Robert Ebert, M.D., John Iglehart, Andrea Kabcenell, R.N., M.P.H., Kurt Kochsiek, M.D., and F.W. Schwartz, M.D.
Source Information
From the Department of Health Policy and Management, Harvard School of Public Health, Boston (R.J.B., K.D., A.E., C.K., S.W.L.); Louis Harris and Associates, New York (R.L.); the Department of Medical Care Policy, Harvard Medical School, Boston (A.E.); the Robert Wood Johnson Foundation, Princeton, N.J. (J.C.C.); the Institute for the Future, Menlo Park, Calif. (I.M., T.M.); and the Institute for Health Policy, Florence Heller Graduate School for Advanced Studies in Social Welfare, Brandeis University, Waltham, Mass. (A.B.C.).
Address reprint requests to Dr. Blendon at the Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115.
References
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Related Letters:
Reforming Our Health Care System
Freedman J. K., Korns N., Robb J. A., Hurt M. A., Grosz R., Armey D., Beach S. G., Longo D. R., Angell M.
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Full Text
N Engl J Med 1993;
329:806-808, Sep 9, 1993.
Correspondence
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