Third, the study shows that with global budgets, some things that are important to practicing physicians disappear. We have no outcomes research in our study, but physicians in Germany and Canada wish that certain things that money could buy were more available.

I will give you two examples of this third finding. In Canada, the problem is access to adequately equipped medical facilities and specialists. Physicians were given a series of measures of practice and asked if they had any serious problem in this area. In Canada, 50 percent of practicing physicians said they had a serious problem getting access to adequately equipped medical facilities for their patients. That number was 14 percent for U.S. physicians.

In Germany, the problem that was most striking had to do with quality of care in inpatient facilities. Physicians were asked to rate the competency and quality of the hospital nursing staff where they most often worked. In the United States, 80 percent of practicing physicians rated the quality of their nursing staff highly. In western Germany, only 30 percent did so.

In short, problems differ from country to country.

Finding number four: We also found a positive side to the problems in Germany and Canada cited in our third finding. Physicians in Germany and Canada have no problems with patients who do not have the ability to pay. When asked whether they had a serious problem with patients who cannot pay for needed care, 73 percent of practicing doctors in the United States said yes. In Germany, only 15 percent said yes; in Canada, 25 percent said yes.

I draw two conclusions from these data. First, universal coverage and global budgets involve some trade-offs. To be honest, the level of expenditures is still so much higher in the United States that we could probably lower our expenditures and see none of the problems that we found in our study for a number of years. But somewhere down the line, there will be a trade-off involving services not being made available to physicians.

Second, the fact that Canadian and German physicians express greater satisfaction, even in the face of trade-offs, than their American counterparts indicates that universal coverage is an advantage for those physicians. They do not have to make the sorts of political decisions that come with patients who cannot pay for care.

In summary, it is important that from the perspective of physicians, global budgets involve trade-offs. There are areas of patient decision-making that physicians feel are appropriate and that they are unable to achieve within the present U.S. system.

I think the debate will be around how important U.S. physicians think the trade-off is between the things physicians in other systems think they

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