MDs give "Needs Improvement" grade to U.S., Canadian and German health systems.

Doctors in the United States, West Germany and Canada believe their health systems all need fundamental reform, according to a survey in the New England Journal of Medicine. The survey indicates that no country has found the panacea for providing affordable, quality health care for its citizens. But U.S. doctors are least satisfied with their health system, citing lack of indigent care as the nation's most pressing health care problem.

* Only 23 percent of the U.S. doctors responding to the survey believe their system works efficiently, compared to 48 percent of West German physicians and 33 percent of Canadian doctors.

* U.S. physicians believe the major problems with our system are lack of access to care by indigent patients (55 percent) and the high cost of care (38 percent). Only 1 percent of Canadian physicians and 5 percent of German doctors mention indigent care as a problem. Canadians are concerned by patient overuse of the health care system (30 percent) and limited access to health care facilities (17 percent). Germans mention the high cost of care (32 percent) and administrative burdens (25 percent) as their top concerns.

* Half of the Canadian respondents are concerned about an inadequate number of well-equipped health care facilities.

* West German doctors are least satisfied with care for the frail elderly. Only 15 percent of them rate these services as excellent or good, compared to 44 percent of U.S. physicians and 36 percent of Canadians.

* More doctors in the United States than in the other two countries believe their patients should seek care earlier.

* A majority of both Canadian and U.S. primary care physicians (66 percent and 60 percent respectively) believe that patient demands for more services than doctors believe clinically necessary is a serious problem.

What Doctors Say Are Problems with the Health-Care System

                                          United               West
                                          States    Canada    Germany

Access to care for indigent patients        55%       1%         5%
High cost of services                       38       11         32
Administrative burden and bureaucracy       12        9         25
Overuse or abuse of system by patients       4       30         19
Access to facilities                         0       17          0

Note: Practicing physicians were asked to cite the two most important problems
with their country's health-care system.
The Most Serious Problems

                                                 United                 West
                                                 States    Canada    Germany

Patients are unable to afford fees or charges      73%       25%        15%
for some aspect of the medical care
you think is necessary.

Patients should have sought or been                51        36         42
referred for medical attention sooner

Excessive delays or disputes in processing         78        24         39
insurance forms or receiving payment
for services rendered

External review of clinical decisions for the      53        28         43
purpose of controlling health care costs

Limited supply of well-equipped                    14        50         20
medical facilities

Patients insist on unnecessary services            42        53         49

Limits on the time you can spend                   35        44         58
with each patient

Shortage of competent nursing staff                54        56         77

Limitations on length of hospital stay             57        30         29

Note: Respondents were asked to rate 12 problems related to patient care as
very serious, somewhat serious, not very serious or not a problem at all.
Those shown here were classified as very serious or somewhat serious by 50
percent or more of the respondents in at least one country.