Prof. Uwe Reinhardt
Health economist, Princeton University

Is one of the factors [contributing to the high cost of U.S. health care] the doctors' income?

That's now the latest target, to blame it on doctors' incomes. Yes, American doctors get paid more, relative to average employees, than doctors in other nations; that is true. It's about five times average employee compensation, and in England it's about two, and in Canada it's about three. So that's certainly true.

However, I would caution, the physicians' take of the whole health care cake is 20 percent, of which close to half goes to pay for their expenses: malpractice, nurses, rent, supplies. ... If you cut physicians' income by 20 percent, which would be a huge cut, you would shave 2 percent of national health spending. It wouldn't bail you out, and you would have a huge cadre of highly demoralized doctors. So this doctor bashing, I think, is barking up the wrong tree. ...

... Every health care system needs some kind of quality controls on the doctors, on the hospitals, and in the American system it seems to be malpractice cases. Is that a good way to do it?

Reinhardt: At the moment that's all we have, and it is somewhat effective. If we didn't have it, we'd be in much, much worse shape. The criticism against that system is that the lawyers who bring the cases get a big cut; the contingency fee system. And a lot of people would say if we abolished this, malpractice would be cheaper. But in countries where the lawyer has to get paid to do the work, and the losing party has to pay the party that prevailed their court costs, in such a system, low-income [plaintiffs] would never bring suit; they would never have a hope. So actually, as un-American as this may sound, I'm actually in favor of the present system until we have something better. ...

Does our malpractice regime add significantly to the cost of American medicine?

The average cost of malpractice [insurance] premiums as a percent of national health spending is around 1 percent. The cost people attribute to the system is what is called "defensive medicine": that doctors will order tests or do procedures not because they're convinced clinically they should do it, but they always have in mind: "I'm sitting in a courtroom and they say, 'Did you do this test?,' and if not, the jury would nail me."

The AMA [American Medical Association] has estimated it could be up to 10 percent [of tests]; we don't really know what it is. I also tell doctors: "Well, on the other hand, these tests are profitable for you. So if we abolished malpractice, would you give up 10 percent of your income?" And that's not so clear to me whether they wouldn't do these tests anyhow.

We asked doctors in all these different countries: How much is your malpractice insurance? Will you ever be sued? And [they had] very low insurance rates, and no, they don't ever expect to be sued. So how do those other countries maintain quality in medical care?

If you take Germany, for example, the doctors are employees of the hospital, and the whole hospital is accountable for everything that happens in its walls. With us, we have the strangest system: A hospital is a free workshop for an independent businessman or -woman called the doctor, who can go in there and order nurses and everyone around and cause costs, etc., but is actually sort of independent. The hospital isn't really accountable for the work even of the anesthesiologists and the radiologists, because they're freestanding entrepreneurs. That system is much more difficult to control, quality-wise. In the other countries, where doctors working in a hospital are employees, there is internal quality control.

Ahmed Badat, M.D.
General practitioner, Shepherds Bush Medical Center, London

In America we have the situation that the drug companies wine and dine the doctors. They give them free golf clubs, and they give them trips to Las Vegas so that you'll prescribe their pill. Is that going on here?

It used to go on about 10 years ago. Not as much as much as the Americans, but they used to take us to weekend trips to Jersey or to Nice, yeah. But the government has stopped that from the last about 10 years. The pharmaceutical industry -- very, very strict now. I think they can't give you anything [worth] more than 3 pounds [or] 4 pounds. ...

... You went to medical school, did you say, in Rhodesia, or here?

I started in Rhodesia, but after two years I came to England, and I did it at the University College Hospital.

University College, London. How much did it cost to go to medical school here?

In my time, [it] was free. My son -- I'll tell you about my son. ... He did three degrees. So his first degree was free, and he paid nothing because the council, the [city] government pays for the tuition. He did a second degree, which was a master's, ... a year course, [for] which I paid 3,000 pounds.

$6,000 for --

Yes, $6,000 for a master's.

Yeah, master's. That's a bargain.

Right? Then he went to medical school, and because there's a shortage of doctors at the moment -- this was five, six years ago -- he was paying 1,100 pounds a year. $2,200.

$2,200 to go to medical school.

In tuition fees. I mean, of [course] your living costs are different, but that is normal. I mean, 1,100 pounds is nothing. I mean, it's free.

It's a bargain.

And they give you a loan, student loan, which is about $7,000 a year, which you repay when you qualify and you're earning X amount of money. And you pay a small amount every year, so, I mean, there's not too much hardship.

Do you have to buy malpractice insurance?

Yes. My malpractice insurance is $6,000 a year.

$6,000 a year. I think a GP [general practitioner] in America would pay that per month.

Yeah. ... I've been practicing here 29 years. I had, I think, only one case. I was sued once. ...

Prof. Karl Lauterbach
Health economist and member of the German parliament

Germany has pretty good results, it has fairly good costs, it's equitable, and yet they're constantly talking about reforming it. Does that mean people are not satisfied?

Well, people are by and large satisfied. Physicians are not always satisfied because they would like to earn more money. We have actually now decided that we [will] increase physician income, in particular for office physicians; we have already increased the income for hospital physicians by about 10 percent. But I don't know a single European system where physicians do not all the time ask for more money. This is basically part of the description of their job.

That's, I think, in every country we've been to.

I think if the physicians are not asking for more money at a given time, then you should worry about them. ... But on average, physicians are doing fairly well. ... For example, an office physician on average has about $10,000 per month after cost of the office, and this is not that bad in the German setting. ...

... So this is a general practitioner ... netting $120,000 a year.

Per year on average, before taxes.

It's not bad money, but it's one-half or one-third of what you'd make in America.

Exactly, but we have more physicians per capita. So if we have fewer physicians in the future, because less physicians are in training currently, then there will be higher income per physician. ... In most European countries, the payment is roughly comparable.

Prof. Naoki Ikegami
Health economist, Keio University School of Medicine

In America we tend to think of a doctor as a rich guy who drives a Lexus to the country club for dinner. Is that the image of a doctor in Japan?

To a certain extent. But ... it's only successful doctors in private practice who can have that kind of lifestyle, and not all those in private practice. As far as those employed in hospitals, ... if they are working in an urban, large medical center, they are going to [make] what their peers in the college would be earning in large companies, so there won't be that much difference. If they go to work in the rural hospital, then they might [make] only twice as much ... as the urban medical center physician. ...

... And this helps lure people to rural hospitals?

Yeah, because the rest of the hospital staff, the nurses and others, are more willing to work in rural hospitals at lower wages, so they can afford to pay higher wages to doctors. ... But this is a whole different notion than the United States, where orthopedic surgeons can get much higher income, especially if they practice in an urban medical center. ...

[Are these lower wages] driving down the number of doctors?

Well, as far as the competition to get into medical school, it's gone up.

Pascal Couchepin
President of Switzerland

Do you have a good enough supply of doctors? Is there a shortage of doctors, as in some countries?

If you look at figures, we have a good supply of doctors. They always say that in the future we shall have a lack of home doctors, family doctors. I'm not sure of that, but we have a problem of formation. ... Every year there [are] about 1,000 students beginning medical studies, and at the end of the formation there are only 600 young people getting the diploma. It means that about 40 percent of the students fail during the studies, although there is a selection at the beginning. ... Forty percent is too much as failure, so probably there is a problem in the formation, education.

But 600 graduates per year, that's enough to keep up the --

No, it is not enough. We need about 1,000 to 1,200. ... The difference is covered by immigration of medical people, first of all from Germany. And to Germany there is immigration [of] people from Eastern Europe. So there is a kind of migration of medical people from Eastern Europe to Germany, from Germany to Switzerland, and Switzerland to nowhere; they stay in Switzerland.

Well, once you're here, why not [leave]?

Because they are the best paid doctors in Europe. ... Also true that they [have] taxes, but at the end of the day, they are in a very good situation, the doctors in Switzerland. ...

Are you trying to limit the treatment or put some limits on doctors to keep the costs down?

There is, first of all, a will to limit the number of doctors themselves, because with new bilateral agreements with the European Union, there is what we call the "free flow of persons"; that our borders are open to immigration. And as the Swiss doctors are better paid than others, we could have a huge increase of immigration of doctors, more than we need. So we decided some years ago to limit the numbers of doctors [coming into] Switzerland, and when somebody wants to open a new practice, they have to apply and to get an authorization from the cantonal state. It is not a very intelligent system, but it is the best one that we have found to limit immigration of doctors.

Dr. Charles Favrod-Coune
Family doctor, Chateau d'Oex, Switzerland

In America we think of a doctor, an internist, as a rich guy; he drives a Lexus or a Mercedes to the country club. Is that the image of a doctor in Switzerland?

No, no more. Perhaps for some surgeons that are working outside the insurance system, on a private basis, [they] can [make] much money. But I would say doctors now are normally paid in Switzerland for their skill, I would say, not at all like directors of some companies that earn very, very much money.

So corporate executives make more than doctors here.

Yes, yes.

And this is okay?

I find this is normal, and I think all the members of my society will agree with this.

This is acceptable to them?

Yes, it's acceptable.

You're not complaining about the fees you're paid or the prices you're paid?

Yes, we are complaining, [because] they are continuously under pressure. I would say the main problem is that ... our health minister is now cutting, for example, laboratory prices and ancillary services' prices, and so the entrepreneurship of a physician that has his own practice is economically more difficult. And this points to a current problem, [which] is that young doctors hesitate to open a practice or to take over a practice. ... And young doctors are economically hesitating to begin the business. And in a really liberal state, one has to make conditions that makes entrepreneurship attractive, and we have reached this limit.

Nigel Hawkes
Health editor, The Times of London

How do doctors feel about the NHS?

... They're fairly unhappy in the NHS. I think family doctors are probably more contented than hospital doctors. Hospital doctors tend to think their advice is ignored. They're told what to do by managers; they're constantly given targets; and they're constantly under pressure. So they're fairly disenchanted. ...

We would think in America, it's just kind of natural that the high-powered heart surgeon in the hospital makes more money than some GP that I go down to when I have a cold. But that's not true in Britain.

No, not any longer. They make, I'd say, about the same amount of money. It depends. If a surgeon has got a lot of private practice, he can make a lot of money, but if he's just working for the NHS, he'd make about the same as a GP.

So the surgeon, the internist, the orthopedist in a hospital is a government employee?

They're employed by the Hospital Trust. The hospitals are all, so to speak, independent organizations. They get their money from the government, but they have a board and directors who run the hospitals, who pay the hospital doctors, the specialist consultants and so on.

Are the GPs NHS employees?

No, the GPs are independent contractors. They're given a sum of money to run their practice based on the number of patients they've got and the quality of service they deliver. Out of that money, they have to pay for the setup of the practice, and the difference is their annual income.

So that gets us to an interesting distinction from America. In America, most medicine is fee-for-service: I have an earache, and the doctor bills me for treating that. But in Britain, they don't charge you for the individual visit.

No, they don't, although hospitals now have a system of payment that attempts to capture this. It's called payment by results, in which, when a patient is treated for a specific condition, the hospital is paid a fixed sum based on a tariff for that treatment. This is intended to increase efficiency, really. That doesn't apply to GPs, though, just the hospitals. ...

... The NHS has done a lot of experimenting on different payment modes, is that right?

Well, under the new contract that came in in 2004 for GPs, there's a quality element. If they can achieve certain quality points, they get paid more. The quality points are things like making sure you've tracked down everybody in your practice who's got diabetes or heart disease, and you've treated them appropriately, and you've kept in touch with them, and you've called them in every six months, those kind of things. ...

Alan Maynard, this British academic, told me that it didn't work at first because they went to the doctors to say, "What should we pay you extra to do?," and the docs just listed all the stuff they do anyway.

Yes, that is true; they all earn pretty near the maximum number of points. ... Now the government is trying to up-rate the quality and make it more difficult to achieve maximum points. But the doctors are still doing it.

David Patterson, M.D.
Consultant physician and cardiologist, Whittington Hospital, London

A GP is like a private businessman, is paid a fee for performance, so you can see why he might change behavior to [produce] good medicine. In hospitals, what's going to affect you? You're not going to be paid any extra for doing things, are you? Because you're an employee of the government.

I'm an employee of the government. I do get paid more for being a better doctor. We have a system in this country, which is a slightly controversial one, but it's one which has the grand title of Clinical Excellence Points, so that if I perform well from a number of different criteria year on, year on, I will rise [on] that additional salary scale. So I can get rewarded for good, high quality work.

Is that sufficient to drive clinician behavior?

It has an influence. I think it's not perhaps quite as potent as driving the GP behavior, if one's going to start differentiating between two parts of the health service. ...

What's it like for a medical leader, then, trying to sort of persuade one's colleagues to do things in a different way? You must run into a lot of push-back.

I think this is the huge place that education [plays], a huge role. And I think education is not about just education and helping people learn new things. It's about an attitude, and I think as a change agent, education is an extraordinarily powerful change agent. So I think if you have the right educational culture, such that you can go to meetings and it will be an educational meeting, into which of course there are ingredients that indicate that change is necessary, it creates a conscious[ness] such that when a good idea comes along, people are prepared to learn about it and to look at it and to be persuaded. Or not, but it's much more likely to take place in that culture. And to have the managers involved in that culture too makes it much more of a team effort.

... What is the core value you're trying to appeal to when you're trying to persuade a clinician, if it's not one of these merit [awards]? Are you appealing to their sense of professionalism to do good medicine? What are you trying to get at?

I think, I'm pleased to say, in medicine physicians -- clinicians, surgeons, psychiatrists -- by and large want to do the best for their patient. And they've gone into medicine for that reason, and it stays with them. So I think if they believe that whatever's on the agenda today is going to allow them to deliver a better deal, whatever it is, for their patient, they'll sign up to it.