Summary

In the debate over health care reform, managed care proposals call for increased dependence on primary care physicians. In the United States today, however, specialists outnumber primary care doctors, while many areas of the country suffer from a scarcity of both. Some health policy analysts believe that this mix and supply of physicians could slow the implementation of health care reforms. GAO examined the methods used by four nations--Canada, Germany, Sweden, and the United Kingdom--to manage their physician supply and specialty distribution. All these industrialized countries have instituted universal care coverage yet spend a lower percentage of their gross domestic product on health care than the United States does. This report also identifies strategies used by these countries to encourage doctors to practice in medically underserved areas.

GAO found that: (1) Canada and Great Britain have established primary care as the cornerstone of their health care delivery systems, and Germany and Sweden have implemented reforms to place greater emphasis on primary care; (2) the four countries manage physician resources with a goal of containing health care costs, leading them to focus on primary care, which can be provided at a lower cost; (3) the countries' strategies for regulating physician supply and specialty mix include managing medical school enrollment, specialist training slots, and employment opportunities; (4) while Canada, Sweden, and Great Britain control medical school enrollment, the German Supreme Court declared enrollment limits unconstitutional; (5) all four countries use medical education limits to manage the mix of physicians; (6) the countries also use incentive strategies to increase the number of primary care physicians, including modifying fee schedules to narrow income disparities between primary care physicians and specialists, reducing specialists' fees under certain circumstances, and increasing primary care physicians' professional autonomy; and (7) Canada, Sweden, and Great Britain have tried various approaches to ensuring an adequate supply of physicians in rural areas, including limiting the number of physicians in overserved areas, creating financial incentives, and assigning medical students to work in underserved areas.