directly or indirectly account for most health care spending. Thus, a central strategy of the managed care plans and integrated health care systems that increasingly dominate health services in the United States is to limit the number of physicians available to health plan members and to manage patient access to physicians, especially specialists. As government officials and employers intensify their efforts to direct members of their respective health insurance programs into so-called managed care plans, questions about the appropriate supply and mix of physicians and other professionals have become increasingly acute for government policymakers, educators, professional organizations, and the public.

Clearly, these questions are complex and deserve careful, rigorous study. Notwithstanding the desirability of a more detailed and prolonged examination, the Institute of Medicine (IOM) concluded that a brief review of data on physician supply and requirements and an examination of options for dealing with the physician workforce would be a valuable—and timely—contribution in the current policy environment. (In this report, the term physician refers to both allopathic and osteopathic physicians.) The intention is to spark informed debate among all interested parties, with a view to encouraging appropriate regulatory or market-oriented steps (or both) to bring about a closer match between physician supply and the requirement for physician services. In so doing, the committee was mindful of the outlook stated by Pritchett (1910, p. xv) in the introduction to the Flexner report:

In the preparation of this report the [Carnegie] Foundation has kept steadily in view the interests of two classes, which in the over-multiplication of medical schools has been forgotten-first, the youths who are to study medicine and to become the future practitioners, and, secondly, the general public, which is to live and die under their ministrations.

That is, this committee, like that of nearly a century ago, sought to be sensitive to the best interests of the nation's young people and cognizant of the public need for expert health care.

THE PHYSICIAN WORKFORCE

The active physician workforce, which numbered 226,000 after World War II (Rivo and Satcher, 1993) and 628,000 in 1992 (Kindig, 1994), has been the subject of intensive, systematic study and debate for nearly 50 years, principally in terms of the match between the expected supply of physicians and the estimated need or demand for physicians (or physician services). Various commissions and other groups have issued a number of reports, often conflicting: some forecast shortfalls between supply and demand; others predict excess



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