the quality or the costs of care, in part because the effects of health care restructuring toward much greater penetration of managed care are unpredictable. Generally, it is not possible to demonstrate that too many physicians will improve the quality of patient care; indeed, if the surplus is made up largely of IMGs, it may dilute quality. In addition, a surplus will contribute to higher aggregate health care costs at least as long as the nation has a significant FFS sector.

  • Having far more physicians than is needed to meet the nation's requirements is a waste of the federal resources currently spent on physician graduate education, and it may also result in a poor personal investment on the part of prospective medical students. When individuals pursue a medical career in the face of a significant oversupply of physicians, their underemployment or underutilization is a tremendous waste of human resources for the nation.

  • Use of large numbers of IMGs here deprives other nations of their own talent and decreases opportunities for able young persons from the United States to enter the medical profession.

Thus, the committee believes that however a better balance is to be achieved, it is in the national interest to avoid a serious oversupply of physicians. The options for doing so are taken up in the next chapter.



The committee opted, for this short statement, not to develop a lengthy critical review. Relevant, albeit selected, articles on various aspects of these issues for the past 15 years or so (i.e., dating to the landmark GMENAC report), other than those already cited in this report, include Ginzberg et al., 1981; Tarlov, 1983; Harris, 1986; Ginzberg, 1989, 1992; Schwartz et al., 1989; Dranove and White, 1994; Moore, 1994; Epstein, 1995.


Evidence supporting this link comes from Canada (Barer et al., 1989). Recently, Canada has moved to a rigidly controlled system of aggregate supply as an explicit strategy to reduce the growth of health system expenditures. This approach involves monitoring the numbers of medical school and graduate training slots, and it proscribes international medical graduates from settling in that nation. These policies are quite recent, so it remains to be seen how effective they will be, but clearly Canada has concluded that only by intensive regulation of physician supply can it achieve national health policy objectives with respect to costs. In view of the fact that Canada has little managed care and is basically a FFS system, however, it may offer less of a direct lesson for the United States today than might have been true a decade or so ago.


Unpublished information being compiled for the IOM study on the future of primary care also reflects great variation across managed care organizations; it suggests that some large HMOs may be staffing at levels not that far removed from the national

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