From just after the Civil War, when medicine began to professionalize, until the late 1970s, doctors and policy makers believed that clinical judgment should not be influenced by the financial interests of doctors. Physicians were highly entrepreneurial, and organized medicine fought to preserve their entrepreneurial interests, but the moral norm that justified their autonomy from state regulation was a strict separation of clinical judgment and pecuniary interests.

Under managed care, the old norm is reversed. A good doctor takes financial considerations into account in making clinical decisions. Theoretically, doctors should consider measures of cost to society, but in practice, the payment systems of managed care plans induce doctors to consider the impact of each clinical decision on their own income. Because doctors share the risks of insuring patients with managed care plans, they have the same incentives as insurers to avoid patients who are expensively sick. The new cultural image of doctors as entrepreneurs masks their considerable loss of clinical autonomy under managed care. It also serves to persuade doctors to accept managed care arrangements and to persuade insurance consumers and patients to accept reduced benefits from employers and the government.

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