To the Editor.
—The lucid analysis by Dr Mechanic1 of the dilemmas presented by managed care neglects one attribute of the health sector that is unchanged by this new approach: the tendency toward revenue maximization by the physician.2 With fee-for-service, this tendency was shrouded from patients because it coincided with their receiving all possible care. Now, as profit-seeking health plans erode public trust, plans can divert consumer dissatisfaction back toward the physician by eliminating gag rules and broadening the prevalence of global capitation. Gag rules then will mutate to self-censorship, while needed care may continue to be withheld. The provider service networks contemplated for Medicare patients will be rife with the same tension.For better or worse, entrepreneurship in the delivery of health care, whether by professionals or by corporate America, affects the physician-patient relationship. Managed care has not solved the problem of paying the physician in the