Professionalism reconsidered: physician payment in a small-practice environment.

Traditional fee-for-service health insurance rested on the assumption that doctors have primary responsibility for decisions about care. Managed competition assumed a new model based on corporate medicine, which has not materialized; also, consumers' ability to replace doctors as primary medical decisionmakers is unproven. Data on practice size show that doctors and patients continue to prefer the small-practice setting, where the doctor's role as the patient's agent is salient. The persistence of the small practice suggests that medical professionalism remains the cornerstone of the health system. If so, it may be more appropriate to pursue quality-oriented refinements of traditional payment approaches, rather than radical transformation.