Managed care creates several dilemmas for the physician executive. Effective management is hindered by lack of analytical tools that stem from current limitations in outcomes research and treatment protocols, altered financial incentives that are controversial and that seem at odds with traditional incentives, and values that create conflict between the needs and expectations of individual patients and populations or groups under managed care. The executive must manage a process that resolves apparent conflict in an explicit ethical framework that acknowledges the limitations of data, with full awareness of the potential conflict between financial incentives and clinical judgement.