Transformation of professional control: Changes in medical work in the shift to managed care

Professions play a central role in coordinating expert work. Despite their importance, little research examines how professions coordinate expert work, or how their role changes over time. This dissertation draws on multi-method analysis to examine the changing role of the medical profession in the shift to managed care. I examine the changing role of the medical profession and consequent changes in patient care practice in three studies. Study 1 uses content analysis to show that the medical profession redefined its control over work in response to the shift to managed care. It deemphasizes individual training, skill and discretion and instead emphasizes rules and measures that define appropriate work practice. Central to this change is the growing discussion and production of clinical guidelines. In response to institutional pressure focused on health care costs, the medical profession grafts new approaches towards medical work with more traditional approaches into new, hybrid forms of professional control. In the second and third studies, I examine the impacts of these new professional controls on patient care practice. The second study extends my initial focus on professions to examine the alternate roles of professions and hierarchies in shaping expert work. In the context of the shift to managed care, I show that the proliferation of clinical practice guidelines responds to growing field-level concerns with cost by reducing the use of resource intensive medical procedures. In so doing, new forms of professional self-control substitute for more direct organizational controls by HMOs. The third study shows that both redefined professional controls and HMOs impact standardization. Both professional and organizational controls can standardize patient care by reinforcing established care practices. In addition, by introducing new patient care practices, they temporarily increase variation for some clinical conditions. This variation decreases as newly introduced practices become better established. My dissertation extends existing research by highlighting the critical role of professions in organizing expert work, explaining their changing role in periods of institutional change, and predicting the impacts of new professional and organizational controls on expert-work.