From the doctor's workshop to the iron cage? Evolving modes of physician control in US health systems

Abstract

As national health systems pursue the common goals of containing expenditure growth and improving quality, many have sought to replace autonomous modes (systems) of physician control that rely on initial professional training and subsequent peer review. A common approach has involved extending bureaucratic modes of physician control that employ techniques such as hierarchical coordination and salaried positions. This paper applies concepts from studies of professional work to frame an empirical analysis of emergent bureaucratic modes of physician control in US hospital-based systems. Conceptually, we draw from recent studies to update Scott's (Health Services Res. 17(3) (1982) 213) typology to specify three bureaucratic modes of physician control: heteronomous, conjoint, and custodial. Empirically, we use case study evidence from eight US hospital-based systems to illustrate the heterogeneity of bureaucratic modes of physician control that span each of the ideal types. The findings indicate that some influential analysts perpetuate a caricature of bureaucratic organization which underplays its capacity to provide multiple modes of physician control that maintain professional autonomy over the content of work, and present opportunities for aligning practice with social goals.

Introduction

As national health systems pursue the common goals of containing expenditure growth and improving quality, many have sought to replace traditional modes (systems) of controlling physicians’ resource use and practice that rely on initial professional training and subsequent peer review (Freidson, 2001; Kitchener, 2000; Pollitt & Bouckaert, 2000). Although variations in national systems and politics have spawned a variety of approaches, a common theme involves extending the use of bureaucratic controls such as hierarchical coordination, salaried positions, and performance management techniques (Hoggett, 1996; Power, 1997).

In Britain, the National Health Service (NHS) has traditionally employed many of the classic features of bureaucratic control (e.g., salaried positions) to align medical practice with social goals including universal coverage. Increasingly, however, UK governments have blamed cost inflation and quality concerns on the limited capacity of the centralized NHS to regulate doctors’ resource-use and practice (DuGay, 2002). After an attempt to discipline doctors through a market system failed in the 1990s, three additional tiers of bureaucratic control have been introduced: (1) the National Institute for Clinical Excellence (NICE) to assess the cost and effectiveness of new drugs and treatments, (2) the Commission for Healthcare Audit and Inspection (CHAI) to review quality improvement efforts including National Service Frameworks (NSFs), and (3) the Modernization Agency to lead patient-process redesign work (Ferlie & Shortell, 2001).

In the United States (US) market system, bureaucratic control of physicians has developed in a different way. Traditionally, the US medical profession avoided the forms of control experienced by their NHS counterparts as members worked individually, or in groups, under a fee-for-service remuneration system. From the early 1980s, purchasers of US healthcare (e.g., government and employers) increasingly blamed poor quality and rising costs on the limited capacity of the market to regulate physicians’ resource-use and practice variation. In this decentralized context, reform efforts have concentrated on exposing physicians to bureaucratic control from inside the hospital organizations they once treated as ‘workshops’ from which to accumulate fees and prestige (Pauly & Redisch, 1973).

For more than 20 years, researchers have examined alterations in relations between physicians, established bureaucratic forms (e.g., the NHS), and newer entities such as US hospital systems (Shortell, Gillies, Anderson, Erickson, & Mitchell, 2000). Prominent among the early US analyses, Scott (1982) specified three ideal-typical systems of structures and practices (modes) concerning physician control: autonomous, conjoint and heteronomous. Despite two decades’ of studies into aspects of change in the US healthcare industry, none has explicitly re-considered Scott's framework in the light of conceptual and practical developments.

This paper reports a study that updates Scott's (1982) typology both conceptually and empirically. Section 1 describes the erosion of the autonomous mode and outlines prominent interpretations of this phenomenon. We then draw from studies of professional work to present a revised typology that incorporates three developments: (1) it omits the autonomous mode to concentrate on bureaucratic arrangements, (2) it includes the ‘custodial’ mode shown to be prevalent in professional organizations (Ackroyd, Hughes, & Soothill, 1989), and (3) it specifies comparative dimensions of three bureaucratic modes of physician control (heteronomous, conjoint and custodial). Section 2 of the paper describes the qualitative methods used to test our conceptual framework using exploratory data from a study of physician control in eight US hospital-based systems. Section 3 presents study findings that illustrate multiple bureaucratic modes spanning each of the three ideal types. The paper concludes by considering the implications of this analysis for future studies of physician control in the US and elsewhere.