The system of alignments challenging physician professional dominance: an elaborated theory of countervailing powers

Abstract

Abstract The growth of managed care in the United States is altering the shape of the system of professions and is accelerating an overall decline of physician professional dominance in that system. An adequate understanding of the changing character of the system of professions demands a consideration of the interacting roles of ‘competing’ health care providers, the state, corporate and consumer forces; however, past research addressing one or more of these forces has not explicitly examined their interrelation. The countervailing powers framework provides a starting point for articulating precisely this sort of interrelation. Using data from a comparative case study of interprofessional competition between certified nurse‐midwives (CNMs) and physicians within select state policy and managed care contexts, this article extends the countervailing powers framework, illustrating how the relationships among relevant parties in the health care system can be understood as a system of alignments challenging physician professional dominance in a complex manner. Specifically, this research finds that the actions of consumers and health care administrators, coupled with state policy evolutions and the expansion of managed care, not only separately challenge physician professional dominance but also work together, as a system, to intensify interprofessional competition between certified nurse‐midwives and physicians, further undermining that dominance.