Medical sociology and health service research - Journal of Health and social behavior

Journal of Health and Social Behavior http://hsb.sagepub.com/Medical Sociology and Health Services Research : Past Accomplishments and Future Policy Challenges Eric R. Wright and Brea L. Perry Journal of Health and Social Behavior 2010 51: S107 DOI: 10.1177/0022146510383504 The online version of this article can be found at: http://hsb.sagepub.com/content/51/1_suppl/S107 Published by: http://www.sagepublications.com On behalf of: American Sociological Association Additional services and information for Journal of Health and Social Behavior can be found at: Email Alerts: http://hsb.sagepub.com/cgi/alerts Subscriptions: http://hsb.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Downloaded from hsb.sagepub.com by guest on December 29, 2010

Wright and Perry Journal of Health and Social BehaviorMedical Sociology and 51(S) S107–S119 © American Sociological Association 2010Health Services Research: DOI: 10.1177/0022146510383504 http://jhsb.sagepub.comPast Accomplishments andFuture Policy ChallengesEric R. Wright1 and Brea L. Perry2AbstractThe rising costs and inconsistent quality of health care in the United States have raised significant questionsamong professionals, policy makers, and the public about the way health services are being delivered. Forthe past 50 years, medical sociologists have made significant contributions in improving our understandingof the nature and impact of the organizations that constitute our health care system. In this article, wediscuss three central findings in the sociology of health services: (1) health services in the U.S. are unequallydistributed, contributing to health inequalities across status groups; (2) social institutions reproduce healthcare inequalities by constraining and enabling the actions of health service organizations, health careproviders, and consumers; and (3) the structure and dynamics of health care organizations shape thequality, effectiveness, and outcomes of health services for different groups and communities. We concludewith a discussion of the policy implications of these findings for future health care reform efforts.Keywords:health services, health care delivery, health care organizations, health care qualityPublic and professional interest in health services recently, sociological health services research hashas increased dramatically over the last two concentrated on the structure of and dynamicsdecades driven primarily by persistent and grow- within health service organizations and how theseing frustrations with the cost and quality of care. factors shape both access and clinical outcomes forMedical sociologists have been interested in the different groups and communities.structure, organization, dynamics, and impact of In this essay, we highlight three key findingshealth services for well over 50 years. Our health that summarize the most important contributions ofcare system has evolved and changed dramatically medical sociology to health services research. Forover the same period, shifting from one focused on the purposes of this paper, we define health servicesproviding acute care for immediate and emergent as the delivery of care by socially recognized,health problems to a more diffuse system strug- professional health care providers that is intendedgling to support individuals with chronic and long- to respond to perceived illness and disease or toterm conditions while also controlling costs(Wholey and Burns 2000). Not surprisingly, medi- 1cal sociological interest in health services has fol- Indiana University-Purdue University Indianapolis 2lowed suit and expanded to examine a wider vari- University of Kentuckyety of settings, conditions, and processes within Corresponding Author:the formal health care delivery system. Scholar- Eric R. Wright, Department of Public Health, Divisionship initially focused largely on understanding the of Health Policy and Management, Indiana Universitystructural and institutional underpinnings of health School of Medicine, 401 W. 10th Street, Suite 3100,care systems, and later on exploring the variability Indianapolis, IN 46202in access to health care across social groups. More E-mail: ewright@iupui.edu Downloaded from hsb.sagepub.com by guest on December 29, 2010

S108 Journal of Health and Social Behavior 51(S)improve an individual’s health status. While many Disease Control 1998; Powell-Griner, Anderson,scholars are particularly interested in specific med- and Murphy 1997). However, men who do consultical technologies, medical sociologists assert that a health professional may receive better treatmentthe delivery of health services is much more than than women for the same condition. The evidencesimply the application of scientific and technical is particularly strong in the case of heart disease.knowledge. Health care services are delivered by Women who present with symptoms of cardiacpeople to people within various social environ- disease are less likely to be referred for diagnosticments, which can influence the way medical tech- tests, given cardiac drugs, or instructed to makenology is delivered or received and, perhaps most lifestyle changes. Conversely, they are three to fiveimportant, the clinical outcomes for people seeking times more likely to be sent home without anyhelp. This review is necessarily selective. Our aims treatment (Lockyer and Bury 2002; McKinlayhere are to summarize a half-century of sociologi- 1996). These patterns delay diagnosis and contrib-cal work and to call for a renewed interest in the ute to higher mortality rates among women withsociology of health services. We conclude by out- heart disease relative to men.lining the policy implications of these findings forfuture health reform efforts. Socioeconomic Status Decades of research by sociologists suggests thatFINDINg 1. HEAlTH SERvIcES people with less income and education face greaterIN AMERIcA ARE UNEqUAlly obstacles accessing health services than their moreDISTRIBUTED, cONTRIBUTINg well-off counterparts, despite having higher health care needs (Dutton 1978; Katz and Hofer 1994).TO HEAlTH INEqUAlITIES Disparities are particularly marked in the area ofAcROSS STATUS gROUPS primary care (Rundall and Wheeler 1979). For example, adults and children of lower socioeco-One of the fundamental concerns of medical soci- nomic status (SES) are less likely to have routineologists over the past 50 years has been to docu- physical examinations and screening procedures,ment and explain gender, socioeconomic, and such as prenatal care, immunizations, mammo-racial-ethnic differentials in health outcomes (see grams, and colonoscopies (Goldman and SmithWilliams and Sternthal 2010 in this issue). Among 2002; Lantz, Weigers, and House 1997; McDonaldthe early explanations for these patterns were dis- and Coburn 1988). Moreover, they are less likelyparities in the distribution of health services among to receive medical intervention in a timely manner,social groups, and substantial attention was and they often receive less intensive and lowerdevoted to documenting systematic differences in quality treatments (Williams 1990). Together,access to health care. More recently, evidence has these patterns result in poorer long-term outcomesemerged suggesting that the adverse impact of and higher emergency room and hospitalizationhealth care disparities on population health is rates for conditions that would not normallyincreasing, highlighting the need for additional require them (Padgett and Brodsky 1992; Pappasresearch (Lesser and Cunningham 1997). As a et al. 1997).result, sociologists have taken a renewed interestand adopted a more complex and comprehensiveapproach to health services research, examining Race and Ethnicitythe nature, quality, and timeliness of care received Because income and educational attainment are sounder a variety of illness conditions. closely linked to race and ethnicity in America, patterns of health care inequality observed in racial-ethnic minority groups are similar to thoseGender found in low-SES populations (Williams and Col-Sociological research has documented significant lins 1995). That is, racial-ethnic minorities gener-gender differences in help-seeking. Women are ally have less access to health services, in particu-more likely than men to visit a doctor for an array lar primary and preventative care, and they alsoof both physical and mental health problems tend to receive delayed treatment and lower quality(Courtenay 2000; Green and Pope 1999; Kessler, acute and long-term care than whites (BlendonBrown, and Broman 1981). They are also more apt et al. 1989; Smedley, Stith, and Nelson 2003;to have a regular physician and to obtain preventa- Williams 1990). Though these patterns are bettertive screenings (Bostick et al. 1993; Centers for established in African American populations, studies Downloaded from hsb.sagepub.com by guest on December 29, 2010

Wright and Perry S109suggest they also extend to Latinos, Asian Ameri- illness experiences and outcomes among memberscans, and Native Americans (Angel and Angel of different social groups making contact with a2006; Collins, Hall, and Neuhaus 1999; Fiscella stratified medical system (Kahn et al. 1994).et al. 2002). While much of the disparity in health This point is illustrated by the case of type twoservices use can be explained by SES differentials, diabetes, a disease whose incidence as well asrace-ethnicity tends to exhibit a modest, indepen- resulting mortality and complications are related todent effect on health services use. These effects SES (Cowie and Eberhardt 1995; Phelan et al.have been attributed to racial discrimination by 2004). Health services disparities probably con-health services providers and racial segregation of tribute little, relative to diet and exercise, to theminorities into communities with less access to overall risk of developing diabetes. Low SEShigh-quality health services (Polednak 1993; affects risk for diabetes onset through a variety ofWilliams and Collins 1995). dynamic, intervening mechanisms that reflect access to resources. For instance, living in working class neighborhoods without safe recreationalDo Health Services Inequities Explain facilities and stores that carry fresh fruits and veg-Group Differences in Health? etables makes it more difficult to exercise regu- larly and eat a balanced diet. In contrast, subsequentFor many decades, equalizing access to quality to onset, differences in mortality rates and the inci-health services was held up as the most promising dence of complications secondary to diabetes (e.g.,solution to reducing health disparities (Mirowsky, blindness, amputations, kidney damage, etc.) areRoss, and Reynolds 2000). However, the national directly related to glucose management and thehealth insurance systems in the United Kingdom diabetes regimen developed by health care providersand Canada, which provided universal access to and implemented by patients (i.e., medication, diet,care, fell short of high expectations for equalizing and glucose monitoring). Remarkably, according tohealth care utilization (Black et al. 1988; Marmot, an ethnography conducted by sociologists LutfeyKogevinas, and Elston 1987; Roos and Mustard and Freese (2005), SES shapes the outcomes of1997). In the 1970s, sociologists began to assert diabetes services at every point in the treatmentthat access explains only a small proportion of the career—including access to particular kinds ofdifferences in morbidity and mortality across services, the organization of care, patterns of healthsocial groups, and many of them began to turn services utilization, the success of patient–provideraway from health services research (Marmot, communication, and the types and quality of treat-Kogevinas, and Elston 1987; Miller and Stokes ments received—even among those who consist-1978; Monteiro 1973; Ross and Wu 1995). Instead, ently have access to long-term diabetes care. Inmedical sociologists pioneered efforts to focus on short, to the degree that health services are a criti-persistent determinants of health and illness that cal component of disease management and recov-are more distal in the chain of causation, i.e., “fun- ery, social status differences in health care are adamental social causes” (Link and Phelan 1995). primary mechanism of health inequalities, particu- Yet some caution that it may be too early to larly given the demographic shift in the Unitedthrow the proverbial baby out with the bath water States toward chronic diseases requiring long-termwhere health services are concerned (Robert and intervention by medical professionals.House 2000). There has very recently been a resur-gence of interest in health services among medicalsociologists, who are now using improved measures FINDINg 2. SOcIAlto reexamine the role of health care systems in INSTITUTIONS REPRODUcEhealth inequalities. For instance, health is increas- HEAlTH cARE INEqUAlITIESingly being conceptualized in terms of functionalstatus and quality of life rather than only by morbid- By cONSTRAININg ANDity or mortality (Bunker, Frazier, and Mosteller ENABlINg THE AcTIONS1994; Levine 1987). There has been a greater focus OF HEAlTH SERvIcEon the impact of chronic conditions and diseasemanagement on daily living. Thus, while health ORgANIzATIONS, HEAlTH cAREservices disparities may account for relatively little PROvIDERS, AND cONSUMERSof the inequality in rates of disease onset, they might A unique strength of the sociological perspective isstill explain a large proportion of the variation in the focus on underlying social structural mechanisms Downloaded from hsb.sagepub.com by guest on December 29, 2010

S110 Journal of Health and Social Behavior 51(S)of phenomena that ostensibly occur at the individual Managed Care and Medicallevel (McKinlay 1996). Sociologists have long con- Decision-makingceptualized medicine as a social institution, highlight-ing the influence of macro factors on help-seeking One of the most significant consequences of insti-and the practice of health care in everyday life (Fre- tutional change for everyday medical practice hasidson 1970; Mechanic 1975; Parsons 1951). The been that most physicians are now rewarded forinstitution of medicine is characterized by a powerful providing fewer services at lower cost. This hasset of social norms, rules, values, and practices that caused concern among sociologists about theprovides a blueprint for the behavior of individuals impact of third-party payers on equitable accessand organizations (e.g., physicians, patients, hospi- and quality of care (Mechanic 2001, 2004). Man-tals, HMOs, etc.), and systematically structures the aged care increases the use of primary care, pre-relationships between them. Sociologists have con- ventative medicine, and outpatient treatment, but ittributed much to our understanding of the ways that reduces hospitalizations, visits to specialists, andculturally and historically shaped institutional forces more intensive, costly procedures (Wholey andconstrain the behavior of health care providers and Burns 2000). In fact, there is evidence that man-consumers, reproducing health care inequalities aged care changes the way that individual doctorsacross social groups (Light 2004). practice medicine. For instance, physicians in Sociologists have been instrumental in docu- health maintenance organizations (HMOs) are sig-menting changes in the institution of medicine nificantly less likely than those in a hospital orover the twentieth century. In what Scott and col- private practice settings to diagnose the exact sameleagues (2000) call the era of professional domi- case of chest pain as cardiac disease, a diagnosisnance (1945–1965), the motivating ideology in with high-cost implications (McKinlay, Potter, andmedicine was commitment to quality care. Addi- Feldman 1996). A critical role of sociologists hastionally, there was a strong sense of obligation to been to identify how managed care unintentionallyprovide health care to all, regardless of a person’s influences physicians and organizations to treatability to pay for it (Klarman 1963). Accordingly, individual patients in ways that reinforce broaderthe poor received free care from physicians and patterns of structural inequality.hospitals, and the population at large paid on a Using a controlled experimental design, sociolo-sliding scale according to their means. In the era of gist John McKinlay and colleagues (1996) demon-federal involvement (1966–1982), concern with strate that the resource environment in which aequitable access prevailed, but the government physician operates interacts with patients’ sociode-increasingly took over responsibility for funding mographic characteristics to shape physicians’ deci-and regulating the fair distribution of health care sions about how to diagnose and treat signs and(Scott et al. 2000). At the same time, health serv- symptoms of illness. For instance, ample evidenceices expenditures began to increase rapidly, and indicates that medical practitioners provide lowerconcerns about cost containment began to over- quality care to older patients relative to youngershadow the long-standing commitment to quality ones, i.e., they are less likely to make referrals to acare and equity that had characterized the institu- specialist, prescribe expensive medications, andtion of medicine since its inception (Brown 1979). perform costly tests and procedures (Wenger et al. In the current era of managerial control and 2003). However, sociologists emphasize that thesemarket mechanisms (Scott et al. 2000), the health biases are exacerbated by cost considerations.care sector is conceptualized as an industry, or Among patients over the age of 65 presenting witheconomic system, and efficiency and profit are chest pain, having health insurance coverage is acentral motivating values. Changes in health pol- strong predictor of receiving a diagnosis of cardiacicy (and ultimately practice) enacted by the Rea- disease rather than a condition requiring less expen-gan administration began as part of a broader sive medical interventions (McKinlay et al. 1996).political movement characterized by welfare state Conversely, health insurance has no significantretrenchment and by the shifting of government effect on patterns of diagnosis in younger patients.control to competitive market forces (O’Connor Along these same lines, physicians practicing in a1998). These events, described in greater detail by fiscally conscious, managed care environment areMechanic and McAlpine (2010, in this issue), cul- over nine times as likely to attribute women’s chestminated in the corporatization of health care and pain to psychiatric problems (e.g., panic disorder,the managed care ethos that pervades the institu- generalized anxiety, etc.) relative to men reportingtion of medicine today. the exact same symptoms, and they are nearly seven Downloaded from hsb.sagepub.com by guest on December 29, 2010

Wright and Perry S111times as likely to diagnose African Americans’ sector; (3) Community and geographic barriers maysymptoms as gastrointestinal in origin compared to restrict access to private facilities and providers,whites. Importantly, the diagnoses more commonly even when patients are publicly insured (Macintyre,applied to lower-status groups are associated with MacIver, and Sooman 1993; Williams and Collinsless costly and time-intensive medical tests and 2001); (4) Finally, private facilities and providerstreatments. In short, when cost containment forces may overtly or subtly discourage publicly-insuredphysicians to make difficult decisions and ration (and uninsured) patients from using their servicescare, they frequently rely on biases that, while prob- (see Mechanic and McAlpine 2010 in this issue). Atably unconscious, nonetheless result in inferior care even greater risk for slipping through the cracks ofand poorer health for vulnerable social groups. our health care system are the working poor and lower middle class—those whose incomes neither qualify them for public insurance nor allow them toSeparate and Unequal:The Public and afford private coverage (Seccombe and AmeyPrivate Health Care Sectors 1995). Indeed, public emergency room departments have effectively become the safety net for Ameri-Some sociologists have also criticized managed ca’s marginally poor, compensating for changes incare and competition as a socioeconomic environ- eligibility criteria and cuts in government fundingment that draws resources away from sectors of the for other social services (Billings, Parikh, andhealth care system that are less profitable but none- Mijanovich 2000; Dohan 2002). However, mosttheless critical (Cunningham et al. 1999; Mechanic agree that emergency room services are an ineffec-1994). Again, this trend has important implications tive, inefficient, and costly solution to gaps in cover-for the types and quality of care received by lower- age.status groups. For instance, managed care organiza- Inequality between private and publicly avail-tions minimize risk by denying coverage to sicker, able health services and facilities is growingless profitable patients and spreading the risk out (Andrulis 1998). The resource environment associ-among a large consumer group that contains both ated with managed care is partially responsible,healthy and sick individuals. These practices shift but rationing care does not inevitably lead to ine-much of the financial responsibility for indigent quality. Rather, this trend is consistent with Ameri-care (i.e., those who are unable to pay for services) can political, economic, and cultural ideologies,to physician groups and hospitals, pressuring them biases, and practices characterized by individual-to balance their budgets by cutting costs associated ism and the privatization and dismantling of thewith uninsured or publicly insured patients. At the social safety net. Unlike in every other industrial-same time, professional resources and government ized nation, health care in the United States is afunds are increasingly being diverted to the profit- commodity rather than a right, and rationing ofable private sector (Waitzkin 2000). This has forced health services is based on socioeconomic statusmany public health facilities to close their doors, rather than clinical need (Jost 2003). Thus, healthshrinking the public sector and widening the health care available to the uninsured and publicly insuredgap between the rich and the poor. Sociologists is inferior to the care received by individuals withhave demonstrated that the result of this profit- employer-based or other private insurance, exacer-driven funding environment is essentially two bating health disparities in underserved groupsdivergent health care systems, public and private, (Institute of Medicine 2004).characterized by radically different experiences andoutcomes (Dutton 1978; Lutfey and Freese 2005;Smedley et al. 2003). FINDINg 3. THE STRUcTURE AND Supporters of the for-profit sector have argued DyNAMIcS OF HEAlTH cAREthat those without private insurance can still access ORgANIzATIONS SHAPE THEprivate health services through Medicare and Medi-caid reimbursements. On the contrary, sociologists qUAlITy, EFFEcTIvENESS, ANDhave identified numerous barriers that minimize use OUTcOMES OF HEAlTH SERvIcESof the private sector by the publicly insured: (1) FOR DIFFERENT gROUPS ANDMedicare and Medicaid often pay less than privatemarket value for a given service, forcing the patient cOMMUNITIESto pay the difference in cost; (2) Medicare and Med- Seeking to understand the implications of organi-icaid policies are notoriously complex, prompting zational structure and dynamics in health servicesconfusion and fear of incurring fees in the private settings, a number of medical sociologists have Downloaded from hsb.sagepub.com by guest on December 29, 2010

S112 Journal of Health and Social Behavior 51(S)focused more narrowly on organizations. Indeed, as the inter- and intra-organizational dynamics thatmuch of the classical work in medical sociology are occurring within increasingly complex healthduring the 1960s and 1970s explored various care systems (Flood and Fennel 1995; Light 2004;aspects of health care organizations, especially the Scott et al. 2000).general, acute-care hospitals (Coe 1978; Goss Understanding these organizational changes is1963; Wilson 1963), as well as medical schools, critical because they reflect fundamental shifts inphysician offices, and psychiatric hospitals (Coe the nature of medical work and the delivery of1978; Freidson 1970; Strauss et al. 1963). With health services. As health care organizations haveadvances in technology and economic opportuni- become more highly specialized, internally differ-ties in the health care sector, and with the epide- entiated, technologically oriented, and more tightlymiological shift from acute to more chronic and integrated (Scott et al. 2000), the professionallong-term health conditions, the types and varieties boundaries of medical work have blurred. Initially,of health care organizations expanded dramatically medical sociologists suggested that these organiza-from the 1960s onward. Nevertheless, these early tional changes had the potential to lead to thestudies had enormous descriptive value and con- “deprofessionalization” of medicine (Haug 1973)tributed to a fundamental understanding of our and to undermine physicians’ professional domi-emerging health system. They also highlighted a nance within the health care system (Light 2004).myriad of organizational challenges in delivering Indeed, the greater emphasis on the “business ofhealth services, including the depersonalization health care” and the rise of health administratorsand devaluing of patients (Coe 1978); the interper- clearly have changed the traditional role of physi-sonal dynamics between doctors and patients (Fre- cians by reducing or restricting their authority overidson 1970; Glaser and Strauss 1965; Goffman clinical decision-making (Hafferty and Light1961) the power relationships and conflicts among 1995). Today’s complex health systems representhealth professional groups (Goss 1963); and the fundamentally new configurations of an increas-tendency toward bureaucratic medical decision- ingly broad array of professional expertise that ismaking and treatment (Freidson 1970; Goss 1963; altering the long-standing system of professionalStrauss et al. 1963). Most importantly, this body of boundaries of technical expertise and knowledge.work sensitized a generation of medical sociolo-gists to the nature of medical work and establisheda reference point that continues to inform the field. Consequences of Organizational StructureIn more recent years, medical sociologists have and Dynamics for Clinical Outcomesexamined critical organizational changes that havehad implications for how and what types of care Sociological health services research emphasizesare delivered, as well as how effective the care is the central role that structural arrangements andfor various social groups. organizational dynamics play in shaping the quality, effectiveness, and outcomes of health services. Eliot Freidson (1970), in his classic book The Pro-Complex Health Care “Systems” fession of Medicine, laid the sociological founda-Changes in the institution of medicine and its fund- tion for this line of research. While Freidson’sing environment in the latter half of the twentieth focus was on the work of physicians, he wascentury, described above, have dramatically among the first to theorize that performance wasreshaped health care organizations. Before man- largely determined by structural and organizationalaged care, hospitals operated largely as autono- factors.mous units. Today, most are evolving to become the Since 1990, interest in more applied researchnuclei of wider, regionally focused health networks on the organizational context of health services hasformed through the acquisition or merger of spe- expanded dramatically. Burns and Wholey (1991),cialty and allied health care agencies and the devel- for example, demonstrated that structural andopment of new ambulatory care facilities (e.g., organizational features of hospitals—includingurgent care centers, outpatient surgery centers) and size, type, and whether a hospital is part of a for-specialty branch hospitals (e.g., children’s, cardiac, mal system (e.g., public vs. private, teaching vs.orthopedic hospitals; Andersen and Mullner 1989; nonteaching, urban vs. rural)—are associated withCuellar and Gertler 2003; Weinberg 2003). Sociol- length of stay and mortality. Similarly, Aiken andogists have been instrumental in highlighting the colleagues have highlighted the impact of thechallenges associated with integrating care, as well organization of care and the degree of autonomy in Downloaded from hsb.sagepub.com by guest on December 29, 2010

Wright and Perry S113nursing on various health outcomes (Aiken, externalities that influence clinical interaction.Clarke, and Sloane 2002; Aiken et al. 1999; Aiken, Hohmann’s model acknowledges that the organi-Smith, and Lake 1994). Finally, sociologists have zational structure and context within which clinicalexamined how organizational features, such as work occurs is essential for understanding out-leadership centralization, differentiation, hierar- comes, but her framework also highlights thechy, and size, can influence both outcomes and the external social environments, including personalextent and nature of the adoption of effective networks and community contexts, which influ-medical technologies in hospitals and health sys- ence both the providers and recipients of healthtems (Fennell and Warnecke 1988; Flood 1994; care services, as well as clinical outcomes.Flood, Scott, and Shortell 1994; Scott 1990). In more recent years, social theory has beenincorporated into health services research, moving HEAlTH SERvIcES IN THEthe field toward a better understanding of complex TWENTy-FIRST cENTURy:mechanisms underlying organizational effective- POlIcy IMPlIcATIONS, FUTUREness. For example, the fragmented and unstablenature of today’s health care organizations has led cHAllENgES, AND REFORMto the rapid adoption of clinical care teams to inte- In a study of consumer attitudes in five industrial-grate services. Health services researchers have ized nations, Davis and colleagues (2004) founddescribed and studied these teams using sociologi- that the United States ranked lowest in efficiency,cal theories of group processes and social interac- effectiveness, and equity, and most Americanstion, ranging from social network conceptualizations believe that the health care system is in desperateof teams (Pescosolido, Wright, and Sullivan 1995) need of reform (Mechanic 2004). In late Marchto more process-related dynamics (Wright et al. 2010, President Obama and the U.S. Congress2006). Similarly, sociological theory is central to were successful in passing major health reform.research on the social dynamics of provider–patient The final reform package, however, focuses pri-interaction, focusing on how organizational factors marily on expanding access to health insuranceinfluence providers’ attitudes toward patients and and generally avoids the deeper and more complexthe approaches they take in communication and challenges in the structure and organization of ourservices delivery (Waitzkin 1991). Indeed, it has health service delivery system. In this regard,been argued that interactional and organizational sociological work on health services has clearcharacteristics of public and private health care policy implications.providers and settings may contribute to the afore-mentioned health and health services disparitiesacross gender, socioeconomic, and racial-ethnic Policy Recommendation 1:The State andgroups and communities (Lutfey and Freese 2005; Federal Governments Should BecomeMalat and Hamilton 2006; Williams 1990). More Involved in Regulating the Delivery of From a broader sociological perspective, Health Services in the United Statesresearch and theory linking organizational dynam-ics and processes to clinical outcomes represent an The persistent health inequalities across socialeffort to open up the black box of health services. groups and communities documented by medicalFifty years of medical sociology has clearly dem- sociologists raise serious doubts about the capacityonstrated that improving health services, while of our current health system to improve the healthnecessary, is not sufficient to improve the health of of our nation’s population. In cross-national studiesall communities and populations. In this regard, the United States does not compare favorably, par-medical sociologists should help to sensitize health ticularly with regard to other advanced, industrial-services researchers to factors from sources other ized Western European nations (Davis 2004). Somethan health care organizations that nonetheless have argued that the key to better outcomes in thesefundamentally shape the experience of health care countries is the strong role of central government inand, in turn, the impact that care has on individu- regulating the delivery of health services. Not onlyals. Hohmann (1999) has offered a helpful multi- do these governments guarantee access to carelevel framework in this regard. While developed through a single payer or a tightly regulated non-with mental health services in mind, the frame- profit health insurance system, but they also sup-work has more general utility. The central concern port and manage the distribution and quality ofis the array of system-related factors and social critical health resources. As documented by Scott Downloaded from hsb.sagepub.com by guest on December 29, 2010

S114 Journal of Health and Social Behavior 51(S)and colleagues (2000), health services have oper- Societyated and developed relatively independentlybecause of the weak regulatory structure within the Sociological contributions to health servicesUnited States and because government agreed to research reviewed in Findings 1 and 2 abovetake over financial responsibility for providing emphasize ways that the existing medical systemhealth care for uninsured and other vulnerable privileges some social groups at the expense of oth-populations during the 1960s and 1970s. As a ers, and thus reproduces broader structural inequal-result, private health care systems have continued ities rooted in gender, race-ethnicity, and socioeco-to make significant economic gains and have nomic status. In short, profit motivation in the pri-secured resources that have allowed them to resist vate health care sector and underfunding in themany efforts to impose stricter regulations (Quad- public sector influence physicians and organiza-agno 2004). More importantly, the broader U.S. tions to make medical decisions that in effect rationhealth care system remains a fragmented, uncoordi- care on the basis of social status rather than onnated patchwork of remarkably independent orga- health care needs. Because it seems unlikely thatnizations driven largely by the pursuit of immediate the United States will move away from a partiallyorganizational and economic interests, not by the privatized system (see Mechanic and McAlpinelonger-term health care needs of the country. 2010 in this issue), and because these sectors are Expanding government’s regulatory role in the inherently profit-driven, the most promising areadelivery of health services must necessarily be for instituting real policy change may be the under-accompanied by a better marriage of research and funded public sector. As argued in Finding 3, manypolicy. In recent years, policy makers have called of our nation’s low-income and racially segregatedfor more “comparative effectiveness” research, communities are being served by a public systemspecialized research that compares the cost and that is struggling to maintain the organizationalclinical efficacy of treatments for particular condi- structure, culture, and leadership afforded to thetions. Recent efforts to improve care have gravi- private sector by government investment.tated toward performance measurement and Current proposals for health care reform willlinking payment to concrete outcomes. While a work to improve access to private services amongfocus on outcomes is undoubtedly valuable, exist- the publicly insured and underserved. However,ing research has barely scratched the surface of the the public/private stratification of our existingbroad and complex social and organizational fac- health services system necessitates a two-prongedtors that shape efficiency and effectiveness. In this strategy. Equally critical is the need to moveregard, sociological research is important because beyond access issues to consider qualitative differ-it underscores that quality care is determined not ences in the health services being utilized by thoseonly by what services are provided, but also how on the margins of society—the most sick, impov-they are delivered, by whom, and to whom. erished, and structurally disadvantaged individuals In sum, increasing state and federal regulation (Mechanic 1994). As described above, existingrequires that the government be optimally informed sociological research suggests that members ofabout the best new directions for health policy and structurally disadvantaged groups face myriadpractice. While many argue against an expanded obstacles to utilizing efficient, cost-effective, androle of government in health care because of fears health-promoting preventative and primary healthof limiting access and innovation, government services, even when they ostensibly have access toalready pays for nearly half of our national health these through public insurance (Dutton 1978; Lut-care expenditures (Sisko et al. 2009). History tells fey and Freese 2005; Macintyre et al. 1993). Thus,us that reducing state and federal regulation in the it is necessary to focus on improving the qualityhealth care marketplace will only result in limiting and organization of services and facilities that ben-access to health services for the most vulnerable, efit, for example, those with severe and persistentexpanding health inequalities and ultimately weak- mental illness, those in remote rural areas, indi-ening the foundations of our democratic society. viduals near or below the poverty line, and members of disadvantaged racial-ethnic minority groups. The goal, then, is not only to provide uni-Policy Recommendation 2: Federal and State versal access to the private sector, but also to liftGovernments Should Invest in Public Health the public sector up to the standards of the private.Service Systems that Reach out to the Most Such a strategy requires careful planning. PolicyStructurally-disadvantaged Members of makers should identify locations for building Downloaded from hsb.sagepub.com by guest on December 29, 2010

Wright and Perry S115facilities, increasing funding, and augmenting serv- Andersen, Ronald and Ross M. Mullner. 1989. “Trendsices and providers that are optimally useful and in the Organization of Health Services.” Pp. 144–165attractive to those in underserved communities. in Handbook of Medical Sociology, edited by H. E.Likewise, it is necessary to consider how the unin- Freeman and S. Levine. Englewood Cliffs, NJ: Pren-sured and underinsured currently utilize those serv- tice Hall.ices that are available, and how to bring people at the Andrulis, Dennis P. 1998. “Access to Care is the Cen-margins into the health care system. For instance, terpiece in the Elimination of Socioeconomic Dis-incentivizing the use of primary, preventative, and parities in Health.” Annals of Internal Medicinefollow-up health care among those currently relying 129:412–16.on emergency room services may be an effective Angel, Jacqueline L. and Ronald J. Angel. 2006. “Minor-strategy. In all, we may simultaneously reduce the ity Group Status and Healthful Aging: Social Struc-cost of health care and improve the health of U.S. ture Still Matters.” American Journal of Publiccitizens by thoughtfully investing in groups and com- Health 96:1152–59.munities that need it most, rather than by allocating Billings, John, Nina Parikh, and Tod Mijanovich. 2000.them on the basis of profit and stakeholder interests. “Emergency Department Use in New York City: A Substitute for Primary Care?” Pp. 1–5 in Issue Brief, Commonwealth Fund, New York.cONclUSION Black, Douglas, Jerry Morris, C. Smith, Peter Townsend,Over the past 50 years, medical sociology has and Margaret Whitehead. 1988. Inequalities inimproved our understanding of the U.S. health care Health: The Black Report/The Health Divide. Lon-system and the wide array of providers and organi- don, England: Penguin UK.zations that comprise it. More important, this body Blendon, Robert J., Linda H. Aiken, Howard E. Freeman,of research has put a spotlight on how the distribu- and Christopher R. Corey. 1989. “Access to Medicaltion and delivery of health services contributes to Care for Black and White Americans. A Matter offundamental social inequalities and health dispari- Continuing Concern.” Journal of the American Medi-ties across many social groups and communities. cal Association 261:278–81.The extraordinary fragmentation and lack of coor- Bostick, R. M., J. M. Sprafka, B. A. Virnig, and J. D.dination suggests a need for more centralized Potter. 1993. “Knowledge, Attitudes, and Personalmanagement, something that the health care mar- Practices Regarding Prevention and Early Detectionket has not been able to achieve on its own. When of Cancer.” Preventive Medicine 22:65–85.taken as a whole, sociological research on health Brown, E. Richard 1979. Rockefeller Medicine Men:services highlights the need for a stronger role of Medicine and Capitalism in America. Berkeley: Uni-government in coordinating and managing the U.S. versity of California Press.health care system. Bunker, John P., Howard S. Frazier, and Frederick Mosteller. 1994. “Improving Health: Measuring Effects of Medical Care.” The Milbank Quarterly 72:225–58.AcKNOWlEDgMENTS Burns, L. R. and D. R. Wholey. 1991. “The Effects ofThe authors contributed equally in the preparation of this Patient, Hospital, and Physician Characteristicsmanuscript. on Length of Stay and Mortality.” Medical Care 29:251–71.REFERENcES Centers for Disease Control (CDC). 1998. “DemographicAiken, Linda H., Sean P. Clarke, and Douglas M. Sloane. Characteristics of Persons without a Regular Source 2002. “Hospital Staffing, Organization, and Quality of Medical Care—Selected States, 1995.” Morbidity of Care: Cross-National Findings.” Nursing Outlook and Mortality Weekly Report 47:277–79. 50:187–94. Coe, Rodney M. 1978. Sociology of Medicine. New York:Aiken, Linda H., Douglas M. Sloane, Eileen T. Lake, McGraw-Hill. Julie Sochalski, and Anita L. Weber. 1999. “Organi- Collins, Karen S., Allyson Hall, and Charlotte Neuhaus. zation and Outcomes of Inpatient AIDS Care.” Medi- 1999. U.S. Minority Health: A Chartbook. New York: cal Care 37:760–72. The Commonwealth Fund.Aiken, Linda H., Herbert L. Smith, and Eileen T. Lake. Courtenay, Will H. 2000. “Constructions of Masculinity 1994. “Lower Medicare Mortality among a Set of and Their Influence on Men’s Well-Being: A Theory Hospitals Known for Good Nursing Care.” Medical of Gender and Health.” Social Science and Medicine Care 32:771–87. 50:1385–1401. Downloaded from hsb.sagepub.com by guest on December 29, 2010

S116 Journal of Health and Social Behavior 51(S)Cowie, Catherine C. and Mark S. Eberhardt. 1995. Glaser, Barney G. and Anselm Strauss. 1965. Awareness “Sociodemographic Characteristics of Persons with of Dying. Chicago: Aldine Transaction. Diabetes.” Pp. 353–85 in Diabetes in America, Goffman, Erving. 1961. Asylums. Garden City, NY: Dou- edited by M. I. Harris, C. C. Cowie, M. P. Stern, E. J. ble Day Anchor Books. Boyko, G. E. Reiber, and P. H. Bennett. Washington, Goldman, Dana P. and James P. Smith. 2002. “Can Patient DC: U.S. Department of Health and Human Services, Self-management Help Explain the SES Health Gra- National Institutes of Health. dient?” Proceedings of the National Academy of Sci-Cuellar, Alison Evans and Paul J. Gertler. 2003. “Trends ences of the United States of America 99:10929–934. in Hospital Consolidation: The Formation of Local Goss, Mary. 1963. “Patterns of Bureaucracy among Hos- Systems.” Health Affairs (Project Hope) 22:77–87. pital Staff Physicians.” Pp. 170–94 in The HospitalCunningham, Peter J., Joy M. Grossman, Robert F. St. in Modern Society, edited by E. Freidson. New York: Peter, and Cara S. Lesser. 1999. “Managed Care and The Free Press. Physicians’ Provision of Charity Care.” Journal of the Green, Carla A. and Clyde R. Pope. 1999. “Gender, Psy- American Medical Association 281:1087–92. chosocial Factors and the Use of Medical Services: ADavis, Karen, Cathy Schoen, Stephen C. Schoenbaum, Longitudinal Analysis.” Social Science and Medicine Anne-Marie J. Audet, Michelle M. Doty, Alyssa L. 48:1363–72. Holmgren, and Jennifer L. Kriss. 2006. “Mirror, Mir- Hafferty, Frederic W. and Donald W. Light. 1995. “Pro- ror on the Wall: An Update on the Quality of Ameri- fessional Dynamics and the Changing Nature of Med- can Health Care Through the Patient’s Lens.” The ical Work.” Journal of Health and Social Behavior Commonwealth Fund, April. 36(Extra Issue):132–53.Dohan, Daniel. 2002. “Managing Indigent Care: A Case Haug, Marie R. 1973. “Deprofessionalism: An Alterna- Study of a Safety-net Emergency Department.” tive Hypothesis for the Future.” Sociological Review Health Services Research 37:361–76. Monographs 20:195–211.Dutton, Diana B. 1978. “Explaining the Low Use of Hohmann, Ann A. 1999. “A Contextual Model for Clini- Health Services by the Poor: Costs, Attitudes, or cal Mental Health Effectiveness Research.” Mental Delivery Systems?” American Sociological Review Health Services Research 1:83–91. 43:348–68. Institute of Medicine. 2004. Insuring America’s Health:Fennell, Mary L. and Richard B. Warnecke. 1988. The Principles and Recommendations. Washington, DC: Diffusion of Medical Innovation. New York: Plenum National Academies Press. Press. Jost, Timothy Stoltzfus. 2003. Disentitlement? TheFiscella, Kevin, Peter Franks, Mark P. Doescher, and Threats Facing Our Public Health Care Programs Barry G. Saver. 2002. “Disparities in Health Care by and a Rights-Based Response. New York: Oxford Race, Ethnicity, and Language among the Insured: University Press. Findings from a National Sample.” Medical Care Kahn, Katherine L., Marjorie L. Pearson, Ellen R. Har- 40:52–59. rison, Katherine A. Desmond, William H. Rogers,Flood, Ann Barry. 1994. “The Impact of Organizational Lisa V. Rubenstein, Robert H. Brook, and Emmett B. and Managerial Factors on the Quality of Care in Keeler. 1994. “Health Care for Black and Poor Hos- Health Care Organizations.” Medical Care Research pitalized Medicare Patients.” Journal of the American Review 51:381–428. Medical Association 271:1169–74.Flood, Ann Barry and Mary L. Fennel. 1995. “Through Katz, Steven J. and Timothy P. Hofer. 1994. “Socioeco- the Lenses of Organizational Sociology: The Role of nomic Disparities in Preventive Care Persist Despite Organizational Theory and Research in Conceptual- Universal Coverage. Breast and Cervical Cancer izing and Examining Our Health Care System.” Jour- Screening in Ontario and the United States.” Journal nal of Health and Social Behavior 36:154–69. of the American Medical Association 272:530–34.Flood, Ann Barry, W. Richard Scott, and Stephen M. Kessler, Ronald C., Roger L. Brown, and Clifford L. Shortell. 1994. “Organizational Performance: Man- Broman. 1981. “Sex Differences in Psychiatric Help- aging for Efficiency and Effectiveness.” Pp. 381–429 Seeking: Evidence from Four Large-Scale Surveys.” in Essentials of Healthcare Management, edited Journal of Health and Social Behavior 22:49–64. by S. M. Shortell and A. D. Kaluzny. Albany, NY: Klarman, Herbert E. 1963. Hospital Care in New York Delmar. City: The Roles of Voluntary and Municipal Hospi-Freidson, Eliot 1970. Professional Dominance: The tals. New York: Columbia University Press. Social Structure of Medical Care. New York: Ather- Lantz, Paula. M., Margaret E. Weigers, and James S. ton Press. House. 1997. “Education and Income Differentials in Downloaded from hsb.sagepub.com by guest on December 29, 2010

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S118 Journal of Health and Social Behavior 51(S) Mortality Weekly Report. CDC Surveillance Summa- Waitzkin, Howard. 1991. The Politics of Medical ries: Morbidity and Mortality Weekly Report. CDC Encounters. New Haven, CT: Yale University Press. Surveillance Summaries/Centers For Disease Con- ———. 2000. The Second Sickness: Contradictions of trol 46:1–31. Capitalist Health Care. Lanham, MD: Rowman andQuadagno, Jill. 2004. “Why the United States Has No Littlefield Publishers. National Health Insurance: Stakeholder Mobilization Weinberg, Dana Beth. 2003. Code Green: Money-Driven Against the Welfare State, 1945–1996.” Journal of Hospitals and the Dismantling of Nursing. Ithaca, Health and Social Behavior 45(Extra Issue):25–44. NY: ILR Press.Robert, Stephanie and James S. House. 2000. “Socio- Wenger, Neil S., David H. Solomon, Carol P. Roth, economic Inequalities in Health: An Enduring Catherine H. MacLean, Debra Saliba, Caren J. Sociological Problem.” Pp. 79–97 in Handbook of Kamberg, Laurence Z. Rubenstein, Roy T. Young, Medical Sociology, edited by C. E. Bird, P. Conrad, Elizabeth M. Sloss, Rachel Louie, John Adams, and A. M. Fremont. Upper Saddle River, NJ: John T. Chang, Patricia J. Venus, John F. Sch- Prentice Hall. nelle, and Paul G. Shekelle. 2003. “The Quality ofRoos, Noralou P. and Cameron A. Mustard. 1997. “Varia- Medical Care Provided to Vulnerable Community- tion in Health and Health Care Use by Socioeco- Dwelling Older Patients.” Annals of Internal Medi- nomic Status in Winnipeg, Canada: Does the System cine 139:740–47. Work Well? Yes and No.” The Milbank Quarterly Wholey, Douglas R. and Lawton R. Burns. 2000. “Tides 75:89–111. of Change: The Evolution of Managed Care in theRoss, Catherine E. and Chia-ling Wu. 1995. “The Links United States.” Pp. 217–237 in Handbook of Medical between Education and Health.” American Sociologi- Sociology, edited by C. E. Bird, P. Conrad, and A. M. cal Review 60:719–45. Fremont. Upper Saddle River, NJ: Prentice-Hall.Rundall, Thomas G. and John R. C. Wheeler. 1979. “The Williams, David R. 1990. “Socioeconomic Differentials Effect of Income on Use of Preventive Care: An in Health: A Review and Redirection.” Social Psy- Evaluation of Alternative Explanations.” Journal of chology Quarterly 53:81–99. Health and Social Behavior 20:397–406. Williams, David R. and Chiquita Collins. 1995. “U.S.Scott, W. Richard. 1990. “Innovation in Medical Care Socioeconomic and Racial Differences in Health: Organizations: A Synthetic Review.” Medical Care Patterns and Explanations.” Annual Review of Sociol- Research Review 47:165–92. ogy 21:349–86.Scott, W. Richard, Martin Ruef, Peter J. Mendel, and ———. 2001. “Racial Residential Segregation: A Funda- Carol A. Caronna. 2000. Institutional Change and mental Cause of Racial Disparities in Health.” Public Healthcare Organizations: From Professional Domi- Health Reports 116:404–16. nance to Managed Care. Chicago, IL: The University Williams, David R. and Michelle Sternthal. 2010. of Chicago Press. “Understanding Racial-Ethnic Disparities in Health:Seccombe, K. and C. Amey. 1995. “Playing by the Rules Sociological Contributions.” Journal of Health and and Losing: Health Insurance and the Working Poor.” Social Behavior 51(Extra Issue):S15–27. Journal of Health and Social Behavior 36:168–81. Wilson, Robert N. 1963. “The Social Structure of a Gen-Sisko, Andrea, Christopher Truffer, Sheila Smith, Sean eral Hospital.” Annals of the American Academy of Keehan, Jonathan Cylus, John A. Poisal, M. Kent Political and Social Science 346:67–76. Clemens, and Joseph Lizonitz. 2009. “Health Spend- Wright, Eric R., Lisa A. Russell, Jeffrey Anderson, ing Projections through 2018: Recession Effects Harold E. Kooreman, and Dustin E. Wright. 2006. Add Uncertainty to the Outlook.” Health Affairs 28: “Impact of Team Structure on Achieving Treatment 346–57. Goals in a System of Care.” Journal of Emotional andSmedley, Brian D., Adrienne Y. Stith, and Alan R. Nel- Behavioral Disorders 14:240–50. son. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press. BiosStrauss, Anselm, Leonard Schatzman, Danuta Ehrlich, Eric R. Wright is professor and division director for health Rue Bucher, and Melvin Sabshin. 1963. “The Hos- policy and management in the Department of Public Health pital and Its Negotiated Order.” Pp. 147–69 in The at the Indiana University School of Medicine. He also serves Hospital in Modern Society, edited by E. Freidson. as the director of the Center for Health Policy at Indiana New York: The Free Press. University-Purdue University Indianapolis. In addition, he Downloaded from hsb.sagepub.com by guest on December 29, 2010

Wright and Perry S119holds an adjunct appointment in the Department of Sociol- focuses on the interrelated roles of social networks andogy in the Indiana University School of Liberal Arts. His interaction, social structure, culture, and biological sys-research interests center on health policy, social responses to tems in disease etiology and the illness career. She hashealth problems, and the social organization and effective- published research on dynamic social network processes,ness of health services and public health programs. stigma and its consequences, youth in foster care, mental illness in children and adults, and gene–environmentBrea L. Perry is assistant professor in the Department of interactions in disease pathways.Sociology at the University of Kentucky. Her research Downloaded from hsb.sagepub.com by guest on December 29, 2010

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