Abstract
A social worker trying to help diabetic, homeless, and other patients in need; a chaplain trying to avoid burnout while giving emotional support; and a palliative care physician and his team trying to change the prevailing physician culture around dying—in Selling Our Souls: The Commodification of Hospital Care in the United States, Adam Reich unfolds the narratives of people like these who work in hospitals trying to realize their aims of giving appropriate care in the midst of intensifying market pressures. Drawing on 121 interviews, observations, descriptive statistics, and archival data, Reich compares three not-for-profit health care organizations in a mid-sized town in California: a former public hospital, a Catholic hospital, and an integrated health management organization. He does not seek to provide a causal explanation of varying hospital care practices but rather “to explore the different dimensions of its variation” (p. 16). The three organizations vary on business strategy, management control strategies, patient and payer mix, and financial performance. In his institutionalist analysis of this complex variation, Reich provides a differentiated theoretical conceptualization of the relationship between morals and markets. He also provides rich narrative accounts and data on organizational dynamics as well as an intriguing set of patterns.
Reich’s main focus is on the institutional legacies that shape how the people working in his cases reconcile the contradictions between their non-economic values and market pressures. The former public hospital’s contradiction is between the scarcity of resources and the practice of providing extensive uncompensated care to underinsured and uninsured patients. The people in this hospital view care as a social right, and Reich interprets their disregard for efficiency and profitability as rebuffing market pressures. In the Catholic hospital, the contradiction is between the values of sacrifice and dignity, with which many in the hospital identify, and management’s marketing of these values to attract high-paying patients, the treatment of uninsured patients with little dignity, and the lowest wages for nurses and ancillary workers among the three cases studied. Reich interprets this case as moralizing market pressures. In the integrated health management organization, customized care according to each patient’s special needs contradicts the organization’s prevailing operating principle of standardizing and rationing care by scaling up efficient practices. Reich interprets this case as taming market pressures through the use of bureaucracy and big data. The author lays out these three types of moral–market relationships by examining the conception of care, the structure of physicians’ work, and the power and division of labor between physicians, nurses, and ancillary workers including the role of labor relations in each of the cases. Another interesting argument in the book is that these three different moral–market relationships correspond to three different historical periods. I find Reich’s well-grounded discussion and critique of the three models highly persuasive.
For me, the most interesting aspect of Selling Our Souls is its main theoretical contribution: a differentiated conceptualization of the conflict between social values and market pressures in health care. Reich does not mention this but if we followed Max Weber’s conceptualization of modernity’s tendency to rationalize, in which formal rationality evermore replaces substantive rationality, we would expect social values to diminish and strictly contradict market pressures. But Reich shows this is only one way the moral–market relationship can play out. In the Catholic hospital, both administrators and physicians integrate morals and market pressures at the expense of the power and wages of nurses and ancillary workers. In the integrated health management organization, administrators use bureaucratic tools to limit physicians’ discretion to the benefit of customer service. Moreover, the integrated health management organization boasts better employment relations with steadier, more limited working hours for physicians in exchange for lower pay and a long history of union representation empowering nurses somewhat vis-à-vis physicians, and generating higher wages for nurses and ancillary workers. It may surprise some that Reich identifies these three different types of moral–market relationships in the classic liberal market economy in which we might expect a more uniform response to market pressures. His institutionalist analysis, however, shows that organizational dynamics are more complex than a simple dichotomy might capture.
In addition to this theoretical contribution, Reich uses various types of data to provide rich accounts and striking critiques. For example, using descriptive statistics that are publicly available because of California’s unique reporting laws, Reich deconstructs administrators’ claims that the Catholic hospital operates primarily for poor patients’ well-being. The Catholic hospital does have a higher absolute amount of unreimbursed care than the former public hospital. At the same time, however, the Catholic hospital’s unreimbursed care largely consists of bills on which the hospital could not collect, and the hospital charges consistently higher prices than the former public hospital. Reich also uses his observations of physicians to great effect. For example, he illustrates the lacking coordination of information at the former public hospital through his description of an ER doctor who carries three phones, a beeper, and a tablet.
Throughout Reich’s discussion of the cases, I found various patterns that hold great promise for further exploration. One such pattern is the relationship between physicians’ compensation and their work behaviors. Reich recounts how physicians at the Catholic hospital billed individually in the classic fee-for-service way. This created incentives to overtreat, competition for high-paying patients, and the practice of discerning a patient’s insurance status by refusing patients with gun or stab wounds, patients without primary care physicians, or patients with Latino names. This contrasts strongly to the former public hospital’s emergency room in which a small collective of local physicians contracted with the hospital and subcontracted work through hourly wages to other physicians. This structure of physician compensation resulted in less variation in pay and extensive, if also paternal, treatment of uninsured patients. Another interesting pattern is how different levels of union power articulate themselves at the workplace level. For example, nurses at the Catholic hospital had a weak union for a long time, treated physicians like clients, had a highly circumscribed spectrum of tasks, and did not take breaks. By contrast, the integrated health management organization had a strong union with a labor–management partnership and an extensive contract that unionists fell back on to elicit management support. Nurses were on equal standing with physicians, often did an array of complex tasks, and generally took lunch breaks. These and other organizational dynamics can be fruitfully explored in further studies.
One limitation is that Reich does not focus on the work of nurses, ancillary workers, or environmental health services workers, opting instead to focus on physicians’ work and to draw mostly on administrator and physician interviews. Reich’s aim of discussing the broad scope of hospital care, along with his statements that nurses at the Catholic and former public hospitals tended to strike often and that the majority of workers at the integrated health management organization consisted of ancillary workers, also indicate that a further look at these occupational and professional groups would be worthwhile.
Another interesting aspect of the book concerns Reich’s account of the dominant business strategy in each of the cases. For example, he states how efficiency, cost-containment, and data-driven scale economies form the integrated health management organization’s main strategic principles. This strategy differs from the volume-based, high reimbursement focus of the fee-for-service world to which the Catholic hospital responds. As Reich points out, the data-driven scale economy approach is the business strategy that is more suited to a value-based environment that may come to dominate U.S. health care. Overall, Selling Our Souls provides a host of interesting insights and patterns like these for further study; a compelling theoretical contribution; and rich stories, especially for those interested in industrial relations in health care, work sociology, market sociology, and organization theory.