Medical sociologists assert that the delivery of health services is much more than simply the application of scientific and technical knowledge. Health care services are delivered by people to people within various social environments, which can influence the way medical technology is delivered or received and, perhaps most important, the clinical outcomes for people seeking help.
More over the rising costs and inconsistent quality of health care have raised significant questions among professionals, policy makers, and the public about the way health services are being delivered. For the past 50 years, medical sociologists have made significant contributions in improving our understanding of the nature and impact of the organizations (hospitals) that constitute our health care system. In this section, three central issues in the sociology of health services have been discussed:
· Health services unequally distributed, contributing to health inequalities across status groups;
· social institutions reproduce health care inequalities by constraining and enabling the actions of health service organizations, health care providers, and consumers;
· the structure and dynamics of health care organizations shape the quality, effectiveness, and outcomes of health services for different groups and communities;
· the policy implications for future health care reform efforts.
One of the fundamental concerns of medical sociologists over the past 50 years has been to document and explain gender, socioeconomic, and racial‐ethnic differentials in health outcomes. Among the early explanations for these patterns were disparities in the distribution of health services among social groups, and substantial attention was devoted to documenting systematic differences in access to health care. More recently, evidence has emerged suggesting that the adverse impact of health care disparities on population health is increasing, highlighting the need for additional research (Lesser and Cunningham 1997). As a result, sociologists have taken a renewed interest and adopted a more complex and comprehensive approach to health services research, examining the nature, quality, and timeliness of care received under a variety of illness conditions.
Sociological research has documented significant gender differences in help‐seeking. Women are more likely than men to visit a doctor for an array of both physical and mental health problems (Courtenay 2000; Green and Pope 1999; Kessler, Brown, and Broman 1981). They are also more apt to have a regular physician and to obtain preventative screenings (Bostick et al. 1993; Centers for Disease Control 1998; Powell‐Griner, Anderson, and Murphy 1997). However, men who do consult a health professional may receive better treatment than women for the same condition. The evidence is particularly strong in the case of heart disease. Women who present with symptoms of cardiac disease are less likely to be referred for diagnostic tests, given cardiac drugs, or instructed to make lifestyle changes. Conversely, they are three to five times more likely to be sent home without any treatment (Lockyer and Bury 2002; McKinlay 1996). These patterns delay diagnosis and contribute to higher mortality rates among women with heart disease relative to men.
Decades of research by sociologists suggests that people with less income and education face greater obstacles accessing health services than their more well‐off counterparts, despite having higher health care needs (Dutton 1978; Katz and Hofer 1994). Disparities are particularly marked in the area of primary care (Rundall and Wheeler 1979). For example, adults and children of lower socioeconomic status (SES) are less likely to have routine physical examinations and screening procedures, such as prenatal care, immunizations, mammograms, and colonoscopies (Goldman and Smith 2002; Lantz, Weigers, and House 1997; McDonald and Coburn 1988). Moreover, they are less likely to receive medical intervention in a timely manner, and they often receive less intensive and lower quality treatments (Williams 1990). Together, these patterns result in poorer long‐term outcomes and higher emergency room and hospitalization rates for conditions that would not normally require them (Padgett and Brodsky 1992; Pappas et al. 1997).
Because income and educational attainment are so closely linked to race and ethnicity in America, patterns of health care inequality observed in racial‐ethnic minority groups are similar to those found in low‐SES populations (Williams and Collins 1995). That is, racial‐ethnic minorities generally have less access to health services, in particular primary and preventative care, and they also tend to receive delayed treatment and lower quality acute and long‐term care than whites (Blendon et al. 1989; Smedley, Stith, and Nelson 2003; Williams 1990). Though these patterns are better established in African American populations, studies suggest they also extend to Latinos, Asian Americans, and Native Americans (Angel and Angel 2006; Collins, Hall, and Neuhaus 1999; Fiscella et al. 2002). While much of the disparity in health services use can be explained by SES differentials, race‐ethnicity tends to exhibit a modest, independent effect on health services use. These effects have been attributed to racial discrimination by health services providers and racial segregation of minorities into communities with less access to high‐ quality health services (Polednak 1993; Williams and Collins 1995).
A unique strength of the sociological perspective is the focus on underlying social structural mechanisms of phenomena that ostensibly occur at the individual level (McKinlay 1996). Sociologists have long conceptualized medicine as a social institution, highlighting the influence of macro factors on help‐seeking and the practice of health care in everyday life (Freidson 1970; Mechanic 1975; Parsons 1951). The institution of medicine is characterized by a powerful set of social norms, rules, values, and practices that provides a blueprint for the behavior of individuals and organizations (e.g., physicians, patients, hospitals, HMOs, etc.), and systematically structures the relationships between them. Sociologists have contributed much to our understanding of the ways that culturally and historically shaped institutional forces constrain the behavior of health care providers and consumers, reproducing health care inequalities across social groups (Light 2004). Sociologists have been instrumental in documenting changes in the institution of medicine over the twentieth century. In what Scott and colleagues (2000) call the era of professional dominance (1945–1965), the motivating ideology in medicine was commitment to quality care. Additionally, there was a strong sense of obligation to provide health care to all, regardless of a person’s ability to pay for it (Klarman 1963). Accordingly, the poor received free care from physicians and hospitals, and the population at large paid on a sliding scale according to their means. In the era of federal involvement (1966–1982), concern with equitable access prevailed, but the government increasingly took over responsibility for funding and regulating the fair distribution of health care (Scott et al. 2000). At the same time, health services expenditures began to increase rapidly, and concerns about cost containment began to overshadow the long‐standing commitment to quality care and equity that had characterized the institution of medicine since its inception (Brown 1979). In the current era of managerial control and market mechanisms (Scott et al. 2000), the health care sector is conceptualized as an industry, or economic system, and efficiency and profit are central motivating values. Changes in health policy (and ultimately practice) enacted by the Reagan administration began as part of a broader political movement characterized by welfare state retrenchment and by the shifting of government control to competitive market forces (O’Connor 1998). These events, described in greater detail by Mechanic and McAlpine (2010, in this issue), culminated in the corporatization of health care and the managed care ethos that pervades the institution of medicine today.
There is a Separate and Unequal distribution of health service in the Public and Private Health Care Sectors. This trend has important implications for the types and quality of care received by lower statusgroups. For instance, managed care organizations minimize risk by denying coverage to sicker, less profitable patients and spreading the risk out among a large consumer group that contains both healthy and sick individuals. These practices shift much of the financial responsibility for indigent care (i.e., those who are unable to pay for services) to physician groups and hospitals, pressuring them to balance their budgets by cutting costs associated with uninsured or publicly insured patients. At the same time, professional resources and government funds are increasingly being diverted to the profitable private sector (Waitzkin 2000). This has forced many public health facilities to close their doors, shrinking the public sector and widening the health gap between the rich and the poor. Sociologists have demonstrated that the result of this profit driven funding environment is essentially two divergent health care systems, public and private, characterized by radically different experiences and outcomes (Dutton 1978; Lutfey and Freese 2005; Smedley et al. 2003). Supporters of the for‐profit sector have argued that those without private insurance can still access private health services through Medicare and Medicaid reimbursements. On the contrary, sociologists have identified numerous barriers that minimize use of the private sector by the publicly insured: (1) Medicare and Medicaid often pay less thanprivate market value for a given service, forcing the patient to pay the difference in cost; (2) Medicare and Medicaid policies are notoriously complex, prompting confusion and fear of incurring fees in the private sector; (3) Community and geographic barriers may restrict access to private facilities and providers, even when patients are publicly insured (Macintyre, MacIver, and Sooman 1993; Williams and Collins 2001); (4) Finally, private facilities and providers may overtly or subtly discourage publicly-insured (and uninsured) patients from using their services. At even greater risk for slipping through the cracks ofour health care system are the working poor and lower middle class—those whose incomes neither qualify them for public insurance nor allow them to afford private coverage (Seccombe and Amey 1995).
Seeking to understand the implications of organizational structure and dynamics in health services settings, a number of medical sociologists have focused more narrowly on organizations. Indeed, much of the classical work in medical sociology during the 1960s and 1970s explored various aspects of health care organizations, especially the general, acute‐care hospitals (Coe 1978; Goss1963; Wilson 1963), as well as medical schools, physician offices, and psychiatric hospitals (Coe 1978; Freidson 1970; Strauss et al. 1963). With advances in technology and economic opportunities in the health care sector, and with the epidemiological shift from acute to more chronic and long‐term health conditions, the types and varieties of health care organizations expanded dramatically from the 1960s onward. Nevertheless, these early studies had enormous descriptive value and contributed to a fundamental understanding of our emerging health system. They also highlighted a myriad of organizational challenges in delivering health services, including the depersonalization and devaluing of patients (Coe 1978); the interpersonal dynamics between doctors and patients (Freidson 1970; Glaser and Strauss 1965; Goffman 1961) the power relationships and conflicts among health professional groups (Goss 1963); and the tendency toward bureaucratic medical decision making and treatment (Freidson 1970; Goss 1963; Strauss et al. 1963). Most importantly, this body of work sensitized a generation of medical sociologists to the nature of medical work and established a reference point that continues to inform the field. In more recent years, medical sociologists have examined critical organizational changes that have had implications for how and what types of care are delivered, as well as how effective the care is for various social groups.
· Expanding government’s regulatory role in the delivery of health services must necessarily be accompanied by a better marriage of research and policy. In recent years, policy makers have called for more “comparative effectiveness” research, specialized research that compares the cost and clinical efficacy of treatments for particular conditions. Recent efforts to improve care have gravitated toward performance measurement and linking payment to concrete outcomes. While a focus on outcomes is undoubtedly valuable, existing research has barely scratched the surface of the broad and complex social and organizational factors that shape efficiency and effectiveness. In this regard, sociological research is important because it underscores that quality care is determined not only by what services are provided, but also how they are delivered, by whom, and to whom.
· Policy makers should identify locations for building facilities, increasing funding, and augmenting services and providers that are optimally useful and attractive to those in underserved communities.
· It is necessary to consider how the uninsured and underinsured currently utilize those services that are available, and how to bring people at the margins into the health care system. For instance, incentivizing the use of primary, preventative, and follow‐up health care among those currently relying on emergency room services may be an effective strategy.