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Selling Our Souls

Selling Our Souls: The Commodification of Hospital Care in the United States

Adam D. Reich
Copyright Date: 2014
Pages: 248
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  • Book Info
    Selling Our Souls
    Book Description:

    Health care costs make up nearly a fifth of U.S. gross domestic product, but health care is a peculiar thing to buy and sell. Both a scarce resource and a basic need, it involves physical and emotional vulnerability and at the same time it operates as big business. Patients have little choice but to trust those who provide them care, but even those providers confront a great deal of medical uncertainty about the services they offer.Selling Our Soulslooks at the contradictions inherent in one particular health care market-hospital care. Based on extensive interviews and observations across the three hospitals of one California city, the book explores the tensions embedded in the market for hospital care, how different hospitals manage these tensions, the historical trajectories driving disparities in contemporary hospital practice, and the perils and possibilities of various models of care.

    As Adam Reich shows, the book's three featured hospitals could not be more different in background or contemporary practice. PubliCare was founded in the late nineteenth century as an almshouse in order to address the needs of the destitute. HolyCare was founded by an order of nuns in the mid-twentieth century, offering spiritual comfort to the paying patient. And GroupCare was founded in the late twentieth century to rationalize and economize care for middle-class patients and their employers. Reich explains how these legacies play out today in terms of the hospitals' different responses to similar market pressures, and the varieties of care that result.

    Selling Our Soulsis an in-depth investigation into how hospital organizations and the people who work in them make sense of and respond to the modern health care market.

    eISBN: 978-1-4008-5037-2
    Subjects: Sociology, Economics, Public Health, Health Sciences

Table of Contents

  1. Front Matter
    (pp. [i]-[vi])
  2. Table of Contents
    (pp. [vii]-[x])
  3. Introduction
    (pp. 1-18)

    The hospital has a paradoxical place in U.S. society.¹ It is central to the nation’s economy, yet many of us are uncomfortable with what is implied by a market for hospital care. The hospital remains a last resort for the poor and desperately sick. It is a place where most of us were born and most of us will die. And it is a place to which we often turn in our moments of greatest physical uncertainty and emotional vulnerability. We have intimate connections to hospitals and strong feelings about them. Perhaps as a result of our ambivalence about the...

  4. PART ONE PubliCare Rebuffs the Market

    • [PART ONE Introduction]
      (pp. 19-25)

      As was the case throughout the United States, hospital care in Las Lomas began in the almshouse, tied deeply to the needs of the dependent poor. Hospital care emerged at a time when the categories that would come to distinguish different sorts of dependency from one another—physical and mental illness, illness and old age, disability and poverty—had not been firmly established. And it emerged at a time when the curative capacities of an embryonic medical profession were questionable at best.

      The early U.S. hospital can usefully be understood as sitting in opposition to the market, in three related...

    • CHAPTER ONE Health Care for All
      (pp. 26-47)

      Sandra Lacks, a social worker at PubliCare Hospital, was an African American woman in her forties, with braided hair tied in a bun behind her head and an authoritative stride. While growing up in a poor section of Boston, Lacks had been introduced to a social worker that “took a liking” to some of her writing and entered her into a citywide speaking contest. Lacks won the contest, and the social worker helped secure a scholarship for her to attend a prestigious East Coast boarding school. “She saw more of me than I saw of myself,” Lacks told me. Making...

    • CHAPTER TWO Privileged Servants
      (pp. 48-58)

      In an address to graduates of the prestigious family practice residency program at PubliCare Hospital in 2000, Dr. Dan Brenner—a leader of the program—decried the influence of the market in modern medicine, suggesting that it corrupted the vocational calling of medical practitioners. By way of analogy, he asked the audience to imagine a health care executive making cost-saving recommendations to a symphony orchestra after watching the orchestra play: “All twelve violins were playing identical notes at the same time. Such duplication could be eliminated with a cost savings of 92 percent in the string section alone.” If physicians...

    • CHAPTER THREE Feels Like Home
      (pp. 59-70)

      On my first morning of observation at PubliCare Hospital, I entered the emergency department a few minutes before the 7 a.m. shift change. I told the clerk at the front desk that I was supposed to shadow Dr. David Harper. She guided me through a secured doorway and left me by the nursing station. There was no doctor to be found. I took a seat and waited until a nurse approached. Since Harper was running late, she told me, I should feel free to start seeing patients myself. She seemed to assume that I was a medical resident. Needless to...

  5. PART TWO HolyCare Moralizes the Market

    • [PART TWO Introduction]
      (pp. 71-77)

      By the early decades of the twentieth century, the hospital had established itself more firmly as a center of medical authority and medical practice. Because of the new technology available in hospitals, and because of physicians’ increasing dependence on these facilities for their own practices, the wealthy began to consider these institutions for their own inpatient (and especially surgical) care.¹ As the medical profession formalized its authority during the first decades of the twentieth century, physicians exerted increasing authority over admissions to the hospital and over the inner workings of the organization more generally.² In order to attract paying patients,...

    • CHAPTER FOUR Sacred Encounters
      (pp. 78-94)

      Amanda Roberts, a chaplain at HolyCare Hospital, was a heavy-set woman in her early forties with wide eyes and an expressive face. Roberts had been a graduate student in chemistry before she decided to begin a divinity program: “I decided that instead of being in a lab, what I really wanted to do was to be out working with people . . . to make the matter of spirit, and how we are really alive and awake in this life, part of the focus of my life.” During a hospital residency she quickly came to appreciate both “how much someone...

    • CHAPTER FIVE Good Business
      (pp. 95-108)

      During an early morning coffee break in the small cafeteria at PubliCare, an older emergency medicine doctor began describing the emergency room down the road at HolyCare. In order to understand it, he told me, I should read a book with a provocative title:The Rape of Emergency Medicine.¹ Published in 1992 by James Keaney, a disillusioned ER doctor and the founder of an alternative professional association for ER physicians, the book documents how a few entrepreneurial ER doctors had, over the course of the 1980s, established large national corporations that contracted with hospitals to manage hospital emergency rooms. These...

    • CHAPTER SIX The Martyred Heart
      (pp. 109-122)

      A unit manager at HolyCare, who began working at the hospital while the sisters were still an active presence, told me, “You haven’t really and truly been scolded until you’ve been scolded by a nun.”¹ And while the sisters were no longer actively working at the hospital, which meant that I never got to experience such a scolding firsthand, I did get an impression of the rigid disciplinary regime that persisted there.

      It is common knowledge among qualitative researchers that the process by which one enters the field often contains important information about the field itself. At PubliCare, my entrance...

  6. PART THREE GroupCare Tames the Market

    • [PART THREE Introduction]
      (pp. 123-126)

      By the early 1970s, across the United States, there were growing calls for restraint and rationalization in what had become—in the minds of many—an unwieldy and unreasonably expensive health system. Patients’ rights advocates, business leaders, and political figures on both the left and the right began to mobilize against the autonomy and excess of the medical profession and the hospital industry. In 1971, the Nixon administration began advocating for grants and loan guarantees incentivizing the establishment of “health maintenance organizations,” or HMOs, integrated health systems that would combine health insurance with health care provision and so provide medical...

    • CHAPTER SEVEN Flourishing
      (pp. 127-146)

      Ted Booth was a palliative care physician in his early fifties at GroupCare, thin with dark curly hair and thick-rimmed glasses. After attending medical school, he arrived in Las Lomas to attend the family practice residency program affiliated with PubliCare. He finished his residency in the mid-1980s and joined the family practice clinic at GroupCare. Booth began practicing medicine just as HIV/AIDS was starting to appear in the county. When GroupCare patients began developing symptoms, he saw how there was “no coordinated care at all, and very little support within the organization.” So he and a few other family practice...

    • CHAPTER EIGHT Disciplined Doctors
      (pp. 147-170)

      Ron Schmidt, a senior medical administrator at GroupCare, was a tall, loping man in his fifties.¹ Before attending medical school, Schmidt had worked as an electrical engineer at a large defense firm, and then as a medical researcher. As he rose through the ranks at GroupCare, from physician to department chief to senior administration, he sought to apply his engineering background to the organization of care: “I started reading about Toyota and the lean production methodology,” he said. But he soon realized that other physicians were not as responsive to the language of efficiency as he was: “You say, ‘Well,...

    • CHAPTER NINE Partnership
      (pp. 171-188)

      Andrew Quan was a thirty-something ER doctor at GroupCare. He had begun college as an engineering major, but when he volunteered in an emergency room he got a taste for the excitement of emergency medicine and never looked back. He switched his major, went to medical school, and joined GroupCare directly after finishing residency. Yet he soon grew frustrated by how little GroupCare seemed to “cater to doctors.” At other hospitals in the area, doctors could park their cars right by the hospital entrance: “That’s important to [doctors] . . . to get to their jobs and get things done.”...

  7. Conclusion
    (pp. 189-198)

    Hospitals serve as signposts in our lives. My daughter Ella’s birth at Berkeley’s Alta Bates Medical Center in the autumn of 2008 is one such marker for me. I will spare the reader a minute-by-minute recounting of her entry into the world. Suffice it to say I remember my giddiness as we drove there. I remember my joy, only a few hours later, the first time I sang Ella to sleep while overlooking San Francisco Bay from our private recovery room. I remember how my stomach lurched when Ella spiked a fever in the hours before we were to be...

  8. Acknowledgments
    (pp. 199-200)
  9. A Note on Methods
    (pp. 201-204)
  10. Notes
    (pp. 205-212)
  11. Bibliography
    (pp. 213-220)
  12. Index
    (pp. 221-234)