Medical Versus Fiscal Gatekeeping: Navigating Professional Contingencies at the Pharmacy Counter Elizabeth Chiarello

C

ommercialization of medicine is a growing trend that threatens to undermine physicians’ commitments to patient care in favor of personal financial interests. Bemoaned by Arnold Relman as early as 1980,1 growing for-profit sectors of health care have been reshaping medicine from a profession into a business, forming the foundation of what he terms a “medical-industrial complex” that threatens to undermine professional identity and reshape health care funding. Commercialization poses new ethical challenges for health care providers who have a financial stake in their health care decisions and may undermine their fiduciary duties to patients. Certainly, commercialization has brought about new trends in medicine — one need only to look as far as the rise in for-profit hospitals, diagnostic laboratories, and proprietary nursing homes to see how opportunities for financial gain reposition physicians’ orientations vis-à-vis patients.2 However, most research has focused exclusively on physicians, overlooking how commercialization’s impact varies across professions and how commercialization occurs in tandem with other trends that catalyze shifts in professional power structures. Further, these studies have drawn attention to macro-level trends in the health care environment rather than addressing how commercialization affects decision-making at the point of care. This study contributes to existing research in three ways: (1) by examining an understudied set of professionals — pharmacists — who have historically navigated the conflicting demands of financial and medical interests; (2) by shifting the focus from macro-level trends to frontline decision-making, considering how commercialization affects daily professional practice; and (3) by evaluating how dimensions of providers’ institutional environments affect their decision-making. I theorize that care provision depends largely on the set of “contingencies,” or organizational and institutional structures, rules, narratives, and routines, surrounding professional work. Although contingencies vary across professions and shift in response to changes in law and policy, they are standard dimensions of professional fields that warrant attention. Contingencies, in part, shape how providers decide whether to engage in medical gatekeeping, “the process by which health care providers allocate resources Elizabeth Chiarello, Ph.D., is an Assistant Professor of sociology at Saint Louis University where she researches institutional influences on health care decision-making. She earned her Ph.D. in sociology at the University of California, Irvine and completed a postdoctoral fellowship at Princeton University’s Office of Population Research.

518

journal of law, medicine & ethics

Elizabeth Chiarello

to patients based on general, scientific knowledge of illness paired with specific, case-based knowledge derived from patient records and interaction” or fiscal gatekeeping, “the process by which healthcare providers attend to the economic interests of various payers when deciding what medical resources to provide.” 3 However, providers’ prioritization of gatekeeping process also influences which contingencies they attend to and how they interpret those contingencies, so con-

Although many decisions become routinized into professional work, ethical challenges disrupt routines and proffer new courses of action, making them important foci of study. I reveal how ethical decision-making depends on both organizational positioning and locus in inter-professional hierarchies and conclude by suggesting how these findings can help scholars understand commercialization as well as other sweeping medical trends.

Drawing on 95 interviews with hospital, independent, and chain pharmacists across the U.S., I demonstrate how pharmacists prioritize specific contingencies when making decisions about patient care. Although many decisions become routinized into professional work, ethical challenges disrupt routines and proffer new courses of action, making them important foci of study. I reveal how ethical decision-making depends on both organizational positioning and locus in inter-professional hierarchies and conclude by suggesting how these findings can help scholars understand commercialization as well as other sweeping medical trends. tingencies are not top-down forces shaping patient care, but aspects of the professional environment that can be interpreted and synthesized to justify professionals’ choices. I develop this theory by focusing on pharmacists, integral, but overlooked members of the health care team. They offer a useful case for examining professional contingencies because, first, their work has historically placed them at the intersection of medical and economic interests — as medical and fiscal gatekeepers — a position in which dominant professions such as physicians increasingly find themselves. Second, although pharmacists’ claims to professional status have been undermined by the nature of their work (they provide a product rather than a service)4 and their positioning vis-à-vis other health care providers (their decisions hinge on those of physicians), changes in the medical landscape have rendered more powerful professions subject to these ostensive shortcomings. Third, pharmacists occupy various workplaces including chain, independent, and hospital pharmacies that offer means of examining how the same professional group contends with different sets of contingencies afforded by their organizational setting. Drawing on 95 interviews with hospital, independent, and chain pharmacists across the U.S., I demonstrate how pharmacists prioritize specific contingencies when making decisions about patient care.5 the buying and selling of health care • winter 2014

Commercialization in Context The commercialization of medicine is not new. Although today’s trends exist in novel forms, they are extensions of historical tensions between commercialization and professionalization as well as sociocultural questions about the extent to which financial concerns should affect care provision. Traditional social science theories of the professions envision health care providers as solo practitioners whose autonomy from state and supervisory oversight affords them significant discretion over their work.6 Today, the corporatization of medicine and the rise of managed care have introduced organizational and economic forces that increasingly constrain professional discretion.7 The mid- to late-20th century saw the growth of large health care organizations and a corresponding shift in the hierarchical structure of care provision. These trends constrained physicians’ discretion by empowering administrators, businesspeople whose understandings of health care conflicted with physicians’ and whose goals of increasing profit hampered physicians’ interests in providing patient care.8 These changes have led some scholars to argue that physicians have been deprofessionalized9 or proletarianized.10 Although there is disagreement about the extent of these trends,11 it is evident that these changes in medicine’s structure legitimated profit as an explicit driving force of professional decision-making, rendered physicians beholden to administrators who 519

S Y MPO SIUM

were business people rather than colleagues, and constrained the discretion of rank-and-file professionals. These economic trends have compelled public debates about prioritizing commitments to patient health in relation to concerns about health care costs. Perhaps nowhere are these questions more prominent than in current debates over rationing.12 Here, the key question is: should physicians condition their care choices on the patient’s ability to pay? Rationing differs from commercialization in that its key focus is on how the care providers offer some patients affects the resources they have available to other patients. The concern is over allocation of scarce resources and the cost to the public of providing extensive care. Commercialization, on the other hand, shifts the focus from public to private resources. Here, the question is about how potential profits shape providers’ resource provision. Nevertheless, both cases raise concerns about compromising the fiduciary relationship between the patient and the physician and concerns about providers’ authority vis-à-vis patients (paternalism used towards financial rather than medical ends). Rationing also draws attention to how frontline decision-making affects economic outcomes, a focus largely missing from the commercialization literature. Both cases require us to consider how cost concerns affect ethical decision-making in medicine. Commercialization has further been used to differentiate professionals from non-professionals. One way early physicians distinguished themselves as professionals is that they did not advertise13 and enjoyed significant discretion over their work.14 Pharmacists, on the other hand, have been considered “incomplete professionals”15 because of their engagement in a commercial enterprise over which they lacked control. In modern medical structures, however, these distinctions begin to break down. The rise of managed care has shifted medical financing from an employer-based fee-for-service model to a multi-payer model that has introduced such programs as health maintenance organizations, diagnosis-related groups, and the resource-based relative value scale.16 These practices have constrained physicians’ discretion by infusing affordability into the patient/physician interaction via insurance companies and the government who act as for-profit and non-profit fiscal gatekeepers, respectively. It has also contributed to the pharmaceuticalization of medical care in which drugs have become increasingly important types of care, linking health care professionals’ work to commercial products.17 Today, assessing who “counts” as a professional is less important than examining the environment in which professionals work since institutional environments provide opportunities and constraints for providers’ 520

behavior as well as means of justifying their actions in socially acceptable ways.18

From Sweeping Social Change to Frontline Decision-Making Most studies of commercialization have focused on broad changes in medicine and the development of new financial ventures. While these studies reveal important changes in the institutional environment surrounding health care, they tell us little about how providers contend with these changes in daily practice. Focusing on providers’ decision-making offers several advantages: (1) It reveals how providers attend to and interpret commercialization trends. Not all environmental changes resonate equally in providers’ daily practice, so focusing on their decisions and understandings of their decisions demonstrates which of these influences are especially powerful. (2) It enables us to examine resistance. Providers are not just institutional dupes,19 accepting messages from their environment and implementing them in daily practice; they exercise their discretionary power to subvert powerful actors and rules with which they disagree. (3) It offers a fine-grained picture of how power flows. Providers are part of inter-professional and organizational hierarchies as well as a complex negotiated order20 each of which affects how they make decisions, sometimes in unexpected ways.

Focus on the Pharmacist Pharmacists make an especially compelling focus of study because they have historically contended with the tensions between economic and medical/professional motivations that characterize commercialized care, because they do so while being subjected to the power of a dominant profession, and because they are becoming increasingly important healthcare professionals. Pharmacists are both health care providers and business people. Unlike physicians who provide services, pharmacists provide products, the sale of which enables their businesses to stay afloat. Although pharmacy has changed significantly over the last several decades with chain pharmacies such as Walmart, Walgreens, and CVS threatening the viability of independent pharmacies, pharmacy remains a mixed sector with professionals distributed across independent pharmacies, chains, and hospitals. Each of these organizational spaces creates a different set of economic motivations and constraints for pharmacists working there. Independent pharmacy owners have a direct and vested interest in the financial well-being of their organization while chain pharmacists receive pressure from supervisors to behave in ways that benefit journal of law, medicine & ethics

Elizabeth Chiarello

the organization’s bottom line. Hospital staff pharmacists are buffered from the economic realities of running a business except as they manifest themselves in organizational policies and routines while hospital pharmacy managers negotiate with other department

most accessible health care professionals which positions them in a consulting role for patients who have not yet seen a physician or who seek explanations for the physician’s actions, consultations that claim pharmacists’ limited time without compensation. Pharmacists have become increasingly important health care providers by seizing opportunities wrought by changes in the health Pharmacists provide a prime case for care system such as the shortage of primary care examining how financial and medical providers25 and the increasing pharmaceuticalization of medicine.26 Pharmacists have tradipressures shape decision-making because tionally been devalued professionals because of they act as both medical and fiscal their subordinate position vis-à-vis physicians gatekeepers — providing patient care and because of their ties to commercial enterprises.27 However, their efforts over the past while ensuring organizational profitability several decades suggest that they are becom— working in distinct institutional and ing steadily professionalized.28 Pharmacists are organizational environments. increasingly recognized as medication experts on the health care team, actively engaged in preventing medical errors due to drug interacheads to make economic decisions for the hospital. tions and consulting with physicians about appropriThus, pharmacists provide a prime case for examining ate care. how financial and medical pressures shape decisionBoth pharmacists’ historical roles as health care making because they act as both medical and fiscal providers managing businesses and their contemgatekeepers — providing patient care while ensurporary roles as drug experts and primary care proing organizational profitability — working in distinct viders position them to offer important insights into institutional and organizational environments.21 the consequences of commercialization. To examine These organizational settings similarly position how commercialization affects daily practice, I now pharmacists differently with respect to physicians turn to the social and economic forces that bear on and patients. Entrenched inter-professional hierarpharmacy work, forces I refer to as “environmental chies link the practice of medicine to the practice of contingencies.” pharmacy as dispensing almost always depends on prescribing, rendering pharmacists secondary deciEnvironmental Contingencies sion-makers in healthcare provision. Their positionProfessional decision-making occurs in the context ing vis-à-vis physicians places them in league with of environmental contingencies that are multiple, many other non-physician health care providers such overlapping, and often conflicting, offering providas nurses, chiropractors, and midwives whose depeners means of justifying their actions by attending to dence on medicine was predicated on physicians’ rise certain contingencies while ignoring others. How to power.22 providers make sense of the contingencies that surProfessional linkages, however, manifest themround them and seize or circumvent them in daily selves differently across organizational settings. decision-making affects the kind of care they provide Unlike nurses who typically work alongside physicians and patient outcomes. Although contingencies vary in hospitals and private practice, pharmacists are segacross professions and shift in response to changes in regated by department within hospitals (they usually law and policy, they are standard dimensions of prowork in the basement where they have limited face-tofessional fields that warrant attention. face interaction with other providers),23 and by orgaI begin by highlighting broad categories of environnization in retail where they are the sole health care mental contingencies. Next, I explicate how conflicts professionals.24 Their location within the organization across these categories create ethical challenges and also affects their contact with patients. In hospitals, affect decision-making by drawing on empirical exampharmacists rarely have direct contact with patients ples from pharmacy. To demonstrate the role of combut have extensive access to patient information via mercialization, I focus on conflicts between economic patient charts. In retail, pharmacists regularly interact contingencies and other kinds of environmental conwith patients and glean information through convertingencies. I have discussed a wider range of conflicts sation rather than charts. Retail pharmacists are the as they play out across organizational settings elsethe buying and selling of health care • winter 2014

521

S Y MPO SIUM

where.29 These examples come from interviews with 95 U.S. pharmacists working in independent, chain, and hospital pharmacies. The study focused on the key ethical issues pharmacists face in daily practice and interviews revealed how pharmacists understand themselves as positioned within their institutional environment and in relationship to other health care providers. In examining the relationship between environmental contingencies and decision-making, it is important to bear two things in mind. First, there is a mutually influential relationship between contingencies and decision-making. Contingencies do not dictate practice, nor are they adopted and implemented en masse into decision-making. Engaging with environmental contingencies involves selecting relevant information, interpreting that information, and constructing meaning as it relates to practice, acts that each permit the professional to exercise substantial power over which forces shape or justify their actions. Much as socio-legal scholars have uncovered variation between the “law-on-the-books” or the law as it is written and the “law-in-action” or the law as it plays out in daily life,30 there are similar disjunctures between the formal and normative rules associated with environmental contingencies and the daily behavior of healthcare providers. Second, organizations mediate the relationship between contingencies and decision-making. As proximate elements of professional environments, organizations (both their formal rules and normative routines) exert direct power over their employees while navigating complex, uncertain environments to achieve their goals. 31 Contingencies, then, bear differently on different types of organizations. Focusing on how a range of contingencies affects decision-making across hospital and retail settings demonstrates how environmental factors such as economic pressures affect professional practice. Environmental Contingencies in the Field of Pharmacy Pharmacy’s commercialized enterprise subjects pharmacists to economic contingencies (both fiscal and market) as well as medical, legal, professional, organizational, cultural, inter-professional, and intra-personal contingencies that health care professionals face more generally. Below, I briefly sketch out each contingency as it manifests itself in the field of pharmacy. The purpose is not to exhaustively elaborate on each contingency, but to map the field of contingencies in which pharmacists are situated as they vary across organizational setting. Although I separate these contingencies to better illuminate the characteristics of 522

each, in reality they are closely intertwined and difficult to tease apart. Economic Contingencies Economic contingencies, those most affected by commercialization, present themselves in two forms: fiscal contingencies, or the costs of running a business, and market contingencies, or positioning vis-à-vis competitors within financial sectors. Fiscal contingencies are those elements of the health care industry that affect who pays for things. Within organizations, administrators focus on the costs of resources and products, staff time, and overhead as well as how and by whom their products and services will be paid for. As Relman notes,32 health care markets differ from traditional markets in that the payer for and user of health care are often different entities, so patients are not “consumers” in the traditional sense. Payers, then, constitute key economic contingencies — how much they will pay for goods and services affects internal organizational questions such as how many people to hire, how many goods to acquire, and how much time to spend with patients to ensure a profit. How fiscal contingencies affect individual providers depends on organizational type and location. Independent pharmacists constantly contend with fiscal concerns as they are both professionals and small business owners, confronting the challenges of making profit as well as providing care. Staff pharmacists in independent pharmacies (non-owner employees) and chain pharmacists are buffered from fiscal concerns because their salary is not tied to the profitability of their business. Chain pharmacists are especially removed from these concerns because they work for large, publicly traded companies where financial decisions are made by administrators higher up the organizational hierarchy. While their bonuses may be tied to their sales and they may experience pressure to generate specific kinds of sales like over-the-counter medications and generics, engaging in these practices does not make the difference between their business succeeding or failing, especially since large chains have the power to divert money from one store to another and rearrange staffing to increase profit. Hospital staff pharmacists are similarly removed from fiscal contingencies and confront them only inasmuch as they are incorporated into routines and practices. However, hospital pharmacy managers regularly confront fiscal challenges. They interact with administrators concerned about the organization’s finances and have a stake in effectively managing money for the department. Market contingencies, or how businesses are situated in relation to suppliers and competitors, similarly vary across organization. Pharmaceuticals are both journal of law, medicine & ethics

Elizabeth Chiarello

expensive and time-limited products. Pharmacies are motivated to purchase neither too little nor too much of the pharmaceuticals they need. Too little means the patient is likely to acquire the medication elsewhere while too much means the drug may expire on the shelf. Regarding competition, chains have several advantages with respect to independents. They purchase their products in bulk, enabling them to secure lower rates than independents that buy much smaller supplies. They also have the flexibility of offering steep discounts in some areas and compensating for them in others. For example, many chain pharmacies have begun offering $4 generics or providing patients with store gift certificates to transfer their prescription to their pharmacy, deals with which independents cannot compete. Competition is somewhat less fierce for hospitals since insurance constrains patients’ hospital choice. Further, hospitals have the advantages of bulk purchasing that chains enjoy. As professional groups secure employment in and invest in for-profit healthcare organizations, economic contingencies become especially salient. Legal Contingencies Legal contingencies are those federal and state laws, policies, rules, and regulations that professionals and health care organizations are required to obey. Pharmacy is regulated at the state level, so most legal requirements come from state legislatures and boards, but federal agencies such as the Food and Drug Administration and the Drug Enforcement Administration and federal legislation such as the Controlled Substances Act establish national processes regarding which drugs are legal to dispense and how those drugs should be dispensed and disposed of. Law’s impact also varies across organizational context. Maintaining a pharmacy license requires pharmacists to know the laws in their state. However, keeping up with and implementing legal changes is easier in chain and hospital settings than in independent ones. In both chains and hospitals, law is built into policies and procedures. Although individual professionals are still responsible for knowing law, these large organizations have legal departments that monitor legal changes and implement them into organizational policy. Independent pharmacy owners, on the other hand, must learn the laws themselves and incorporate them into their organizational practices. As socio-legal scholars have continually demonstrated, the presence of law does not necessarily mean that providers follow the law. Instead, providers, like other frontline workers,33 interpret, enact, and resist the law in daily practice. Thus, law acts as a contingency, but not always a constraint. the buying and selling of health care • winter 2014

Medical/Professional Contingencies Medical/professional contingencies are those professional norms and routines that providers are expected to follow. Health care professionals are socialized to adopt specific understandings of medicine and of their professional duties through education and training. These notions of what it means to be a professional, and specifically a medical professional, pervade their understandings of their professional roles, their relationships to patients, and the purpose for engaging in their work. Health care professionals are expected to act as fiduciaries by putting the needs of patients ahead of their own, to work in the interest of the public health, and to obey established sets of professional ethics while enjoying the autonomy and discretion characteristic of professionals more generally. Formal education interacts with tacit knowledge gleaned through professional education and training (both initial education and continuing education) to influence professional practice. Over years of work experience, professionals begin to understand their profession in new ways that may conflict with the demands of training and education, conflicts that they reconcile through the process of providing care. Cultural Contingencies While medical/professional contingencies offer narratives about professional practice generated by the profession itself, cultural contingencies offer narratives about professional work generated by the broader public. These include those aspects of work that the public (or, more accurately, interested portions of the public) deem acceptable for professionals who enjoy significant cultural power, state protection from competition, and access to public funds. Cultural contingencies are most evident in public debates present in mass media through the efforts of activists and politicians who seek to determine what professional actions are appropriate.34 Current debates over ethical issues like rationing, end-of-life care, abortion, and physician participation in lethal injection all speak to how the public understands professional work and how those understandings comport with professionals’ understandings of themselves. The heated conflict over whether pharmacists should be required to dispense Emergency Contraceptive Pills provides an excellent example of how cultural perceptions of providers and providers’ perceptions of themselves conflict, raising questions of whether pharmacists are permitted to make decisions based on personal/ moral rather than professional/scientific grounds.35 Organizational Contingencies Organizational contingencies are aspects of the organization such as formal rules and policies as well as 523

S Y MPO SIUM

informal norms and practices that channel professional behavior to achieve organizational goals. Again, there is significant variation across pharmacy types based on the shape of the organizational hierarchy and the mechanisms for enforcing policy. Independent pharmacies are characterized by flat organizational hierarchies that usually consist of a pharmacy owner, a few staff pharmacists, and pharmacy technicians. This arrangement facilitates significant interpersonal interaction between pharmacy owners and employees and limits the role of formal policy in shap-

Inter-Professional/Inter-Occupational Contingencies Health care providers are part of an extensive interprofessional/inter-occupational network that places some professionals (especially physicians) in dominant positions and others (especially pharmacists and nurses) in subordinate positions. Inter-professional/ inter-occupational contingencies are the division of labor and power among diverse professions and occupations that affect work processes, decisionmaking opportunities, and outcomes. The rise of allopathic medicine enabled physicians to dominate

The contingencies described are varied and complex, offering pharmacists a range of potentially conflicting messages about appropriate courses of action. Pharmacists must reconcile these in daily, face-to-face interaction with patients. It is here, in the provider-patient interaction, that the power of commercialization becomes most evident. As pharmacists contend with the demands of their profession and the demands of their business, they engage in both medical and fiscal gatekeeping. Pharmacists’ rich descriptions of the challenges they face at work offer insights into how they manage these challenges. ing practice. My interviews with pharmacists suggest that independent pharmacists often adopt informal policies that serve specific purposes, but that interpersonal power tends to take precedence over both formal and informal policy. Both chain and hospital pharmacies are characterized by steep organizational hierarchies and extensive formal policies and procedures. Chains track their employees’ efficiency and profitability and establish mechanisms for processing customer complaints. Staff pharmacists interact directly with regional managers who interact with decision-makers higher up the organizational chain. Chain pharmacists display many of the characteristics of employees in large organizations more generally. In hospitals, decisions about policy and formulary are made by committee, requiring pharmacy managers to negotiate with those in other departments about the hospital’s needs. Staff pharmacists have little say over the form these policies take but are expected to follow them. Accountability here comes from tracking and ongoing interaction with other professionals in the organization, a characteristic that is missing from retail pharmacy. Formal policy and practice (like law and practice discussed earlier) are loosely coupled, offering room for providers to exercise discretion even in the face of explicit policy.

524

other health care professionals by subordinating their work and placing themselves in a supervisory role.36 As a result, pharmacists’ and nurses’ main duties, dispensing drugs and administering therapies depend on physicians’ diagnoses and orders. Inter-professional dynamics are salient in pharmacists’ interactions with physicians and nurses such as when pharmacists call the physician’s office to attempt to change the drug prescribed to one the patient can afford (in retail) or one on the formulary (in hospitals). These phone calls initiate negotiations between professionals with differing amounts of power that can have various impacts on patient outcomes. In addition to this dependence on physicians, pharmacists in both hospital and retails settings depend on technicians, generally low-wage workers who have taken over the classic tasks of dispensing, colloquially known as the “count, pour, lick, and stick” of pharmacy.37 Pharmacists also depend to some extent on colleagues, though this varies by setting. Pharmacists most often work alone or with a pharmacy technician rather than with other pharmacists except in large chain stores and in hospitals. They tend to make decisions alone, though they may call on colleagues to resolve especially troubling issues. Interprofessional/inter-occupational arrangements shift over time as jurisdictional lines change through contestation, abandonment, and cooperation.38

journal of law, medicine & ethics

Elizabeth Chiarello

Intra-Personal Contingencies Despite a shared education and title, professionals retain distinct identities and perspectives. Intrapersonal contingencies are individual commitments and experiences that shape providers’ worldviews and subsequent action. At first glance, these do not appear to be part of the environment because they are individual-specific, but closer examination suggests that they are internalized elements of earlier environments that become taken-for-granted over time.39 These worldviews shape how providers engage with their environment, especially how they interpret circumstances, understand their responsibilities, and decide whether to accept or resist prescribed courses of action. Pharmacists’ positions on dispensing birth control, syringes, and narcotics, for example, reflect their worldviews and personal experiences rather than just their professional training.

Environmental Contingencies and Decision-Making Having identified the array of environmental contingencies surrounding pharmacists’ work, let us now turn to how these contingencies affect professional decision-making. The contingencies described above are varied and complex, offering pharmacists a range of potentially conflicting messages about appropriate courses of action. Pharmacists must reconcile these in daily, face-to-face interaction with patients. It is here, in the provider-patient interaction, that the power of commercialization becomes most evident. As pharmacists contend with the demands of their profession and the demands of their business, they engage in both medical and fiscal gatekeeping. Pharmacists’ rich descriptions of the challenges they face at work offer insights into how they manage these challenges. The pharmacists I interviewed were very patientcentered, but they grappled with pressures from economic contingencies (both direct and indirect) that undermined their ability to effectively serve patients. I begin with three examples that exhibit conflicts among economic and other contingencies and then systematically unpack these conflicts to reveal how pharmacists reconcile them. These pharmacists were responding to the question: “What would you consider the key ethical challenges pharmacists face in daily practice?” Michael, an independent pharmacist in New Jersey, discusses ways that insurance companies prevent patients from getting appropriate care by requiring them to try less expensive therapies first. This places Michael in a conflict between his training and commitment to patient care (medical/professional contingencies), the physician’s drug choices (inter-profesthe buying and selling of health care • winter 2014

sional contingencies), and the payer’s demands (fiscal contingencies). You get into situations where the insurance company may not want to pay for something but yet the doctor has obviously prescribed it. There may be an alternative therapy. It may not be as good. However if the patient doesn’t have any insurance you get caught in an ethical decision. The patient can’t afford the medicine. I went to school to provide healthcare to people, but yet they are stuck because the better product may be more expensive…yet it may have been more cost effective actually to use the more expensive product first because it may have worked.… Usually the insurance will not pay for a particular stomach medicine and forgetting about the cost issue you are left with an ethical problem because the doctor wrote for XYZ and XYZ is not covered under their insurance and you have to call the doctor and speak to the patient and convince them that what the doctor wants is going to work as well as what the original prescription was. What I am thinking of is a different class [of drugs], they are both stomach medicines but they work a little bit differently and it happens regularly because one type does not have generics, very expensive, and the other is less expensive, been on the market for years and many insurances require the patient to use the generic inexpensive one first before they will pay for the more expensive product [the drugs he is referring to are Zantac® and Prevacid®]… I will see the patient, came in and talked to me and said “Oh I am having some stomach discomfort what can I try?” So they may have tried Mylanta® or Maalox®, they come back, it’s still not working so then they went to the doctor, the doctor decided to put them on the other product. I know they have already been suffering for a week before they get to the doctor. Now the doctor puts them on the product, they come here and I tell them their insurance doesn’t pay for that product. Some of the insurances the doctor can speak with the insurance and it will then be covered after a discussion or sometimes it’s no, they must get the Zantac® first, fail therapy on the Zantac® and then they can get the other. So it may be a two-week course of therapy, two weeks of hell for the patient that we see that you can’t tell from a computer screen. You don’t know how long the patient has been suffering with this; you don’t know how much they have complained about whatever their particular con525

S Y MPO SIUM

dition is, so it sometimes leaves us in an uncomfortable position because we are the bearer of the bad news. The doctor gave them the prescription then they are coming to us and the patient can’t get what they need…even though it’s the patient’s insurance, we are the person standing there preventing them from getting their medication. In this common scenario, the insurance company’s efforts to minimize costs by requiring patients to try less expensive drugs first (a fiscal contingency) interferes with the patient’s ability to access the physician’s preferred drug (a medical/professional contingency). Since the patient cannot afford the more expensive drug, s/he suffers longer, resulting in compromised care from the pharmacist’s perspective. When insurance companies constrain the care patients can access, sometimes physicians work with the pharmacist to ensure access, but other times the pharmacist is left to advocate for the patient alone. Amit, a chain pharmacist in Mississippi, describes attempting to negotiate with a physician and an insurance company to acquire medication for an elderly patient. We had a patient today, this female; she needs this triglyceride medicine, it’s brand name only. She’s failed on other generics in other classes, it doesn’t work; so we called the physician, the physician is like “well I don’t fill out PAs” [prior authorization forms]. And so we said “well the medicine is $600 dollars, what are we supposed to do?” And they’re like “well, she can pay for it.” Now, she’s not going to pay for it. She’s on Medicare Part D, she’s retired, her income’s probably per month $400 bucks, right? So, then you call the insurance and say “hey, she’s failed on all of these meds, this is the only drug left, her triglyceride count is, you know, a thousand, what are we to do?” And they’re like “well, the doctor needs to send in paperwork.” Well then you’re in a catch-22 because neither person is wanting to help, right?... My job is not to act as an agent between insurance and the physician, that’s the physician’s office manager’s job…we have at least ten or fifteen cases a week of this stuff. Of patients who just don’t get their medicine if somebody doesn’t care. And I mean, that is a part of our job is to make sure that they’re taking their meds correctly, up to a certain point, you know?… You’ve got to be empathetic, because you have an older person here, she paid money to go see a physician…The company is great, the com526

pany gets a script count, but for us it’s like the pharmacy code of ethics, you know, that’s our job, this patient is coming to us, they trust us; they don’t know, for instance, the patient I was talking about, she doesn’t know what the triglyceride medicine is, or what it’s supposed to do. But I know that hey, if her triglycerides get high enough, she’s going to have pancreatitis and pass away. So it’s my job to make sure to relay whatever information I can to either the insurance or to the physician to get it done. You know, do we get paid at the end of the day? Yeah, everybody gets paid, you know, if I don’t do my job and you know fill medicines correctly and get Med-Plus40 reimbursed; I won’t have a job. Just as a physician, if he doesn’t diagnose patients, he doesn’t, you know, charge the right diagnosis code and get paid by insurance; same thing with insurance, if they don’t sell their policies, don’t get a premium, don’t get copays, they don’t make any money. I mean money is the name of the game at the end of the day… The physician’s unwillingness to fill out documentation (an inter-professional contingency), paired with the insurance company’s documentation requirement (a fiscal contingency), threatens to deny the patient access to care. Because the pharmacist considers it his professional ethical duty to provide care (a medical/ professional contingency), he takes extra measures to ensure the forms are completed. He notes that this also has the function of ensuring loyalty to his business, but also notes how money motivates the key parties involved — the pharmacy, the physician, and the insurance (based on their own fiscal contingencies). Rachel, a hospital pharmacy manager in New Jersey discusses how uninsured patients affect the hospital’s finances. We are located in a pretty affluent zip code in a pretty affluent county. And yet we still have the need for significant charity care. Just because you live here doesn’t necessarily mean that you have health insurance or that you can afford to pay for your own care. Even though from a moral perspective we really shouldn’t take into consideration whether or not patients can pay for their care, and I don’t think that actually comes into play when we actually dispense or treat the patients, it’s something that makes me question should we be rationing care? Or from an ethical — like from a moral perspective, too, you know, you’re potentially utilizing extremely expensive care and in some cases potentially at the expense journal of law, medicine & ethics

Elizabeth Chiarello

that the hospital’s not going to get reimbursed. And then what does that do to the overall health care system? And so, hospitals operate on a razor thin margin and here, we’re no exception. We really don’t make very much money and most hospitals in the state are in the red. We have documented financial losses. All patients deserve to be treated but I think from the standpoint even of the medical staff a lot of this I think can go back to them and the medical staff will say, “Oh, well, you know, I could treat this patient in my office but they don’t have insurance. Just send them to the hospital.” Why is that okay for them to do that but yet we can’t refuse to treat somebody because of their inability to pay or to qualify for any kind of insurance? Knowing that from a facility perspective, it’s not in our best interests to always treat every single one of these patients.

routines for purchasing medication and providing care, strategies for increasing profit, relationships with and among their employees, and degree and type of interaction between provider and patient. Hospitals purchase large amounts of a subset of medications at a discounted rate while chains purchase a wide array of medications at a discounted rate. Independents purchase a small amount of a diverse set of drugs for higher rates. These costs constitute significant portions of their overhead. Chain pharmacies engage in various tactics to increase profit including tying employee bonuses to performance goals, upselling medications (especially generics and over the counter medications), pushing refills by calling patients using automatic systems, and offering promotions such as $4 generics and store gift cards for transferring prescriptions. These strategies that help chain pharmacies compete in the marketplace (market contingencies) are in tension with medical/professional and legal contingenThese three stories (and others) illuminate the cies because they can compromise the consistency of care and lead to medical specific challenges pharmacists face as health errors. As described earlier, indepencare providers working in business settings such dents tend to have flatter hierarchies as pressure to make profit, appropriateness than chain and hospital pharmacies, and retail pharmacies afford patient/ of consulting, managing affordability, and pharmacist interaction largely absent interacting with insurance companies. in hospitals. Understanding patients’ circumstances makes pharmacists more sympathetic to their needs and Rachel highlights how different organizations deal motivates them to engage in time-consuming efforts with fiscal contingencies. Although she does not think to ensure access. Compare Michael and Amit’s stories that patients’ ability to pay should affect the care they to Rachel’s — as retail pharmacists, the two men have receive (a medical/professional and cultural contindirect knowledge of their patients’ financial circumgency), she wonders whether refusing to treat some stances. Michael knows the patient has been trying to patients would benefit the hospital that is already relieve stomach problems for weeks while Amit knows struggling to stay afloat. She expresses frustration that the patient is elderly and living on a fixed income. with private physicians’ offices that send uninsured Michael expresses frustration over the patient’s plight patients to the hospital instead of treating them in while Amit works actively to acquire care. Rachel, on their own practice. She notes that the hospital canthe other hand, does not have intimate knowledge of not refuse to treat (a legal contingency) while private her patient’s lives, leading her to consider rationing practices can. From her perspective, this creates an care a potential course of action because caring for undue burden on the hospital system and the health uninsured patients negatively affects the hospital’s care system writ large. finances. Organizational contingencies, then, affect These three stories (and others) illuminate the spehow providers negotiate competing medical/profescific challenges pharmacists face as health care prosional and fiscal contingencies. viders working in business settings such as pressure Pharmacists not only work for profit-motivated to make profit, appropriateness of consulting, manemployers who are interested in making profit, but aging affordability, and interacting with insurance also find themselves mediating relationships among companies. other profit-motivated key parties (the physician and the insurance company and, indirectly, pharmaceuProfit tical companies). Consider how generic medications Profit drives organizational arrangements and busiaffect profit differently for each stakeholder. Insurness decisions. Organizations vary in terms of their ance companies and pharmacies (both hospital and the buying and selling of health care • winter 2014

527

S Y MPO SIUM

retail) have an interest in dispensing generic drugs because they are less expensive and increase profit. Drug companies have an interest in making sure that physicians prescribe and that pharmacists dispense name-brand drugs because that increases their profit. Therefore, they strategically target physicians and hospital pharmacy managers to attempt to convince them to use their products. This conflict speaks to how economic contingencies work against each other and how these tensions come to the fore in professional decision-making. Chain pharmacies encourage pharmacists to dispense generic medications, but pharmaceutical representatives encourage physicians to prescribe name brands. In most states, retail pharmacists can switch to a generic drug as long as it is therapeutically equivalent and hospital pharmacists can switch drugs as long as they are in the same class and are on the hospital’s formulary. Drug companies maintain their patents by reformulating their drugs so there is no generic equivalent — altering dosing, creating slow-release formulas, and combining their drugs with other drugs in doses that cannot be replicated by combining two drugs. Therefore, when physicians prescribe expensive drugs that the patient cannot afford and for which there is no generic substitute, the pharmacist must use already limited time to call the physician and suggest a cheaper drug, thereby risking a confrontation with him or her. The power imbalances between physicians and pharmacists serve to advantage the drug companies in their quest for profit. An indirect economic contingency — pharmaceutical companies’ means of making profit — bears on interprofessional contingencies, placing physicians and pharmacists on different sides, and offers a counterweight to the pharmacy’s profit motives. Consulting In pharmacy, time is money. The more efficiently pharmacists fill prescriptions, the more money they acquire for employers. However, routinized dispensing procedures prevent pharmacists from exhibiting the range of their professional training and from providing what they consider to be good patient care. Pharmacists consider patient consultation an important part of their job, but feel pressure to keep it to a minimum. Donald, an independent pharmacist in California, notes that pharmacists have more interactions with patients than physicians and often spend more time consulting with them: “Very frequently, you don’t see your doctor every single month and if you do, you have maybe 5 minutes with them. Unless there’s something major going on, you don’t have a whole lot of time with your doctor. People have no problem spending 15-20 minutes talking to me. Which corporations 528

don’t like pharmacists to do.” Consulting is necessary because in addition to being part of the pharmacist’s job (a medical/professional contingency), physicians frequently fail to explain why the patient is taking specific drugs (an inter-professional contingency) and pharmacists, who are legally accountable for medical errors, have an interest in preventing them (a legal contingency). However, pharmacists are not paid for consulting (in part due to physicians’ lobbying, an inter-professional contingency), so the pro-bono work they do detracts from their ability to serve other customers and can create conflict with management (an organizational contingency). Physicians are subject to similar fiscal contingencies as pharmacists — a focus on efficiency of care that constrains patient-provider interaction. New physicians spend an average of eight minutes with patients,41 not nearly enough time to conduct a patient interview, diagnose the condition, and explain the drugs to the patient while pharmacists are encouraged to dispense as quickly as possible, often dispensing one prescription every three minutes. The fiscal contingencies surrounding medicine spill over into pharmacy when physicians do not adequately explain the purposes of the drugs, creating an indirect economic contingency on the pharmacist by way of the physician. Perhaps physicians are able to constrain their time with patients because they know that a secondary gatekeeper — the pharmacist — will double-check their work and share legal accountability. Pharmacists, then, face a conflict between fiscal contingencies (both direct and indirect), legal contingencies, and medical/professional contingencies that affect whether or not they consult. Affordability Business concerns prompt pharmacists to ensure that patients pay for their medications, but medical/professional concerns lead pharmacists to question whether patients can afford their medications. Pharmacists in retail settings have direct knowledge of their patients’ circumstances and have some tools at their disposal to help them out, but these tools are often short-term rather than long-term solutions. Hospitals similarly have some mechanisms for helping patients stay out of the hospital, but again, solutions tend to be restrictive due to the hospital’s financial concerns. A focus on affordability extends economic contingencies to include both fiscal and market concerns faced by the organization and fiscal concerns faced by the patient, and organizational contingencies shape opportunities and constraints for providers helping with those challenges. Organizational tactics for increasing profit can reveal patient hardships about which pharmacists journal of law, medicine & ethics

Elizabeth Chiarello

were previously unaware. Heather, who works for a chain pharmacy in Mississippi, describes her chain’s policy of calling some patients each week to ensure that they are taking their medications and getting refills. This serves the dual purpose of ensuring adherence to a medical regimen (a medical/professional task) and increasing profit (a fiscal/organizational task). When making those calls, Heather discovers patients who are unable to afford their medications. “They just get it when they can or they might just get it a week at a time,” she explains. “It’s just expensive and they just can’t afford it. And some of them just stretch it out. They say, ‘I just take one every other day’ or ‘I just split it in half ’ or ‘I just take it when I need it.’” While the chain is equipped to provide medication to someone who is running out, the kinds of hardships Heather encounters go beyond the chain’s capacity for care. Hospitals are required to care for admitted patients, but struggle with how to handle uninsured and/ or indigent patients after discharge. Giving patients medications upon discharge decreases the likelihood that they will end up back in the hospital, but raises questions of how much to give. Pharmacists have various tools at their disposal for helping patients who cannot afford their medications such as calling the physician, providing coupons, dispensing an advance supply of the drug, and, in rare cases, paying the patient’s copay out of pocket. However, some options are more effective in certain settings and these tend to be short-term, unsustainable options. Calling the physician can have mixed results. Some physicians are receptive to helping the patient afford medications while others yell at the pharmacist and insist that they dispense the pharmaceutical originally prescribed. Sometimes physicians refuse to take steps to help the patient afford the medicine, leaving the pharmacist in a bind. Consider Amit’s story at the beginning of this section — to make the drug affordable, the physician needed to fill out a form, because the physician would not fill out the form, the insurance company would not cover the drug, leaving an elderly woman with a potentially fatal condition. Even in the best-case scenario with a cooperative physician, reaching the physician takes time out of a pharmacist’s busy day, so the pharmacist can only advocate for some patients at the expense of others. Most of the solutions that pharmacists offer to help patients afford their medicine are short-term and limited — they cannot apply these solutions to all of their patients, so they have to be selective. This is one area where physicians are better equipped than pharmacists; physicians can give a pro-bono office visit since their medical “product” is actually a service, but pharmacists provide products that are owned and the buying and selling of health care • winter 2014

accounted for by their superiors, so their ability to dole them out is constrained. Providing the patient with an advance supply of the drug, usually a few pills to treat the condition for a few days, is a risky endeavor and the effectiveness of this strategy varies by setting. Susan, an independent staff pharmacist in Mississippi explains that she occasionally gives patients some medication when they cannot afford it. She explains: “The first boss I ever had told me if someone came in and they needed their medicine and it was my judgment that they needed the medicine and they didn’t have the money for it, he told me that I would never be called upon to explain why I gave that medicine away. And it taught me a big lesson way back when. And so I’ve sort of lived by that. And almost invariably if you pick it up, then sooner or later it comes back and they will be in and they will say, ‘That medicine I got, I need to pay you for it now.’ But you just have to pick and choose.” While this has been a successful strategy for Susan for the select few patients she does it for in a small, intimate setting, it has backfired for some chain pharmacists. Sarah tells a different story: “I learned very quickly, you know, ‘Bleeding Heart,’ they all call me. I’m all, ‘Okay, I’ll give you a few.’ Well, then they’d never come back, you know, and that was happening over and over. And my [co-]pharmacist was a seasoned veteran, she’d been working for like six years or something like that. And she was like, ‘Don’t do it. We don’t do that.’” While Susan internalized her first boss’s message about prioritizing patient need over financial gain (medical/professional contingencies over fiscal ones), Sarah quickly learned that this strategy was problematic and eventually stopped doing it. Increased willingness to provide small supplies of drugs at independent pharmacies compared to chain pharmacies seems counterintuitive because independent pharmacists have a direct financial stake in ensuring that all drugs are paid for while chain pharmacists are paid the same regardless of how much money the chain makes. However, chain pharmacists are more hesitant because they are more closely monitored and required to answer to management while independent pharmacists are more lenient because this stance helps them to establish a small, loyal customer base. Affordability concerns also affect patients’ ability to use non-traditional medications and practitioners. For example, Owen, a compounding pharmacist,42 explains why he generally caters to a high-end clientele. He claims he cannot take the state’s Medicare program because it would put him out of business, but he does try to convince middle-income patients of the value of compounding. Closely intertwined economic interests (between physicians, drug companies, insur529

S Y MPO SIUM

ance companies, and other third-party payers) draw boundaries around the kinds of care patients can access. The major concern is not exclusively health, but medical care within specific, pre-established boundaries that are highly contingent on economic motivations. Insurance Insurance is perhaps the biggest fiscal contingency with which pharmacists contend. They spend significant time calling physicians and working with patients

out forms. While many pharmacists feel compelled to help patients with these tasks due to their professional commitments as health care providers (medical/professional contingencies), they feel it creates an undue burden on them, especially when they face uncooperative physicians (an inter-professional contingency). Pharmacists also resist dealing with insurance companies because they consider it inappropriate for insurance companies to practice medicine. Susan explains how insurance practices undermine physician discretion and instill fear in the patient: “[the patient]

Because prescriptions are originated by one professional (the physician) and carried out by another (the pharmacist) and because insurance belongs to neither one, responsibility for helping patients with insurance is unclear. Physicians have staff available to process their claims, but pharmacists stand to benefit from reimbursement. Managing insurance requires pharmacists to use their limited time to call physicians and insurance companies and help patients fill out forms. While many pharmacists feel compelled to help patients with these tasks due to their professional commitments as health care providers (medical/professional contingencies), they feel it creates an undue burden on them, especially when they face uncooperative physicians (an inter-professional contingency). to ensure that the prescribed care is covered. This serves to ensure patients can comply with the treatment regimen (a medical/professional contingency) and that pharmacies get paid (a fiscal contingency). Pharmacists express frustration about engaging in these practices because they believe that working with insurance falls outside of their scope of practice (recall Amit stating “my job is not to act as an agent between insurance and the physician, that’s the physician’s office manager’s job”) and because they disagree with insurance companies dictating medical practice (recall Michael’s struggles to get patients access to effective stomach medicine). Working with insurance affects both profit and affordability as described above. Because prescriptions are originated by one professional (the physician) and carried out by another (the pharmacist) and because insurance belongs to neither one, responsibility for helping patients with insurance is unclear. Physicians have staff available to process their claims, but pharmacists stand to benefit from reimbursement. Managing insurance requires pharmacists to use their limited time to call physicians and insurance companies and help patients fill 530

had gone to their doctor that they trust and he writes a drug and you come in and you say, ‘Well your insurance doesn’t cover this.’ You can tell in their face they panic because my doctor has told me that this is what I need to fix me….It’s very frustrating to call a doctor and say, ‘After all your hard work and your tests and everything, guess what? The insurance doesn’t cover this. So what’s your second or third choice?’” Whether it is requiring a less expensive, less effective stomach medication or requiring the physician to pick their second or third choice, pharmacists find insurance companies’ interference with patient care inappropriate, especially since they recognize that drug companies court physicians with new drugs when older drugs may be equally or even more effective. Susan continues: “I think sometimes we, as medical professionals, tend to jump on the new stuff — new drugs — when maybe if we spent a little more time, there was something already out there that would have done the trick and would have been better cost-wise and would have helped. But because the drug reps are pushing the new stuff, that’s what you hear. If you hear it all the time, then you forget about other things that are

journal of law, medicine & ethics

Elizabeth Chiarello

out there.” Knowing that less expensive medications might be effective motivates pharmacists to call the physician to attempt to change the drug when patients cannot afford it, but pharmacists only do this with a select few patients lest they risk physicians thinking that they are practicing medicine. Evidence provided here suggests that while dealing with insurance, pharmacists face medical/professional, inter-professional, and fiscal contingencies.

Commercialization’s Impact on Professional Decision-Making Research on commercialization has brought to the fore how broad changes in health care financing can undermine physicians’ commitments to patients and, indeed, their designation as health care professionals. However, by focusing on broad trends and physicians, this line of inquiry has overlooked commercialization’s affects on frontline decision-making and non-physician health care providers. This study addresses these issues by considering commercialization’s effect on daily decision-making in pharmacy, an overlooked set of health care providers who have historically navigated competing economic and professional interests. Evidence demonstrating how pharmacists engage in fiscal and medical gatekeeping in distinct organizational settings suggests approaches to examining other health care professionals facing commercialization. In particular, I contend that commercialization affects frontline decisionmaking by altering the environment surrounding professional work, repositioning economic contingencies with respect to other kinds of contingencies such as medical/professional, organizational, and legal, and privileging some contingencies over others. These contingencies do not exist in isolation, but engage with each other, creating contradictory messages that providers reconcile in the course of daily practice. Conflicts among contingencies create some of the major ethical challenges in medicine — tensions between fiscal and professional contingencies fuel debates over health care rationing and end-of-life care; tensions between cultural and professional contingencies foster questions about patient autonomy versus paternalism; tensions between cultural, legal, medical/professional, and intra-personal contingencies undergird the decades-long contest over abortion and reproductive health. Commercialization raises a separate set of questions, but does so through familiar mechanisms. The contingencies I have examined here are not unique to pharmacy, but are common across health care professionals. Other professionals may face additional sets of contingencies and may be differentially impacted by the contingencies presented the buying and selling of health care • winter 2014

here, but nevertheless face a complex, contradictory, changing practice environment. For example, the rise of managed care, the growth of physician groups, and the spread of for-profit hospitals have collectively altered the economic realities of providing medical care. These forces channel physicians’ interests and, in turn, their decision-making processes. Perhaps concerns over commercialization are overstated. While commercialization certainly alters the professional work environment, it does not overhaul it. This pharmacy study demonstrates that both professional and financial commitments are evident, even in a highly commercialized professional field. Pharmacists engage in many tactics to err on the side they consider right, often prioritizing medical/professional contingencies over fiscal ones despite their financial stake in specific outcomes. Instead of conceptualizing commercialization as a path-dependent, unidirectional process, it may be better understood as an ongoing, multi-directional process that shapes not whether professionals are guided by medical or economic interests, but the extent to which are they guided by each. This poses challenges for researchers seeking to track the effects of commercialization and for policy makers and advocates seeing to mitigate its unsavory consequences since it requires attention to an array of simultaneous influences that can be difficult to capture empirically. Those interested in understanding and shaping the effects of commercialization should pay special attention to those factors that mediate its influence. Several factors mediate the effect of commercialization, particularly organizational arrangements and the inter-professional division of labor. Organizations affect how providers are positioned in relationship to patients. Proximity to patients affects the provider’s commitment to the patient’s fiscal contingencies versus the organization’s. By affording extensive patient interaction, retail pharmacies position pharmacists as both fiscal gatekeepers to the organization, concerned about meeting specific goals set by management, and fiscal gatekeepers to the patient, concerned about ensuring that patients can afford their medication. Commercialization does not simply create a set of providers exclusively concerned about their financial gain. This force is mediated by direct interaction with patients with whom providers sympathize and consider vital to their work. Locus of billing processes affects the provider’s awareness of the patient’s ability to pay. Differences in billing between medicine and pharmacy may account for variation in patient advocacy. Physicians have receptionists or, increasingly, entire departments who do their billing for them. Since patients learn about 531

S Y MPO SIUM

the cost of medications and procedures after seeing the physician, the physician is generally unaware of the hardships patients face. Retail pharmacists, on the other hand, do their own billing and act as cashiers to the patient (or stand close by as the technician does so). Therefore, retail pharmacists have more insight into patients’ financial challenges that may prompt them to try to resolve them to the best of their ability. As businesspeople they contend with their own economic concerns, but as professionals they contend with the economic concerns of their patients that they are privy to because of their organizational structure. Organizations shape the power of inter-professional contingencies by affecting the proximity between health care professionals. Consider variation in how nurses and pharmacists interact with physicians. Nurses work closely with physicians in both clinical and hospital settings while pharmacists tend to be isolated from them. Physical isolation affords pharmacists opportunities to challenge physicians’ choices in interactions with patients and to refuse to provide medications in some circumstances. However, distance between providers means that they may fail to achieve a degree of trust that is important for shaping patient care, especially since pharmacists work with a vast array of physicians while nurses work with a smaller subset. Further, professionals’ interests are closely tied to their position in the hierarchy. Pharmaceutical companies target physicians with new, patented medications, offering free samples and associated products. This compels physicians to prescribe newer medications when older, effective medications may be available. The pharmacist, who has not received the drug company’s message, may consider older drugs better, but have a difficult time convincing physicians to change to them given their status as dispensers rather than prescribers. Yet, organizations’ power is mediated by the provider’s commitments to good health care. Even though organizations incentivize pharmacists to upsell products and work efficiently, pharmacists often opt instead to devote their time to consulting with patients and working with insurance (even if it negatively affects their efficiency and their associated bonuses) or recommending product alternatives like a heating pad, food product, or exercise that do not necessarily translate into a sale. These findings suggest various directions for future work on commercialization. Researchers should focus more closely on how commercialization affects daily decision-making in conjunction with broader trends. We should examine how different kinds of providers contend with commercialization, comparing primary care physicians to specialists and physicians to non532

physician providers like nurses and pharmacists. We should examine professionals working in a wide array of organizational environments including for-profit and non-profit settings, large, hierarchical organizations and small, flat organizations, clinics and hospitals, and private physicians’ offices and retail clinics. We should examine how shifts in inter-professional relationships mediate the effect of commercialization. The growth of clinical pharmacy increasingly renders pharmacists “drug experts” on the health care team while the spread of retail clinics brings nurse practitioners into spaces generally dominated by pharmacists. How will direct interaction between pharmacists, physicians, and patients in hospital settings affect their attention to economic versus medical/professional contingencies? How will the presence of another primary care provider in pharmacy settings affect pharmacists’ rates of pro-bono consulting? These questions beg further research. Finally, we should consider the effects of different kinds of commercialization. We may expect providers to behave differently if they stand to profit a business they work for (whether they own it or not) versus a business in which they are a stakeholder. While scholars have raised valid concerns about the impact of commercialization on health care professionals’ work, we should contextualize commercializing processes within broader health care environments and attend to how these forces collectively influence daily decision-making on the frontlines of care. Acknowledgements

The author would like to thank Calvin Morrill, Carroll Seron, Francesca Polletta, and Tracy Weitz for comments on earlier drafts. She would also like to express her gratitude to the Andrew W. Mellon Foundation, the American Council of Learned Societies, the U.S. Department and Health and Human Services Agency for Healthcare Research and Quality, the Princeton University Office of Population Research, and the University of California, Irvine Center for Organizational Research, without whom this research would not have been possible.

References

1. A. S. Relman, “The New Medical-Industrial Complex,” The New England Journal of Medicine 303, no. 17 (1980): 963-970; A. S. Relman, “The Health Care Industry: Where Is It Taking Us?” New England Journal of Medicine 325, no. 12 (1991):854859; “Medical Professionalism in a Commercialized Health Care Market,” JAMA 298, no. 22 (2007): 2668-2670. 2.  Id. Relman (1980). 3. E. Chiarello, “How Organizational Context Affects Bioethical Decision-Making: Pharmacists’ Management of Gatekeeping Processes in Retail and Hospital Settings,” Social Science & Medicine 98 (2013): 322-24. 4. N. K. Denzin and C. J. Mettlin, “Incomplete Professionalization: The Case of Pharmacy,” Social Forces 46, no. 3 (1968): 375-381. 5. These data were gathered as part of a larger study on institutional influence on pharmacists’ ethical decision-making. Specifically, I examined how legal, political, and organiza-

journal of law, medicine & ethics

Elizabeth Chiarello tional factors interacted with pharmacists’ personal beliefs to influence care provision. I designed the study to focus on decisions about providing Emergency Contraceptive Pills (ECPs) that had received significant public and scholarly attention at the time of the study, but other ethical concerns such as those addressed here emerged over the course of research. I collected a maximum variation sample of pharmacists in four states with different “pharmacist responsibility laws” that dictate whether pharmacists can use moral justifications to refuse to provide care, see A. Kuzel, “Sampling in Qualitative Inquiry,” in B. F. Crabtree and W. L. Miller, eds., Doing Qualitative Research (Thousand Oaks, CA: Sage Publications, 2000); M. Q. Patton, Qualitative Evaluation and Research Methods (Newbury Park, CA: Sage Publications, 1990). I selected four states that varied by law and geographic region – California, Kansas, Mississippi, and New Jersey. Within each state, I selected one conservative and one liberal metropolitan county (determined using presidential voting records from 1980-2008) and within each county I selected retail and hospital pharmacists. Retail pharmacists included those working at three major national chains that were consistent across the states, and privately-owned independent pharmacies while hospital pharmacists included those working at Catholic, secular, and group (such as HMO) locations. The sample consisted of 24 hospital pharmacists, 40 chain pharmacists, and 31 independent pharmacists. Pharmacists varied by age, gender, and race/ethnicity. The benefit of a maximum variation sample is its ability to capture a full range of perspectives rather than the average perspective that would more likely be generated by a probability sample. This enables a solo researcher to assess similarities and differences across contexts. I recruited pharmacists by phone and conducted interviews in person using a semi-structured interview instrument that focused on how pharmacists identify and resolve ethical issues in daily practice, how they make decisions about providing ECPs, and how they would resolve hypothetical ethical challenges. Interviews lasted between 24 minutes and 3.25 hours, yielding a total of 123 interview hours. After having the interviews professionally transcribed, I coded them using grounded theory analytical techniques that involve coding, memo-writing, and theoretical sampling, see K. Charmaz, Constructing Grounded Theory: A Practical Guide through Qualitative Analysis (Thousand Oaks, CA: Sage Publications, 2006); K. Locke, Grounded Theory in Management Research (Thousand Oaks, CA: Sage Publications, 2001); K. Locke and K. Golden-Biddle, “An Introduction to Qualitative Research: Its Potential for Industrial and Organizational Psychology,” in S. G. Rogelberg, ed., Handbook of Research Methods in Industrial and Organizational Psychology (Malden, MA: Blackwell Publishers, 2002). This approach, widely used by qualitative researchers in the social sciences, enables patterns and categories to emerge from the data rather than fitting the data to predetermined categories. For elaboration on the research design and analytical techniques used for this study, see Chiarello, supra note 3 and E. Chiarello, “Pharmacists of Conscience: Ethical Decision-Making and Consistency of Care,” Dissertation, University of California, Irvine, 2011, available at (last visited November 21, 2014). 6. E. Freidson, Professional Dominance: The Social Structure of Medical Care (New York: Atherton Press, 1970); E. Freidson, Profession of Medicine; A Study of the Sociology of Applied Knowledge (New York: Dodd, Mead, 1970); E. Freidson, Professional Powers: A Study of the Institutionalization of Formal Knowledge (Chicago, IL: University of Chicago Press, 1986); M. S. Larson, The Rise of Professionalism: A Sociological Analysis (Berkeley: University of California Press, 1977). 7. W. R. Scott, Institutional Change and Healthcare Organizations: From Professional Dominance to Managed Care (Chicago: University of Chicago Press, 2000); P. Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic

the buying and selling of health care • winter 2014

Books, 1982); R. Weitz, The Sociology of Health, Illness, and Health Care: A Critical Approach (CengageBrain.com, 2009). 8. See Scott, supra note 7. 9. M. R. Haug, “Deprofessionalization: An Alternative Hypothesis for the Future,” Sociological Review Monograph 20, no. S1 (1973): 195-211; M. R. Haug, “A Re-Examination of the Hypothesis of Physician Deprofessionalization,” The Milbank Quarterly 66, Supplement 2 (1988): 48-56; M. R. Haug and B. Lavin, Consumerism in Medicine: Challenging Physician Authority (Beverly Hills: Sage Publications, 1983). 10. J. B. McKinlay and J. D. Stoeckle, “Corporatization and the Social Transformation of Doctoring,” International Journal of Health Services 18, no. 2 (1988): 191-205. 11. E. Freidson, Professionalism: The Third Logic (Cambridge, UK: Polity, 2001). 12. R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); P. A. Ubel, Pricing Life: Why It’s Time for Health Care Rationing (Cambridge, MA: MIT Press, 2000); A. S. Relman, “The Trouble with Rationing,” New England Journal of Medicine 323, no. 13 (1990): 911-913. 13. See Relman (1980), supra note 1. 14. See Freidson, Profession of Medicine (1970), supra note 6. 15. See Denzin and Mettlin, supra note 4. 16. See Weitz, supra note 7. 17. J. Abraham, “The Sociological Concomitants of the Pharmaceutical Industry and Medications,” in C. Bird, P. Conrad, A. Fremont, and S. Timmermans, eds., Handbook of Medical Sociology (Nashville: Vanderbilt University Press, 2010): 290308; S. E. Bell and A. E. Figert, “Medicalization and Pharmaceuticalization at the Intersections: Looking Backward, Sideways and Forward,” Social Science & Medicine 75, no. 5 (2012): 775-783. 18. E. Goodrick and T. Reay, “Constellations of Institutional Logics,” Work and Occupations 38, no. 3 (2011): 372-416. 19. N. Fligstein and D. McAdam, A Theory of Fields (New York: Oxford University Press, 2012). 20. A. Strauss et al., “The Hospital and Its Negotiated Order,” in The Hospital in Modern Society, ed. E. Freidson (New York: The Free Press of Glencoe, 1963): 147-169. 21. I have addressed this in part elsewhere. See Chiarello, supra note 3. 22. See Starr, supra note 7. 23. Except clinical pharmacists who increasingly round with physicians. 24. Although this is changing with the advent of retail clinics in pharmacy. 25. T. Bodenheimer and H. H. Pham, “Primary Care: Current Problems and Proposed Solutions,” Health Affairs 29, no. 5 (2010): 799-805. 26. See Abraham and Bell and Figert, supra note 17. 27. See Denzin and Mettlin, supra note 4, and A. Birenbaum, “Reprofessionalization in Pharmacy,” Social Science & Medicine 16, no. 8 (1982): 871-878. In the Shadow of Medicine: Remaking the Division of Labor in Health Care (Rowman & Littlefield, 1990). 28. Pharmacy education has become longer and more clinicallyfocused, now requiring a 6-year PharmD (doctorate of pharmacy) that includes one year of clinical rotations. Pharmacists are also taking on primary care duties by providing immunizations, managing chronic conditions, initiating care via collaborative practice agreements with physicians, and dispensing behind-the-counter drugs over which they exercise primary discretion. In conjunction with pharmacists’ own efforts, health care has become increasingly pharmaceutical based and the number of drugs on the market have proliferated, making it difficult for physicians to keep up with the rapid changes in drug therapies. 29. See Chiarello, supra note 3. 30. L. Edelman and M. Suchman, “The Legal Environments of Organizations,” Annual Review of Sociology 23 (1997): 479515; C. Heimer, “Competing Institutions: Law, Medicine, and Family in Neonatal Intensive Care,” Law & Society Review 33,

533

S Y MPO SIUM no. 1 (1999): 17-66; V. Jenness and R. Grattet, “The Law-inBetween: The Effects of Organizational Perviousness on the Policing of Hate Crime,” Social Problems 52, no. 3 (2005): 337-359. 31. P. J. DiMaggio and W. W. Powell, “The Iron Cage Revisited: Institutional Isomorphism and Collective Rationality in Organizational Fields,” American Sociological Review 48, no. 2 (1983): 147-160. 32. See Relman (1980), supra note 1. 33. M. Lipsky, Street-Level Bureaucracy: Dilemmas of the Individual in Public Services (New York: Russell Sage Foundation, 1980); S. Maynard-Moody and M. Musheno, Cops, Teachers, Counselors: Stories from the Front Lines of Public Service (Ann Arbor: University of Michigan Press, 2003). 34. P. Conrad and J. W. Schneider, Deviance and Medicalization: From Badness to Sickness, Expanded ed. (Philadelphia: Temple University Press, 1992). 35. See Chiarello, supra note 3. 36. See Starr, supra note 7.

534

37. The “count and pour” refer to counting pills and pouring liquid medicine into bottles and the “lick and stick” refer to the process of adhering the label. 38. A. Abbott, The System of Professions: An Essay on the Division of Expert Labor (Chicago: University of Chicago Press, 1988). 39. P. L. Berger and T. Luckmann, The Social Construction of Reality: A Treatise in the Sociology of Knowledge (Garden City, NY: Doubleday, 1967). 40. Pseudonym for a large, chain pharmacy. 41. P. Chen, “For New Doctors, 8 Minutes Per Patient,” New York Times, May 30, 2013. 42. Compounding pharmacists are specialty pharmacists who prepare customized drugs to meet patients’ needs. While all pharmacies do some forms of compounding, most compounding occurs in a few pharmacies that specialize in this practice. See (last visited November 12, 2014).

journal of law, medicine & ethics

Copyright of Journal of Law, Medicine & Ethics is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.