Are Corporations Re-Defining Illness and Health? The Diabetes Epidemic, Goal Numbers, and Blockbuster Drugs.

While pharmaceutical industry involvement in producing, interpreting, and regulating medical knowledge and practice is widely accepted and believed to promote medical innovation, industry-favouring biases may result in prioritizing corporate profit above public health. Using diabetes as our example, we review successive changes over forty years in screening, diagnosis, and treatment guidelines for type 2 diabetes and prediabetes, which have dramatically expanded the population prescribed diabetes drugs, generating a billion-dollar market. We argue that these guideline recommendations have emerged under pervasive industry influence and persisted, despite weak evidence for their health benefits and indications of serious adverse effects associated with many of the drugs they recommend. We consider pharmaceutical industry conflicts of interest in some of the research and publications supporting these revisions, and in related standard-setting committees and oversight panels. We raise concern over the long-term impact of these multifaceted involvements. Rather than accept industry conflicts of interest as normal, needing only to be monitored and managed, we suggest challenging that normalcy, and ask: what are the real costs of tolerating such industry participation? We urge the development of a broader focus to fully understand and curtail the systemic nature of industry's influence over medical knowledge and practice.

Corporate Logic in Clinical Care: The Case of Diabetes Management.

As large corporations come to dominate U.S. health care, clinical medicine is increasingly market-driven and governed by business principles. We examine ways in which health insurers and health care systems are transforming the goals and means of clinical practice. Based on ethnographic research of diabetes management in a large health care system, we argue that together these organizations redefine clinical care in terms that prioritize financial goals and managerial logics, above the needs of individual patients. We demonstrate how emphasis on quality metrics reduces clinical work to quantifiable outcomes, redefining diabetes management to be the pursuit of narrowly defined goal numbers, despite often serious health consequences of treatment. As corporate employees, clinicians are compelled to pursue goal numbers by the heavy emphasis payers and health systems place on quality metrics, and accessing the required medications becomes the central focus of clinical practice.

Racialized Risk in Clinical Care: Clinician Vigilance and Patient Responsibility.

Racial/ethnic identity is contingent and arbitrary, yet it is commonly used to evaluate disease risk and treatment response. Drawing on open-ended interviews with patients and clinicians in two US clinics, we explore how racialized risk is conceptualized and how it impacts patient care and experience. We found that racial/ethnic risk was a common but poorly defined construct for both patients and clinicians, who intermingled concepts of genetics, biology, behavior, and culture, while disregarding historical or structural context. We argue that racializing risk embodies social power in marked and unmarked bodies, reinforcing inequality along racial lines and undermining equitable health care.

Electronic Health Records and the Disappearing Patient.

With rapid consolidation of American medicine into large-scale corporations, corporate strategies are coming to the forefront in health care delivery, requiring a dramatic increase in the amount and detail of documentation, implemented through use of electronic health records (EHRs). EHRs are structured to prioritize the interests of a myriad of political and corporate stakeholders, resulting in a complex, multi-layered, and cumbersome health records system, largely not directly relevant to clinical care. Drawing on observations conducted in outpatient specialty clinics, we consider how EHRs prioritize institutional needs manifested as a long list of requisites that must be documented with each consultation. We argue that the EHR enforces the centrality of market principles in clinical medicine, redefining the clinician's role to be less of a medical expert and more of an administrative bureaucrat, and transforming the patient into a digital entity with standardized conditions, treatments, and goals, without a personal narrative.

"They Treat you a Different Way:" Public Insurance, Stigma, and the Challenge to Quality Health Care.

Under the Affordable Care Act, Medicaid Expansion programs are extending Medicaid eligibility and increasing access to care. However, stigma associated with public insurance coverage may importantly affect the nature and content of the health care beneficiaries receive. In this paper, we examine the health care stigma experiences described by a group of low-income public insurance beneficiaries. They perceive stigma as manifest in poor quality care and negative interpersonal interactions in the health care setting. Using an intersectional approach, we found that the stigma of public insurance was compounded with other sources of stigma including socioeconomic status, race, gender, and illness status. Experiences of stigma had important implications for how subjects evaluated the quality of care, their decisions impacting continuity of care, and their reported ability to access health care. We argue that stigma challenges the quality of care provided under public insurance and is thus a public health issue that should be addressed in Medicaid policy.