Caught Between: How Pain Specialists Navigate Regulation, Reimbursement, and Risk in the U.S. and France

• In Event: 20251 - Is there a Doctor in the House? Updating the Medical Sociology Agenda around Doctoring

Abstract

Through comparative analysis, this paper identifies the role of state regulators, healthcare reimbursement structures, and the medical industry in pain specialists’ “doctoring” in the United States and France. Drawing from over fifty interviews conducted with pain specialists between 2016 and 2019, I show how physicians in each country differently perceive and navigate their regulators and payers when deciding whether and how to provide potentially risky pain relief to their patients. I distinguish between administrative and litigious forms of regulation, highlighting that the socialization of provider risk in France enables a friendlier relationship between pain specialists and centralized administrative regulators, counterintuitively encouraging pain specialists’ clinical autonomy. In contrast, in the United States, pain specialists perceive their regulators as litigious professional outsiders, and their payers as enemies that threaten their autonomy. The relatively weak federal regulation of doctors in the United States leads to the increased power of payers and lawyers to control clinical practices through reimbursement and litigation, ultimately restricting pain specialists’ professional autonomy and expert discretion in treating pain. This paper contributes to sociological analyses of the relationship between risk and professional autonomy in biomedicine. While the literature has typically focused on the effects of individualizing patient risk, my data demonstrate how decentralizing regulation and individualizing provider risk limit physicians’ clinical autonomy.

Author

• Jane Pryma, Boston University