IOM Should Learn About Social Determinants Not Preach Them

The Institutes of Medicine has somehow discovered Social Determinants and now indicates that Social Determinants should be taught. If IOM truly understood social determinants, it would understand how it has distracted the United States from areas important to actually improving quality in health care delivery.
Patient situations and social determinants shape 60 - 70% of outcomes
... with clinical interventions left with only 10 - 20%. When you grasp this, you can understand the great folly of pay for performance, value based, and readmission penalties. Even worse is the tiny potential for EHR, HIT, MU, MACRA or other manipulations to impact care in ways that truly matter. Remember that we are now spending tens of billions more a year on areas that essentially have no chance of improving outcomes other than profit margins for corporations in addition to bloating administrative costs to attempt to address quality in ways that cannot do so.

Patient outcomes are largely fixed in place 
... as most studies demonstrate. If you match up the patient determinants and situations correctly, you should expect no difference. This is why resident work hours restrictions did nothing for quality (and why new studies were unethical). Primary Care Medical Home, Nurse Practitioner versus Physician, and other studies also demonstrate no differences because of design. IOM multiplied the assumptions with their NP report largely based on studies that could not demonstrate a difference. 

When Studies Demonstrate Quality Differences,
Expect Differences in Patients, Populations, Providers

If you understand the true shaping forces in health care, then you can also understand why rural hospitals and clinics serving the underserved have had lower outcomes, not to mention other factors such as lesser payment by CMS design, less local resources, and other differences. This is also why family practices will suffer most due to penalties because they are most likely to care for people with more complex health problems, fewer resources, lesser health status, lesser housing/environments, and lower social determinants. It is hard enough to deliver basic access to care where care is most needed without facing lower payment and rapidly accelerating costs of delivery. 

The demise of small hospitals and small practices is about payment design
and payment design has worsened.
The name of the game is still the same for best profit under old and new payment designs. It is most important for insurers, health systems, and practices to choose to care for the advantaged and avoid those lesser in social determinants, situations, and other areas.

The Take Home About Quality Studies

If you see a quality difference even in a major journal or national report, you should expect a difference in the patients, providers, situations, or all of the above. 
If there is a difference demonstrated, it could be because the author chooses their own outcomes to pursue or the study outcomes are really about superficials (staff, timing, satisfaction) rather than how patients function after visits, how they relate to clinicians, and how they can improve their own care (Annals of FM).

IOM Needs Training - in Social Determinants (Can Physicians Heal Thyselves?)

From To Err is Human through Bridging the Quality Chasm to the latest reports, IOM has been on a Quality Binge. IOM reports have attributed too much blame to physicians and assumed too much result by addressing medical errors. Flawed equations failed to include important controls or failed to come close to resembling the process of care. Other studies have given too much credit to insurance access - thus the major focus of 2010 health reform and the lack of improvements in access to care. Even now many still equate access to insurance with access to care despite the inability of insurance to address the workforce needed for access - something only better payments for basic office codes can do.
Health leaders in the United States have distracted the nation from interventions that could matter - such as investments in nutrition, resources for the elderly, and greater investment in primary care. What they have continued to do is increase the cost of administration and overall costs without improving outcomes - reinforcing the current American design of health care.

Can Social Determinants Be Taught

The medical school design is incapable of such teaching. The first two years are about basic sciences and passing board exams focused on these areas. The last two years are about landing a prestigious residency position via hospital and other rotations.

Empathy, service orientation, and awareness of others who are different - these are areas that are quite difficult to understand unless you share origins or life experiences with your patients. IOM obviously does not understand that medical schools are admitting students that are quite the opposite of the types needed to grasp these areas. It can take decades to understand the day in and day out consequences of disparities, health access barriers, and inadequate resources.
The retention of information taught in Social Determinants 101
is not going to last beyond the course exam. 
Remember the difficulties getting authorities to believe the problems at Flint Michigan - and the damage done for years in Flint.
The damage continues in many locations and many situations
because of the disconnect between those in need and those who lead. 
Medical students and those who lead health care are as exclusive as they have ever been and are quite separated from lower and middle income Americans in more degrees and in more dimensions than ever before. 
The IOM should work to heal themselves by packing panels with those who have better understanding of situations and social determinants before attempting to lead the nation in health care.

Blogs indicate that primary care can be recovered and should be recovered.


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