Integrating Social and Medical Care: Could it Worsen Health and Increase Inequity?

In 1936, the sociologist Robert Merton proposed a set of reasons why interventions in complex social systems might produce unintended consequences (1). Among them were: 1) inadequate knowledge about the complexity of the problem or its potential outcomes; 2) Self-fulfilling predictions about the impact of an intervention; and 3) Errors in designing the intervention because interventionists fail to systematically consider possible consequences or focus exclusively on short-term effects.

In this paper, Gottlieb and Alderwick provide three instructive examples of the potential unintended consequences of interventions to address social determinants of health (2). They suggest that imposing work requirements in state Medicaid programs may worsen population health, because reductions in access to care for those who no longer qualify may outweigh health benefits resulting from employment. They point out that "big data" analyses that incorporate social risk factors to predict health outcomes are susceptible to unrecognized bias because of the provenance of the data, and that predictions based on biased data may lead to discriminatory decisions. Finally, they suggest that medical efforts to address the physiological consequences of social stress could divert resources from the root causes of stress, such as poverty itself.

Each example confirms Merton's typology. Medicaid work requirements oversimplify the complex relationships between work participation and health. Biased predictive models may change decisions in ways that reinforce those biases. Medicalization of socially-derived stress may substitute individual palliation for social prevention.

Clinical trials of new medications routinely assess harms and unexpected effects as well as potential benefits. Although health care and health policy interventions take place in complex adaptive systems (3), they rarely assess unintended consequences with equal rigor. Recent efforts to understand the unintended consequences of innovations in information technology and overuse of medical tests have confirmed Merton's wisdom and updated his typology (4,5). As we develop interventions to address social needs in clinical settings, we must continue to refine our understanding of how these interventions can go awry, develop measurement strategies to assess the balance of benefits and harms, and incorporate approaches to mitigate those harms in those interventions. Over the decades, we have learned that we cannot fully anticipate the unintended effects of biomedical interventions in individuals, but we need to demonstrate comparable humility as we address the "upstream" social forces that so profoundly affect human health.

REFERENCES
1. Merton RK. The unanticipated consequences of purposive social action. Am Sociol Rev 1936;1:894-904.
2. Gottlieb LM, Alderwick H. Integrating social and medical care: could it worsen health and increase inequality? Ann Fam Med 2109;17:77-81.
3. Lipsitz L. Understanding health care as a complex system: the foundation for unintended consequences. JAMA 2012;308:243-244.
4. Bloomrosen M, Starren J, Lorenzi NM, et al. Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting. J Am Med Inform Assoc 2011;18: 82-90.
5. Korenstein D, Chimonas S, Barrow B, et al. Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments. JAMA Intern Med 2018;178:1401-1407.

Competing interests: None declared