Addressing Racial Health Disparities in Dermatology: Adapting the 5As Social Care Framework

Over the last 3 years, the field of dermatology, along with the broader medical profession, has taken a renewed interest in acknowledging social and structural drivers of racial health inequities. While many dermatologists recognize the impact of these determinants on their patients’ skin diseases, translating this understanding into actionable steps remains challenging.

To address this gap, a recent Viewpoint published in JAMA Dermatology¹ offers actionable guidance using the “5As Social Care Framework” from the National Academies of Sciences, Engineering, and Medicine’s (NASEM) report on Integrating Social Care into the Delivery of Health Care.² By adapting this framework to the needs of dermatologists, this Viewpoint encourages dermatologists to play a vital role in mitigating the consequences of social and structural determinants of health on their patients.

NASEM’s framework defines five types of social care activities:

Clinical Practice: The First Three As

1. Awareness: Dermatologists must inquire about social risk factors that may impact their patients’ healthcare access, disease, or treatment options. For instance, injectable biologic medications prescribed for conditions like psoriasis, atopic dermatitis, and hidradenitis suppurativa often require refrigeration. Dermatologists need to know if patients have reliable access to refrigeration, which may be a challenge for those without stable housing or financial resources.
2. Assistance: Using standardized screening tools, dermatologists can better understand their patients’ social resources. After gathering this information, they should connect patients with appropriate community resources to mitigate social risks, such as housing support organizations or utilities financial assistance programs.
3. Adjustment: Dermatologists should use the collected information to tailor their clinical practices. For example, if a patient lacks reliable refrigeration, dermatologists might offer non-perishable treatment alternatives or schedule appointments for medication administration in the clinic.

Structural Change: The Last Two A’s

4. Alignment: Dermatologists in private practice can align their insurance acceptance policies to provide equitable care to Medicaid enrollees. According to the Kaiser Family Foundation, nearly 60% of Medicaid enrollees in 2021 were people of color,³ yet only 17% of non-academic dermatology practices accept Medicaid insurance.⁴ Those that do often provide longer wait times for Medicaid patients compared to those insured by Medicare or private insurance.⁴ By accepting Medicaid, dermatologists can help reduce racial disparities in dermatologic outcomes.
5. Advocacy: Dermatologists can engage in political advocacy at local, state, and federal levels to support initiatives that improve racial health disparities. This includes advocating for universal health coverage, reliable broadband service, the CROWN Act, and the Wigs as Durable Medical Equipment Act.

Conclusion

It is estimated that only 10%-20% of health is determined by clinical care.⁵ Dermatologists must expand their medical decision-making beyond pathophysiologic factors to include social and structural determinants of health. The health and well-being of patients depend on it.

References:

1. Williams J, Amerson EH, Chang AY. How Dermatologists Can Address the Structural and Social Determinants of Health—From Awareness to Action. JAMA Dermatol. 2022;158(4):351-352. doi:10.1001/jamadermatol.2021.5925
2. Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health, Board on Health Care Services, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. National Academies Press; 2019:25467. doi:10.17226/25467
3. Distribution of the Nonelderly with Medicaid by Race/Ethnicity. KFF. Published October 28, 2022. Accessed November 8, 2022. https://www.kff.org/medicaid/state-indicator/medicaid-distribution-nonelderly-by-raceethnicity
4. Creadore A, Desai S, Li SJ, et al. Insurance Acceptance, Appointment Wait Time, and Dermatologist Access Across Practice Types in the US. JAMA Dermatol. Published online January 13, 2021. doi:10.1001/jamadermatol.2020.5173
5. Hood CM, Gennuso KP, Swain GR, Catlin BB. County Health Rankings: Relationships Between Determinant Factors and Health Outcomes. Am J Prev Med. 2016;50(2):129-135. doi:10.1016/j.amepre.2015.08.024