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What is the meaning of “social determinants of health”

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 Meaning of social determinants of health

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 Meaning of social determinants of health

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SDH refers to the social, economic, and environmental conditions in which people grow up, live, work, and age, all of which have a considerable impact on health outcomes and quality of life.

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Telemedicine refers to the provision of remote clinical services, via real-time two-way communication between the patient and the healthcare provider, using electronic audio and visual means.

The convenience of telemedicine

In primary care, telemedicine is usually in the form of phone calls, where the patient seeks the doctor's advice about non-emergency medical problems which do not require the doctor to see the patient. Telemedicine does not replace face-to-face consultation when it is needed but instead complements it.

The real role of telemedicine at present lies in the convenience it offers to patients and practitioners by obviating the necessity for a physical visit to get medical advice or treatment. It is also cost-effective in comparison to the process of waiting to see a doctor or other healthcare provider.

Telemedicine can also help select urgent calls after a doctor's office is closed. It is of immense value in the follow-up of patients with chronic diseases such as diabetes, high cholesterol, or high blood pressure. In these individuals who are not experiencing any immediate medical problem, but require help with dosage adjustments, lifestyle regimens, prescription refills, or even just access to group support, can benefit from the convenience of telemedicine.

An added convenience is that telemedicine consultations can be arranged to follow all needed laboratory investigations or vital sign monitoring. In fact, telemedicine has been practiced by doctors for a long time, though not under this name. While this may be true, the use of broadband internet technology has made both audio and video calls affordable and available to a wider spectrum of society, making this a feasible alternative to the conventional system.

Important terms in telemedicine

Telemedicine is practiced from a hub, which is the site from where the distant practitioner delivers service through a telecommunications system.

At first, specialized videoconferencing equipment was necessary, with customized diagnostic peripherals, such as stethoscopes or EKG monitors attached to the system. The health provider who was with the patient would use the diagnostic tools under the guidance of the distant physician, to provide the required patient data.

Today, telemedicine usually employs a desktop computer, with a special video card. The computer's advantage is that it can store data securely. High-speed telephone lines or satellite connections allow interaction between both locations.

On the other hand, the patient is at the originating or spoke site, and receives the service via a telecommunications service, often with the mediation of a telepresenter.

Telemedicine has several definitions, but the broadest one covers the use of services outside the traditional real-time interactive telecommunication health service. This includes services such as store-and-forward, where camera images are stored and forwarded, all the while the consultation is completed via a telecommunication system. Though these are not real-time or interactive, they are still useful for treatment delivery. Remote monitoring is another aspect of telemedicine.

Benefits of telemedicine

Telemedicine requires no significant outlay other than a web camera and a secure patient portal that connects the doctor to a secured electronic medical record database online. This type of system ensures the safety of the private information discussed during a telemedicine call, while also providing the treating clinician with the ability to store necessary medical records. In addition to these required devices, the physician will also require a medical license that has been provided by the same state where the patient receives will receive their prescription.

Those who support the use of telemedicine point to its convenience, reduced waiting times, expanded access to high-quality medical diagnosis and treatment, as well as its lower cost as compared to most other medical consultations. In addition, the ready availability of patient records online has the potential to make patient prescriptions more reliable and accurate.

By providing second opinions more easily and faster, telemedicine can also make the patient and physician experience better. Finally, it produces improved health outcomes, which should be the primary goal of all health services.

Many studies that have drawn direct comparisons between telemedicine and other approaches to patient management have shown that a clear benefit associated with the use of telemedicine. The benefit was greatest in the areas of teleradiology, telemental health, telecardiology (echocardiography in particular), home telecare, and teledermatology. Many researchers agree, however, on the limited evidence at present on the benefits or cost-effectiveness of telemedicine, which requires further studies.

Is Telemedicine The Future Of Health Care?

References

Further Reading

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Telemedicine refers to the provision of remote clinical services, via real-time two-way communication between the patient and the healthcare provider.

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Relates to how social ties, community participation, and social support networks influence health outcomes. It considers social cohesion, discrimination, and the availability of support systems. Strong social relationships and engaged communities can help people manage with stress and reduce health risks, encouraging resilience and improving overall health. Social support networks offer emotional, informational, and practical resources that promote well-being and improve the ability to manage problems, including health-related issues.

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Committee for a Responsible Federal Budget

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Telehealth services filled crucial medical care gaps during the COVID-19 pandemic and will appropriately remain an important part of the health care system going forward. Telehealth services can increase access to timely and effective care, and, in some cases, improve the efficiency and quality of the health care system.

However, it is important that telehealth policy be designed and implemented carefully to avoid increases in utilization, misaligned provider payment incentives, fraud, and abuse.

During the pandemic telehealth largely acted as a substitute for traditional care.Yet, the pandemic experience is not representative of a future where telehealth is more fully integrated into patient practice and provider business models. The United States has a uniquely poor track record when it comes to effective health care at low cost and new technologies often burden our system with rising costs.

Though telehealth has the potential to reduce some health care expenditures, both the Congressional Budget Office (CBO) and the Government Accountability Office (GAO) project that increased use of telehealth will add to overall health care costs.

Based on a recent CBO score of a five-month extension of pandemic authorities, permanent expansion could cost Medicare alone $25 billion over ten years, even without expanded use.As telehealth use grows, there is the potential for even greater costs in both federal health care programs and the private sector.

With policymakers rapidly approaching a decision point on the direction of telehealth policy, it is important that they take time to fully understand the health and fiscal implications of adding telehealth services to our menu of care. Rather than make permanent decisions in the coming months, any extension of telehealth authorities should have proper guardrails, checkpoints to allow for data analysis and learning, and a way to align incentives for better and less expensive care.

Much has been written on the merits and promises of telehealth.The purpose of this paper is to outline key health care costs and federal budget challenges that should be considered when developing long-term regulations surrounding telehealth.

The State of Play for Telehealth Coverage

In response to the pandemic, Congress gave the Department of Health and Human Services (HHS) the authority to waive restrictions on Medicare telehealth coverage for the duration of the officially declared Public Health Emergency (PHE). This new authority allowed anyone to receive services in their home, using a wide variety of audio-video technology with the option for audio-only care. It also allowed patients to see new providers rather than being required to have a preexisting relationship before permitting telehealth visits. The private sector followed Medicare's telehealth expansion, increasing patient access and helping providers stay in business.

Telehealth waivers have been repeatedly extended along with extensions of the PHE, which can be renewed every 90 days by the HHS secretary. The most recent extension from April 16, 2022, will be in effect until July 15, 2022. Additionally, the Fiscal Year (FY) 2022 omnibus appropriations bill (signed on March 15) allows for the telehealth waivers to extend 151 daysafter the PHE ends.

The omnibus also requires the Medicare Payment Advisory Commission (MedPAC) and the HHS Office of the Inspector General to provide an analysis and recommendations on telehealth by the middle of 2023 covering the implications of expanded Medicare coverage; utilization of services; Medicare expenditures; Medicare payment policies; program integrity risks; recommendations on preventing waste, fraud, and abuse; and other relevant topics.

Congress will ultimately need to determine the parameters for telehealth coverage in Medicare and Medicaid. This decision will also indirectly influence private insurance coverage decisions, although lawmakers might decide to legislate those directly. Some legislation will need to pass within five months of the end of the PHE in order to avoid a dramatic disruption in ongoing care, but there is no reason for that legislation to include permanent and blanket changes in policy. That is especially important because of the above-mentioned essential information from the mandated HHS and MedPAC reports.

The Cost Challenges of Telehealth

The promise of telehealth is that it can increase access to care. It can bring doctors to places they wouldn't necessarily be, and it cuts out the requirement for patients to physically travel to an appointment. One study estimated that the time commitment inherent in these visits, along with the need to take off work, costs patients $89 billion a year in total lost time and wages. In some scenarios, expanded telehealth may also reduce direct health care costs: for example, allowing a patient to avoid a more costly trip to a doctor's office.

However, telehealth is likely to increase health care costs overall, especially if policymakers don't pay special attention and care to its design. With federal and overall health care costs continuing to grow faster than the economy, these cost increases should be of particular concern.

When thinking about the long-term direction for telehealth authorities, we suggest attention to the following challenges related to the federal budget, and to national health expenditures.

Utilization - telehealth services should ideally help reduce over-utilization of care, but could end up substantially increasing patient utilization of health care services.

Provider incentives - telehealth services should ideally help providers reduce the cost of care, but payment incentives might lead to more costly care - especially if telehealth services continue to be reimbursed at parity with in-person care.

Fraud and abuse - telehealth services are at particular risk for fraudulent billing.

Below, we discuss each of these challenges and the opportunities for policymakers to address them through caution and guardrails.
The Risk of Increases in Utilization
The easier it is to access a given health intervention, the higher utilization is likely to be. Conversely, increased friction through high deductibles or increased cost-sharing reduces utilization. Depending on the quality of care, higher utilization may improve, worsen, or have little effect on health outcomes; but it will nearly always result in higher costs.

Thus, it is very likely the case that an expansion of telehealth, by removing some of the friction from provider-patient interaction, will lead to increased utilization. This will be the case in the aggregate, despite there being some circumstances where a telehealth appointment might allow a patient to avoid a longer or more intensive interaction with the health care system.

Policymakers will need to manage the transition to telehealth to avoid excessive increases in utilization. Unfortunately, policymakers are often unwilling to follow through on restrictions.

An example from the pandemic is illustrative. The CARES Act allowed those in high-deductible plans tied to Health Savings Accounts to receive telehealth services without having to meet their deductibles - even though these deductibles are core to the benefit design of such plans (which are meant to control cost growth). Rather than allow this emergency measure to expire as intended at the end of 2021, Congress revived the waivers in the recent omnibus bill, extending them through the end of 2022.

Not only does this choice drive up overall utilization of care but adds unjustified incentives to specifically increase utilization of telehealth services, which are given a financial advantage over in-person care. Policymakers should avoid creating these perverse incentives when designing a new telehealth regime.
The Problem of Payment Incentives and Payment Parity
The decisions providers make as telehealth expands have important implications for growing health care costs. In the United States' health care system, doctors and hospitals have substantial influence on the volume, intensity, and price of care - more so than patients do in most cases.

Avoiding dramatic increases in provider-led utilization will be especially important in government programs like Medicare, which have few mechanisms for managing care. Already, utilization in fee-for-service Medicare is slated to grow nearly 4 percent per year through 2030 when adjusted for demographics.

To avoid further driving up health care costs, an expansion of telehealth would ideally occur only within the context of a shift away from fee-for-service payment to alternative payment models like Accountable Care Organizations. Such value-based payment (VBP) approaches could be an opportunity to maximize the opportunities of telehealth without substantially increasing spending. VBP could also create guardrails for providers to promote quality care through telehealth in a manner that is good for patients' health while protecting Medicare from a payment system that promotes volume in the maximization of profits.

Examples explored by our Health Savers Initiative, like site-of-service-based payment, Part B drug ad-on fees that promote higher-priced drugs, and insurance plan gaming of risk adjustment in Medicare Advantage all demonstrate the same design flaw. Payment policies legislated to achieve worthwhile goals created misaligned incentives, yet the ability of the executive branch to re-align incentives was limited by that legislation, and Congress became hesitant to revisit the policies because the interest groups profiting from the incentives lobby them to avoid changes.

Thus, getting incentives right for telehealth, and, perhaps, more importantly creating the means or action-forcing ability to review them regularly, will be crucial to limiting any negative fiscal impact. As providers have the time to create new telehealth business models and build technological capacity, provider payment incentives should bend providers towards value, substitution, and quality.

It is especially important that policymakers resist calls for mandating permanent payment parity, where telehealth visits are paid at the same rate as in-office visits. Doing so would drive up overall health care costs, undermine any potential telehealth might have to reduce costs in select circumstances, and be highly problematic for the goal of appropriately aligning incentives.

Parity is problematic because just like on the patient side, telehealth is a form of care that should have less friction for the provider. Theoretically, the time spent by a provider interacting with a patient during a telehealth appointment might be similar to an in-person visit. However, there are numerous other ways in which telehealth can be less burdensome on a provider's time and resources.And, as groups of providers utilize telehealth more, there will be opportunities to get paid for shorter, follow-up interactions - some of which might be happening in the current system without payments attached.

The physician fee schedule in Medicare already accounts for the overhead costs to providers. So, separating payments as telehealth expands can still consider the costs of maintaining telehealth technology while incorporating any overhead savings.

The Special Case Of Mental Health Coverage
New Opportunities for Fraud and Abuse
According to the American Bar Association, potential problems include up-coding time and complexity; misrepresenting the virtual services being provide; billing for services not rendered; and kickback schemes that spread profit from unnecessary tests, medications, and equipment.

While there are existing statutes making these acts unlawful, there must be guardrails in place to make misuse more difficult and easier to discover. MedPAC has already suggested some ways to accomplish this, such as additional scrutiny to outlier clinicians who bill many more telehealth services per beneficiary than other clinicians and prohibiting "incident-to" billing for telehealth services provided by any clinician who can bill Medicare directly.

Permanent coverage for audio-only communication needs to also have limitations to ensure that it can serve as a benefit for those without access to video or in-person care, without allowing provider preference or skimping to perpetuate inequities or gaming.

That is why a study of these communications, their evolution, and differences in care quality will be essential. One key step taken by CMS in its 2022 Payment Policies rule was to create an audio-only claims identifier to identify mental health services delivered through telehealth.

There is also precedent for in-person requirements as a condition for reimbursement to reduce fraud. Such current requirements for home health services and durable medical equipment have resulted in $2 billion in savings to Medicare between 2010 to 2019.

Conclusion

Health care, even beneficial care, is not free. Increases in costs are passed along to employees and Medicare beneficiaries in the form of higher premiums and to taxpayers through additional Medicare and Medicaid spending, higher insurance subsidies through the tax code, or more borrowing through the national debt.

How much telehealth expansion will cost the federal government must be taken seriously. In addition to waiting for the data and research to decide what permanent decisions to make on telehealth authorities, having circuit breakers in the process for re-evaluating will be important from both a regulatory standpoint and a fiscal one. A large and bipartisan group of lawmakers have advocated for a two-year extension of telehealth waivers. MedPAC has also suggested this time frame. This should be the maximum extension Congress considers, ideally including mental health in the more limited extensions.

Because telehealth as a mode of care is here to stay, the argument that authorities need to be made permanent in order to convince providers to invest in technology is not convincing. Instead, the occasional expiration of authorities will provide policymakers the opportunity to review research into telehealth's impact on health care costs. That way, it will be possible to pair extensions with other health care cost reductions. There are numerous ways to control health care costs and using the opportunity of expanding benefits is a natural opportunity to enact cost controls.

Telehealth has become an essential tool for the delivery of health care services for millions of Americans. Congress should take the time to develop comprehensive and sound legislation that would improve accessibility, but provide proper safeguards that protect patients and federal spending levels. It is ideal for short-term legislation to include components to ensure fraud protection, include studies to gather the impact telehealth has made on health care access and delivery, and give Congress time to further debate the issues.

Endnotes
2 "H.R. 2471, the Consolidated Appropriations Act, 2022." Congressional Budget Office, March 14, 2022. https://www.cbo.gov/publication/57928; "Medicare and Medicaid: Covid-19 Program Flexibilities; Considerations for Their Continuation." U.S. Government Accountability Office. Accessed April 1, 2022. https://www.gao.gov/products/gao-21-575t; "H.R. 5201, Telemental Health Expansion Act of 2020." Congressional Budget Office, December 4, 2020. https://www.cbo.gov/publication/56874. 3 CBO scored five months of expansive telehealth authorities as costing $663 million (see "H.R. 2471, the Consolidated Appropriations Act, 2022.") Assuming that cost remains constant as a share of Medicare Part B spending, it would total nearly $25 billion through fiscal year 2031. 4 Arielle Kane and Charlie Katebi, "Telehealth Saves Money and Lives: Lessons from the Covid-19 Pandemic," Progressive Policy Institute, November 10, 2021, https://www.progressivepolicy.org/publication/telehealth-saves-money-an...; Wyatt Koma, Juliette Cubanski, and Tricia Neuman, Medicare and Telehealth: Coverage and Use During the COVID-19 Pandemic and Options for the Future. Kaiser Family Foundation, May 19, 2021, https://www.kff.org/medicare/issue-brief/medicare-and-telehealth-covera...; Jacob C. Warren and K. Bryant Smalley, "Using Telehealth to Meet Mental Health Needs During the COVID-19 Crisis." The Commonwealth Fund, June 18, 2020, https://www.commonwealthfund.org/blog/2020/using-telehealth-meet-mental.... 12 For example, research shows that delays in seeking care increase at the age of 64, and doctor visits jump at age 65, when the population nears and then becomes eligible for Medicare. Evidence from the Affordable Care Act's expansion of health insurance is similarly persuasive. The reverse also holds true. Increased friction through high deductibles or increased cost-sharing reduces utilization, leading to lower spending levels and restrained cost growth. Even administrative burdens serve as dampers on utilization on par with financial barriers. See in order: Molly Frean, and Mark Pauly. "Does High Cost-Sharing Slow the Long-Term Growth Rate of Health Spending? Evidence from the States." NBER, October 15, 2018. https://www.nber.org/papers/w25156; and "Does Health Insurance Affect Health Care Utilization and Health?" NBER. Accessed April 1, 2022. https://www.nber.org/bah/2004number1/does-health-insurance-affect-healt....; Jonathan Gruber and Benjamin D. Sommers. "Fiscal Federalism and the Budget Impacts of the Affordable Care Act's Medicaid Expansion." NBER, March 16, 2020. https://www.nber.org/papers/w26862; Joseph Santos, and James C. Capretta. "National Health Expenditure Report Shows We Have Not Solved the Cost Problem: Health Affairs Forefront." Health Affairs, December 6, 2017. https://www.healthaffairs.org/do/10.1377/forefront.20171205.607294/full/; Austin Frakt. "U.S. Health Care Costs a Lot, and Not Just in Money." The Incidental Economist, September 7, 2021. https://theincidentaleconomist.com/wordpress/u-s-health-care-costs-a-lo.... 18 Michael E. Chernew and J. Michael McWilliams. "The Case for ACOs: Why Payment Reform Remains Necessary." Health Affairs Forefront, January 24, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20220120.825396/; "The 2021 Report of the Medicare Trustees." CMS. Accessed April 8, 2022. https://www.cms.gov/OACT/TR/2021. 22 Ravitz, "The Economics of a Telehealth Visit: A Time-Based Study at Penn Medicine." 25 CMS has currently set those intervals at six months after the first telehealth visit, and then within 12 months after that visit. They also allow those in-person visits to be with any clinician in the same provider group to more easily meet the requirement. 31 Over the last two years, the Department of Justice (DOJ) announced criminal charges against 86 medical providers accounting for over $4.5 billion in losses from telehealth fraud and 138 medical providers accounting for over $1.4 billion in losses, with $1.1 billion of that being from telehealth fraud. See in order: "Justice Department Recovers over $3 Billion from False Claims Act Cases in Fiscal Year 2019." The United States Department of Justice, January 21, 2020. https://www.justice.gov/opa/pr/justice-department-recovers-over-3-billi...; "Justice Department's False Claims Act Settlements and Judgments Exceed $5.6 Billion in Fiscal Year 2021." The United States Department of Justice, February 2, 2022. https://www.justice.gov/opa/pr/justice-department-s-false-claims-act-se.... 34 "March 2021 Report to the Congress: Medicare Payment Policy." 35 Chernew, "RE: File code CMS-1751-P." 37 Committee for a Responsible Federal Budget, "Reducing Medicare Advantage Overpayments" February 23, 2021, https://www.crfb.org/papers/reducing-medicare-advantage-overpayments; Richard Gilfillan, and Donald M. Berwick, "Medicare Advantage, Direct Contracting, and The Medicare 'Money Machine,' Part 1: The Risk-Score Game" Health Affairs, September 29, 2021. https://www.healthaffairs.org/do/10.1377/forefront.20210927.6239/. 38 U.S. Department of Health and Human Services, Office of Inspector General, "Billions in Estimated Medicare Advantage Payments From Diagnoses Reported Only on Health Risk Assessments Raise Concerns", OEI-03-17-00471, September. 2020 https://oig.hhs.gov/oei/reports/OEI-03-17-00471.pdf; Medicare Payment Advisory Commission, March 2021 Report to the Congress: Medicare Payment Policy, March 15th, 2021, page 352. https://www.medpac.gov/document/march-2021-report-to-the-congress-medic...; Chernew, "RE: File code CMS-1751-P." 39 Pipes, "Don't Dam The Telehealth Flood." 42 Private insurers are expanding their telehealth offerings. Throughout 2021, 65 percent of employers with 50 or more employees that covered telehealth services made changes to their coverage in order to expand benefits. It is projected that by 2027, the telehealth sector will bring in $20 billion in revenues for technology companies and equity funding has already reached close to that. See: Kaiser Family Foundation, "Section 13: Employer Practices, Telehealth and Employer Responses to the Pandemic" 2021 Employer Health Benefits Survey Nov 10, 2021. https://www.kff.org/report-section/ehbs-2021-section-13-employer-practi...; Bloomberg Intelligence, "Telehealth Sector Projected to Bring in up to $20 Billion in U.S. Revenue by 2027" Press Announcement, February 24, 2022. https://www.bloomberg.com/company/press/telehealth-sector-projected-to-....

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Fiscal Considerations for the Future of Telehealth | Committee for a Responsible Federal Budget

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Telehealth services filled crucial medical care gaps during the COVID-19 pandemic and will appropriately remain an important part of the health care system going forward.

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Affects an individual's ability to obtain critical resources that support well-being. Income, work, food security, and secure housing are all important considerations. Financial insecurity, unemployment, and poverty can reduce access to nutritious food, healthcare, and safe living circumstances, increasing the risk of chronic diseases, stress, and poor health outcomes. Addressing economic stability by increasing job opportunities, maintaining wage parity, and expanding access to social support programs is critical for improving health outcomes and eliminating inequities across communities.

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Health care access and quality include concerns like primary care access, health insurance, and health literacy, all of which have a substantial impact on people's ability to prepare for and respond to emergencies. For example, those without a primary care physician may struggle to obtain emergency prescription drugs, uninsured individuals may find vital services such as vaccines or mental health care too costly, and a lack of health literacy can impede informed decision-making during crises.

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Centers for Disease Control and Prevention. (n.d.). Education access and quality: Discussion guide. U.S. Department of Health and Human Services. Retrieved November 17, 2024, from https://www.cdc.gov/prepyourhealth/discussionguides/education.htm

National Academies of Sciences, Engineering, and Medicine. (2020). Communities in action: Pathways to health equity. National Academies Press. https://doi.org/10.17226/25837

U.S. Department of Health and Human Services. (2024). Healthy People 2030: Social determinants of health. Retrieved November 17, 2024, from https://odphp.health.gov/healthypeople/objectives-and-data/social-determinants-health

World Health Organization. (n.d.). Social determinants of health. Retrieved November 17, 2024, from https://www.who.int/social_determinants

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Importance of Social Determinants of health  

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Importance of Social Determinants of health  

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What Makes Us Healthy? Understanding the Social Determinants of Health

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In 2022, 42.3% of the U.S. population identified as a racial or ethnic minority, reflecting ongoing disparities due to social and economic conditions, such as racial discrimination, which has been linked to higher infant mortality rates, poorer health status, and limited access to quality healthcare. In 2022, there were 7.7 million single-parent homes, which can lead to poor physical and mental health results for both parents and children.

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Which social determinant factor do you think has the biggest impact on health?

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Education access and quality have an impact on people's ability to prepare for and respond to emergencies, with elements such as educational attainment, language competence, and literacy all playing important roles. Limited English abilities might make it difficult to grasp preventative measures, while a lack of media literacy can make it difficult to discover trustworthy crisis information.

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The environment in which people live, work, learn, play, age, and worship have a significant impact on individual and community health outcomes. These environments, including homes, schools, workplaces, places of worship, and transportation systems, influence the availability, accessibility, and quality of resources required for thriving communities. Housing insecurity and segregation, infrastructure disinvestment, workplace environmental risks, and food access and production are all major concerns. Policies like redlining, government rental aid, and the Farm Bill are examined to determine their impact on health inequalities.