Pooja Chandrashekar, AB

The scale of the coronavirus disease 2019 pandemic and its disproportionate impact on vulnerable populations has spurred unprecedented focus on and investment in social determinants of health (SDOH). Although the greater focus on social determinants is laudable and necessary, there is a tendency for health care organizations to implement SDOH programs at scale without rigorous evidence of effect, rather than targeting interventions to specific patients and assessing their impact. This broad, and sometimes blind, application of SDOH interventions can be costly and wasteful. We argue for rejecting the “more is better” mindset and specifically targeting patients who truly need and would substantially benefit from SDOH interventions. Matching interventions to the most appropriate patients involves screening for social needs, developing rigorous evidence of effect, and accompanying policy reform.

There is a tendency for health care organizations to implement social determinants of health (SDOH) programs at scale without rigorous evidence of effect, rather than targeting interventions to specific patients and assessing their impact.

Efforts to screen for and address SDOH should receive the same scrutiny as clinical interventions to diagnose and treat disease.

Matching SDOH interventions to the most appropriate patients involves screening for social needs, developing rigorous evidence of effect, and accompanying policy reform.

Long before coronavirus disease 2019 (COVID-19), there was ample evidence that social factors are primary drivers of health outcomes. However, the scale of the pandemic and its disproportionate impact on vulnerable populations have spurred unprecedented focus on and investment in social determinants of health (SDOH).

 Payers such as Tufts Health Plan and Humana have committed funding to addressing social isolation, food insecurity, and transportation access among seniors. At the federal level, HHS provided $1.3 billion to support community health centers in managing patients’ medical and social needs.

 On the surface, the bet being made is straightforward and grounded in common sense: If social factors are driving poor health and, in turn, greater health care spending, then investments to address those factors should lead to better outcomes and lower overall health care costs.

Although the greater focus on social determinants is laudable and necessary, optimism should be tempered by our relatively limited understanding of whether and which SDOH interventions actually improve the social circumstances or health of vulnerable patients.

 Interventions can be quite expensive and, if applied to individuals where there is little to no benefit, wasteful.

There is a tendency for health care organizations to implement SDOH programs at scale without rigorous evidence of effect, rather than targeting interventions to specific patients and assessing their impact. We believe that efforts to screen for and address SDOH should receive the same scrutiny as clinical interventions to diagnose and treat disease. Just as we would never prescribe an antibiotic for a patient whose infection could not be appropriately treated by that medicine, we should be careful not to prescribe social interventions without confidence that they will solve the problem at hand.

For example, one might suspect that providing rideshare services to patients in the Medicaid program would reduce no-shows. Yet, a clinical trial conducted at 2 clinics in West Philadelphia, Pennsylvania, showed that patients offered rideshare services missed the same number of appointments as controls. Upon further investigation, researchers found that other factors (eg, caregiver role for family members, stress, pressure to be at work) posed a greater obstacle to some patients than transportation.

 These findings caution against the broad, and sometimes blind, application of SDOH interventions.

Similarly, intensive care management programs for patients with high use of health care services have been tested in select populations to improve outcomes and reduce spending. The “hotspotting” program created by the Camden Coalition of Healthcare Providers is an oft-cited example that uses hospital admissions data to identify “superutilizers” and coordinate outpatient care and social services in the months following discharge. However, a recent randomized controlled trial (RCT) showed that the program did not result in the expected decreases in readmission rates.

 Patients enrolled in the program had diverse medical and social needs, and it is possible that the Camden model’s approach to care management was insufficient for some.

Although COVID-19 should motivate us to shore up investments in SDOH, it is also a pivotal opportunity to rethink our one-size-fits-all approach and curb overuse in our resource-constrained system. This requires rejecting the “more is better” mindset and specifically targeting patients who truly need and would substantially benefit from SDOH interventions. When interventions are broadly applied, the entities that most stand to benefit are the growing for-profit industry of vendors focused on this area, not the patient. Although social services can be used by nearly everyone, organizations must be thoughtful about matching interventions to the most appropriate patients. This involves (1) screening for social needs, (2) developing rigorous evidence of effect, and (3) accompanying policy reform.

Selectively providing social resources to those most in need requires an accurate and reliable method of identifying these individuals. Although most hospitals screen at least some patients for health-related social needs, this screening is often fragmented and ad hoc.

Providers often believe that comprehensive social needs screening is not feasible in a clinic setting, but the success of programs such as WellRx in Albuquerque, New Mexico, proves otherwise. In this pilot, an 11-question instrument was used to screen 3048 patients over a 90-day period. Medical assistants and community health workers connected patients who screened positive for unmet social needs with appropriate services and resources. Although similar programs at other institutions have produced mixed results, the WellRx pilot demonstrates that a consistent and systematic approach to screening is indeed possible.

There is no standard method for social needs screening, and approaches should be tailored to each community and organization. This starts with selecting the right screening tool—although the number and use of screening tools are increasing, few are validated.

 Codesigning screening tools with patients, clinicians, and community stakeholders is a useful strategy; patients can provide valuable insights into the most important questions to ask, clinicians can ensure that screening processes dovetail with their clinical work, and representatives of community-based organizations are privy to the needs and preferences of the communities they serve.

Once individuals with social needs are identified, the next step is matching them to the appropriate interventions. However, the evidence base for SDOH interventions is scant and many questions remain unanswered. Which interventions have the greatest impact on health, and for which patients are these most effective? What are the requisite contextual factors necessary to ensure that an intervention is delivered effectively?

If we expect to make real progress, it is time to start treating SDOH interventions with the same rigor as biomedical interventions. A national survey of health care executives revealed that most do not monitor or evaluate SDOH interventions—and if they are evaluated, most evaluations are uncontrolled pre-post studies or cross-sectional studies without a follow-up period of greater than 1 year.

As a useful model, consider the process of drug development: Compounds are designed and synthesized based on medical need, hypotheses are tested in animal studies, results are analyzed, and compounds are modified accordingly to maximize efficacy and minimize toxicity. This process is iterated before compounds are sent off to clinical trials and ultimately reach the market.

Similarly, an evidence-based approach to evaluating SDOH interventions means starting small, observing what does and does not work, and making adjustments as needed. Although the Camden trial results were disappointing, a growing number of RCTs have demonstrated the value of using implementation science to evaluate SDOH interventions. The Individualized Management for Patient-Centered Targets (IMPaCT) program is an excellent example. This community health worker intervention that helps patients with low incomes achieve their chronic disease management goals was first piloted in a primary care clinic in Philadelphia, studied via a single-center RCT, and then expanded to 3 clinics. A multicenter RCT showed that the intervention improved patient-perceived quality of care while reducing hospitalizations.

 SDOH interventions are neither homogenous nor simple, but this is an outstanding example of using rigorous science to evaluate and fine-tune an intervention for a specific population.

These RCTs are also a reminder to widen the aperture on our metrics for success. Of course, organizations need to understand whether patients are using provided services and whether these services are producing their intended effects. However, the Camden and IMPaCT trials illustrate the importance of measuring outcomes beyond health care utilization. Social needs are, by definition, personal, and a combination of quantitative and qualitative metrics is needed to capture the breadth of an intervention’s impact on people’s lives. Moreover, addressing SDOH takes time—organizations must have the patience to realize long-term improvements in health outcomes.

Increasing awareness that social determinants have a profound influence on health care outcomes and costs has motivated a slew of policy changes and recommendations intended to incentivize providers to screen for and address patients’ social needs.

 Although these reforms are a step in the right direction, they can have unintended consequences, such as pressuring organizations into the broad application of SDOH programs.

We recommend that policies incentivize the targeted provision of SDOH interventions to specific communities or individuals most likely to benefit from these services. One way to do this is by holding hospitals and health systems accountable for (1) comprehensive screening to distinguish between patients with and without social needs and (2) rigorous studies examining the effects of interventions on specific subpopulations. For example, federal and state departments of health could require that organizations implement and report data on these components of proposed SDOH interventions to be eligible for funding.

The COVID-19 crisis represents a generational opportunity to reshape our approach to addressing SDOH. It is not enough to continue investing in SDOH because it is “the right thing to do.” At the same time, we are not advocating for depriving patients in need of adequate access to social services. Rather, the reality is that most health systems, especially those in underserved communities, have little bandwidth to meaningfully address social determinants for high-need patients. Pursuing a more targeted approach can ensure that interventions actually bear fruit for individual patients and reduce wastage of limited resources.


 SCAN Group and Health Plan (SHJ), Long Beach, CA; Stanford University School of Medicine (SHJ), Stanford, CA; Harvard Medical School (PC), Boston, MA.

 Dr Jain owns stock in Anthem, Blink Health, Curisium, Cyft, Datavant, Embedded Healthcare, Firefly Health, General Electric, Koneksa Health, Merck, Safeguard Scientifics, Thrive Earlier Detection, Valera Health, Vertex, Vital, and U.S. Healthworks. Ms Chandrashekar reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (PC); drafting of the manuscript (PC); critical revision of the manuscript for important intellectual content (SHJ, PC); provision of patients or study materials (SHJ); and administrative, technical, or logistic support (SHJ).

 Sachin H. Jain, MD, MBA, SCAN Group and Health Plan, 3800 Kilroy Airport Way, Long Beach, CA 90806. Email: Sjain@scanhealthplan.com.

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Articles

We must rethink our one-size-fits-all approach to social determinants of health interventions and instead target patients who truly need and would benefit from these interventions.

Implementing a Targeted Approach to Social Determinants of Health Interventions

Telemedicine offers a promising solution to the growing physician shortage, but state-based medical licensing poses a significant barrier to the widespread adoption of telemedicine services. We thus recommend a mutual recognition scheme whereby states honor each other’s medical licenses. Successfully implementing mutual recognition requires policy, technological, and administrative changes, including a federal mandate for states to participate in mutual recognition, consistent standards for using and regulating telemedicine, a mechanism to enable interstate data sharing, financial support for states, and a “state of principal license” requirement for physicians. Reforming the United States’ outdated system of state-based medical licensure can help meet patient demand for virtual care services and improve access to care in rural and medically underserved areas.

The United States’ antiquated system of state-based medical licensure creates unnecessary hurdles that reduce the potential of telemedicine to address the growing physician shortage and improve access to care in rural and medically underserved areas.

Mutual recognition, a scheme whereby states honor each other’s medical licenses, is a comprehensive potential solution to enhance license portability and eliminate barriers to virtual care.

Implementing mutual recognition necessitates policy, technological, and administrative reforms to protect patient safety, prioritize the financial well-being of states, and streamline physician reimbursement.

By 2030, the United States could see a shortage of nearly 120,000 physicians.

 Telemedicine can alleviate the impacts of this shortage by helping physicians make use of unused time and see additional patients, allowing patients to access a larger pool of physicians and connecting specialists to hospitals in rural and medically underserved areas.

 Although telemedicine is growing in use and acceptance, state licensing laws create false geographic barriers and pose a significant challenge to widespread adoption.

In the United States, state medical boards regulate physician licensing, creating a patchwork of inconsistent state licensure laws. With few exceptions, physicians must acquire and maintain a license for each state in which they practice medicine. This antiquated system of state-based medical licensure, originally enacted in the 19th century to reduce medical malpractice and protect patient safety, has profound implications for the promise of telemedicine to increase access to care for vulnerable populations and mitigate the impacts of the national physician shortage.

 In this commentary, we argue for moving away from state-based medical licensure and describe policy, technological, and administrative changes necessary for moving toward portable medical licensure.

Physicians must be licensed in each state where current and future patients are located, so physicians practicing telemedicine across state borders may be responsible for obtaining and staying compliant with up to 51 different state practices of medicine at any given time. There are some exceptions—for example, 10 states issue special purpose licenses for physicians who wish to come to their state for a limited time, scope, and purpose, such as to demonstrate a new technique or to educate medical students.

 However, these exceptions are few and far between.

The multistate licensure process is long and expensive; some states require physicians to pay annual license renewal fees, complete additional coursework, submit required documentation, and participate in interviews. Even after physicians complete these requirements, state medical boards can take several months to process licensing applications.

 Along with imposing substantial direct costs on physicians, state-specific licensing reduces competition that could lower healthcare prices, limits opportunities for physicians to gain experience by seeing more patients, and exacerbates health disparities.

 The impact of restricting telemedicine falls hardest on poor patients, the uninsured, and those who rely on state Medicaid programs, many of whom lack access to reliable transportation and cannot travel across state lines to see specialists.

Over the past decade, the Federation of State Medical Boards (FSMB), a national nonprofit organization that represents 70 state medical and osteopathic boards, has advanced several proposals to enhance license portability and reduce regulatory barriers to telemedicine. These include the Uniform Application and the Federation Credentials Verification Service, which are both web-based applications that eliminate the need for physicians to reenter identifying information and credentials when applying for multiple licenses. Most recently, the FSMB instituted the Interstate Medical Licensure Compact, an agreement to expedite the medical licensure process among member states. Physicians in good standing can freely practice in member states as long as they possess a “full and unrestricted” license in their state of principal license (SPL). To date, only 24 states have joined the compact.

These proposals are a step in the right direction but far from the solution. They simply streamline—not eliminate&mdash;the process of applying for multiple medical licenses. Additionally, they do not reduce the cost to doctors of maintaining multiple medical licenses, estimated at $300 million each year.

 As a more comprehensive solution, we recommend a mutual recognition scheme whereby states honor each other’s medical licenses. This model has been successfully adopted in Europe and Australia and by the Veterans Health Administration, US military, and US Public Health Service.

 Furthermore, because standards for medical education apply nationwide and physician training requirements are set by federal agencies such as HHS, mutual recognition is warranted.

Proponents of the status quo argue that mutual recognition compromises patient safety, reduces revenues from state licensing fees, and complicates physician reimbursement. To address these challenges, mutual recognition should be accompanied by (1) a federal mandate, (2) consistent standards for using and regulating telemedicine services, (3) increased data sharing among states, (4) financial support for states, and (5) a requirement for physicians to select an SPL.

To reduce barriers to interstate medical practice, some states have attempted unilateral action. For example, in 2016, the Florida House of Representatives passed a bill with a provision allowing physicians licensed in other states to offer telemedicine services in Florida. However, the Florida Senate eliminated the provision. To avoid similar situations, Congress can require states to participate in mutual recognition. In fact, legal research suggests that federal action to promote interstate telemedicine is justified based on the Commerce Clause of the US Constitution, which states that Congress has the power “to regulate commerce…among the several states.”

 Another benefit of instituting a federal mandate is a consistent set of definitions needed to support mutual recognition (eg, SPL).

Standards for Using and Regulating Telemedicine Services

Each state currently defines the “practice of medicine” differently, making it difficult to discern what constitutes an acceptable telemedicine consultation in any given state. Standards of practice, conduct, and behavior during telemedicine consultations—including requirements related to physician credentialing, patient education, and physician supervision of other healthcare professionals&mdash;vary widely among states.

 Thus, the shift to mutual recognition must be accompanied by efforts to establish consistent standards for using and regulating telemedicine services. These standards should be defined at the federal level.

State medical boards are tasked with the responsibility of monitoring and disciplining physicians licensed in their state. However, due to gaps in information sharing among states, nearly one-third of physicians disciplined in one state are able to practice elsewhere without limitations, repercussions, or public disclosure. This is especially dangerous in a mutual recognition scheme in which out-of-state physicians routinely see and treat patients with little oversight.

For mutual recognition to promote patient safety, information on malpractice, medical errors, and license cancellation or suspension must be shared among states, made publicly available to patients, and used to enforce disciplinary actions across state borders. States should use resources like the National Practitioner Data Bank, established in 1986 as a central data repository for malpractice payments and state disciplinary actions, to conduct rigorous background checks before physicians participate in telemedicine consultations and deliver care across state borders.

Given the administrative and technological costs of implementing mutual recognition and dismantling the existing state-based medical licensure system, HHS could provide states with incentive payments for adopting mutual recognition agreements and eliminating state-specific licensing and renewal fees. Additionally, HHS could offer grant funding to enhance interstate data sharing systems and other functions that promote mutual recognition. While financial support for states is an important first step, mutual recognition can reduce healthcare costs in the long run as telemedicine services increase access to care for rural and underserved populations.

One challenge of mutual recognition is attributing physicians to any given state. This can complicate physician reimbursement for telemedicine services and reduce the effectiveness of state healthcare programs dependent on physician participation. A possible solution is requiring physicians to select a single SPL for questions regarding reimbursement and attribution. This requirement already exists for physicians participating in the Interstate Medical Licensure Compact. Because physicians would fall under the jurisdiction of their SPL’s medical board, the SPL could hold primary responsibility for collating information from interstate data-sharing systems and enforcing disciplinary action against errant physicians.

The environment of medicine is changing. More than three-fourths of patients want access to virtual care services, and patients across all age groups express a desire to use telemedicine to gain easier, more immediate access to physicians.

 To meet growing patient demand and solve our country’s critical physician shortage, we can and must reform our outdated state-based licensing system.

 Harvard Medical School (PC), Boston, MA; CareMore Health System (SHJ), Cerritos, CA; Stanford University School of Medicine (SHJ), Stanford, CA.

 Dr Jain is an employee of CareMore and Aspire Health, which are both multistate provider entities. Ms Chandrashekar reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (PC, SHJ); drafting of the manuscript (PC); critical revision of the manuscript for important intellectual content (PC, SHJ); administrative, technical, or logistic support (SHJ); and supervision (SHJ).

 Sachin H. Jain, MD, MBA, CareMore Health System, 12900 Park Plaza Dr, Cerritos, CA 90703. Email: Sachin.Jain@caremore.com.

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6. Vestal C. Why physician licensing is a problem for telemedicine. Governing website. governing.com/news/headlines/why-telemedicine-is-a-problem-for--.html. Published March 7, 2014. Accessed December 9, 2018.

7. Heuser EZ. What do consumers want from virtual visits? Advisory Board website. advisory.com/research/market-innovation-center/research-briefs/2017/virtual-visits-briefing. Published April 27, 2017. Accessed December 9, 2018.&ensp;

In this commentary, the authors argue for moving away from state-based medical licensure and describe policy, technological, and administrative changes necessary for implementing portable medical licensure.

Pooja Chandrashekar, AB

Articles

Implementing a Targeted Approach to Social Determinants of Health Interventions

Eliminating Barriers to Virtual Care: Implementing Portable Medical Licensure