Telehealth will save lives—for as long as it has funding
The federal government and private insurers greatly increased Americans' telehealth access during the pandemic. Will these changes be permanent?
Stephen Johnson is a St. Louis-based writer whose work has been published by outlets including PBS Digital Studios, HuffPost, MSN, U.S. News & World Report, Eleven Magazine and The Missourian.
- When telehealth visits began skyrocketing after the pandemic began, hospitals had to increase their number of virtual appointments by magnitudes. Most did it seamlessly.
- Big Think spoke to Dr. Martin Doerfler, senior vice president of clinical strategy and development at Northwell Health, about this transition and how it benefited patients.
- Telehealth has proven its value during the pandemic, but it might stop evolving unless the federal government redesigns the regulatory framework so that insurers cover it and patients can afford it.
When COVID-19 began spreading across the U.S. in early 2020, the nation's telehealth infrastructure entered a trial by fire.
It was paramount for hospitals to minimize in-person care—not only to limit the spread of the virus, but also to ensure hospitals wouldn't become overwhelmed, like they had in Italy. That's a key reason why, in March, Medicare and most private insurers sought to increase access to telehealth by relaxing restrictions, waiving fees, and reimbursing practitioners for virtual visits at the same rate as in-person visits.
Soon after the establishment of these temporary measures, telehealth visits skyrocketed. A report from the U.S. Department of Health and Human Services found, for example, that about 43 percent of primary care visits were conducted through telehealth in April, compared to just 0.1 percent in February.
How did that transition go? Despite having just weeks to prepare, most U.S. health care organizations managed to massively increase their virtual caseload with astounding seamlessness. Dr. Martin Doerfler, senior vice president of clinical strategy and development at Northwell Health, was one of the thousands of health care professionals who witnessed the transition.
"We went from the proverbial 'zero to 60' over a matter of weeks, and provided good care with very high degrees of patient satisfaction," Doerfler said.
Prior to the pandemic, Northwell Health—the largest hospital system in New York—was conducting about 150 telehealth visits per month between 20 to 40 physicians. But in May alone, Northwell had conducted approximately 65,000 visits with roughly 8,000 health care professionals across the health system.
Doerfler cited an example of a single mother whose young child had chronic illnesses, including respiratory problems, which made in-person visits especially dangerous during the pandemic. The pediatrician was able to evaluate the child, speak to the mother through a telehealth translation service, and provide the family with the necessary steps to keep the child healthy. The mother was happy to avoid having to take her child on public transportation to visit a hospital in person and still receive the care she needed.
Three hours to drive 200 miles is no different than three hours to take two trains, two buses and a cab.
Clinicians at Northwell have used telehealth to adapt to the pandemic in many ways, from sending phlebotomists to elderly patients' homes after virtual visits, to connecting new mothers with lactation specialists via secure, encrypted telehealth channels.
"There are all sorts of examples throughout health care where this technology, and the willingness of patients and clinicians to embrace it, allowed for care of the type of issues that are normally done face-to-face," Doerfler said.
Telehealth programs that existed before the pandemic also helped to keep both patients and hospital staff safe by minimizing in-person visits. For example, Northwell's TelePsychiatry Department connects people in crisis, who might typically go to the emergency department, with a behavioral health specialist in about 45 minutes, any time of day or week. That is a considerable improvement since emergency department staffing typically does not include psychiatrists or other specialists who can help someone experiencing a behavioral health emergency.
The success of telehealth during the pandemic begs the question: Why hasn't US health care already embraced virtual care?
What are the obstacles facing telehealth?
One of the biggest obstacles to widespread adoption of telehealth has been a lack of national legislation providing financial incentive for health centers to adopt it.
States laws vary on how practitioners are paid for telehealth visits. In some states, laws require insurance providers to cover telehealth visits at parity—at the same rate as in-person visits. But in states without parity laws, there's little incentive for health care organizations to invest in telehealth infrastructure and training.
Access is also a major obstacle. The Centers for Medicare and Medicaid Services (CMS) generally reimburse practitioners for telehealth visits only when patients live in "designated rural underserved areas."
But not all underserved areas are in small, remote places. After all, a single parent living in Brooklyn, New York, might also have trouble accessing quality health care.
"Three hours to drive 200 miles is no different than three hours to take two trains, two buses and a cab," Doerfler said. "So access is almost certainly going to be improved by the greater availability of telehealth in that direct-to-patient, in-their-home-or-office, setting."
Lack of internet access is also a problem. A paper published by the JAMA Network in August found that 41 percent of Medicare beneficiaries don't have a computer at home with access to high-speed internet, and roughly the same number don't have a smartphone with an unlimited data plan.
What is the future of telehealth?
Credit: Daniilvolkov via AdobeStock
Lawmakers in both parties and health care professionals have indicated a desire to make permanent some of the regulatory changes to telehealth enacted during the pandemic. That's key, because without the financial incentives to continue expanding telehealth, health care providers may revert to the pre-pandemic approach.
"One issue, which is important for health care and non-health-care folks to know, is that telehealth will continue to expand dramatically as long as there's funding and reimbursement for it," said Michael Dowling, Northwell's president and CEO. "If the insurance companies and government decide, 'We don't want to pay for telehealth going forward or virtual visits,' then it's going to slow down. If there is no delivery system, no health care system, hospital, or doctor is going to continue to expand telehealth if they don't get reimbursed for it."
Yet some of the nation's biggest insurers have already stopped waiving telehealth deductibles and copays for some customers, even though there's no clear end in sight for the pandemic.
The long-term solution, Doerfler said, is for CMS to start paying for telehealth services, at parity, up and down the chain, and passing federal legislation that requires self-insured health care plans to pay for telehealth services as they would in-person visits.
Telehealth is proven to work for urgent care, primary care and some specialty care, and it clearly expands access to behavioral health care, according to Doerfler. "Some have said that costs of providing telehealth are lower than face-to-face care, but most of the costs are unchanged, and new ones are added with technology requirements. When the patient receives a very specific service there are billing codes used to define that service. If the service is less, the code represents that. If the service is the same, the code will represent that and needs to be paid at parity."
Doerfler added that, while telehealth can't replace all traditional health care services, it should be "in the toolbox" for patients and physicians.
"In the modern world, where this type of technology is being used for all sorts of personal and business uses, excluding something as personal as your care between you and your doctor from fitting into that modern paradigm makes no sense," Doerfler said.
Eating veggies is good for you. Now we can stop debating how much we should eat.
- A massive new study confirms that five servings of fruit and veggies a day can lower the risk of death.
- The maximum benefit is found at two servings of fruit and three of veggies—anything more offers no extra benefit according to the researchers.
- Not all fruits and veggies are equal. Leafy greens are better for you than starchy corn and potatoes.
The famous cognition test was reworked for cuttlefish. They did better than expected.
- Scientists recently ran the Stanford marshmallow experiment on cuttlefish and found they were pretty good at it.
- The test subjects could wait up to two minutes for a better tasting treat.
- The study suggests cuttlefish are smarter than you think but isn't the final word on how bright they are.
Proof that some people are less patient than invertebrates<iframe width="730" height="430" src="https://www.youtube.com/embed/H1yhGClUJ0U" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe><p> The common cuttlefish is a small cephalopod notable for producing sepia ink and relative intelligence for an invertebrate. Studies have shown them to be capable of remembering important details from previous foraging experiences, and to adjust their foraging strategies in response to changing circumstances. </p><p>In a new study, published in <a href="https://royalsocietypublishing.org/doi/10.1098/rspb.2020.3161" target="_blank" rel="noopener noreferrer">The Proceedings of the Royal Society B</a>, researchers demonstrated that the critters have mental capacities previously thought limited to vertebrates.</p><p>After determining that cuttlefish are willing to eat raw king prawns but prefer a live grass shrimp, the researchers trained them to associate certain symbols on see-through containers with a different level of accessibility. One symbol meant the cuttlefish could get into the box and eat the food inside right away, another meant there would be a delay before it opened, and the last indicated the container could not be opened.</p><p>The cephalopods were then trained to understand that upon entering one container, the food in the other would be removed. This training also introduced them to the idea of varying delay times for the boxes with the second <a href="https://www.sciencealert.com/cuttlefish-can-pass-a-cognitive-test-designed-for-children" target="_blank" rel="noopener noreferrer">symbol</a>. </p><p>Two of the cuttlefish recruited for the study "dropped out," at this point, but the remaining six—named Mica, Pinto, Demi, Franklin, Jebidiah, and Rogelio—all caught on to how things worked pretty quickly.</p><p>It was then that the actual experiment could begin. The cuttlefish were presented with two containers: one that could be opened immediately with a raw king prawn, and one that held a live grass shrimp that would only open after a delay. The subjects could always see both containers and had the ability to go to the immediate access option if they grew tired of waiting for the other. The poor control group was faced with a box that never opened and one they could get into right away.</p><p>In the end, the cuttlefish demonstrated that they would wait anywhere between 50 and 130 seconds for the better treat. This is the same length of time that some primates and birds have shown themselves to be able to wait for.</p><p>Further tests of the subject's cognitive abilities—they were tested to see how long it took them to associate a symbol with a prize and then on how long it took them to catch on when the symbols were switched—showed a relationship between how long a cuttlefish was willing to wait and how quickly it learned the associations. </p>
All of this is interesting, but what use could it possibly have?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTcxNzY2MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY2MTM0MzYyMH0.lKFLPfutlflkzr_NM6WmnosKM1rU6UEIHWlyzWhYQNM/img.jpg?width=1245&coordinates=0%2C10%2C0%2C88&height=700" id="77c04" class="rm-shortcode" data-rm-shortcode-id="7eb9d5b2d890496756a69fb45ceac87c" data-rm-shortcode-name="rebelmouse-image" data-width="1245" data-height="700" />
A diagram showing the experimental set up. On the left is the control condition, on the right is the experimental condition.
Credit: Alexandra K. Schnell et al., 2021<p> As you can probably guess, the ability to delay gratification as part of a plan is not the most common thing in the animal kingdom. While humans, apes, some birds, and dogs can do it, less intelligent animals can't. </p><p>While it is reasonably simple to devise a hypothesis for why social humans, tool-making chimps, or hunting birds are able to delay gratification, the cuttlefish is neither social, a toolmaker, or is it hunting anything particularly <a href="https://gizmodo.com/cuttlefish-are-able-to-wait-for-a-reward-1846392756" target="_blank" rel="noopener noreferrer">intelligent</a>. Why they evolved this capacity is up for debate. </p><p>Lead author Alexandra Schnell of the University of Cambridge discussed their speculations on the evolutionary advantage cuttlefish might get out of this skill with <a href="https://www.eurekalert.org/pub_releases/2021-03/mbl-qc022621.php" target="_blank" rel="noopener noreferrer">Eurekalert:</a> </p><p style="margin-left: 20px;"> "Cuttlefish spend most of their time camouflaging, sitting and waiting, punctuated by brief periods of foraging. They break camouflage when they forage, so they are exposed to every predator in the ocean that wants to eat them. We speculate that delayed gratification may have evolved as a byproduct of this, so the cuttlefish can optimize foraging by waiting to choose better quality food."</p><p>Given the unique evolutionary tree of the cuttlefish, its cognitive abilities are an example of convergent evolution, in which two unrelated animals, in this case primates and cuttlefish, evolve the same trait to solve similar problems. These findings could help shed light on the evolution of the cuttlefish and its relatives. </p><p> It should be noted that this study isn't definitive; at the moment, we can't make a useful comparison between the overall intelligence of the cuttlefish and the other animals that can or cannot pass some variation of the marshmallow test.</p><p>Despite this, the results are quite exciting and will likely influence future research into animal intelligence. If the common cuttlefish can pass the marshmallow test, what else can?</p>
Three lines of evidence point to the idea of complex, multicellular alien life being a wild goose chase. But are we clever enough to know?
- Everyone wants to know if there is alien life in the universe, but Earth may give us clues that if it exists it may not be the civilization-building kind.
- Most of Earth's history shows life that is single-celled. That doesn't mean it was simple, though. Stunning molecular machines were being evolved by those tiny critters.
- What's in a planet's atmosphere may also determine what evolution can produce. Is there a habitable zone for complex life that's much smaller than what's allowed for microbes?
Protozoa—a term for a group of single-celled eukaryotes—and green algae in wastewater, viewed under the microscope.
Credit: sinhyu via Adobe Stock<p>Another way the story of life on Earth might not get repeated elsewhere in the cosmos relates to the composition of planetary atmospheres. Our world did not begin with its oxygen-rich air. Instead, oxygen didn't show up until almost two billion years after the planet formed and one billion years after life appeared. Earth's original atmosphere was, most likely, a mix of nitrogen and CO2. Remarkably it was life that pumped the oxygen into the air as a byproduct of a novel form of photosynthesis invented by a novel kind of single-celled organism, the nucleus-bearing eukaryotes. The appearance of oxygen in Earth's air was not just a curiosity for evolution. Life soon figured out how to use the newly abundant element and, it turns out, oxygen-based biochemistry was supercharged compared to what came before. With more energy available, evolution could build ever larger and more complex critters.</p><p>Oxygen may also be unique in allowing the kinds of metabolisms in multicellular life (especially ours) needed for making fast and fast-thinking animals. Astrobiologist <a href="http://faculty.washington.edu/dcatling/Catling2008CatalystMag.pdf" target="_blank" rel="noopener noreferrer">David Catling</a> has argued that only oxygen has the right kind of chemistry that would allow for animals to form on any world.</p><p>Atmospheres may play another role in what can and can't happen in the evolution of life. In 1959, <a href="https://astro.uchicago.edu/alumni/su-shu-huang-1949.php" target="_blank" rel="noopener noreferrer">Su-Shu Huang</a> proposed that each star would be surrounded by a "<a href="https://www.nasa.gov/ames/kepler/habitable-zones-of-different-stars" target="_blank" rel="noopener noreferrer">habitable zone</a>" of orbits where a planet would have temperatures neither too hot nor too cold to keep life from forming (i.e. liquid water could exist on the planet's surface). Since then, the habitable zone has become a staple of astrobiological studies. Astronomers now know that the outer part of the habitable zone will be dominated by worlds with lots of greenhouse gases like CO<em>2</em>. A planet in a location like Mars, for example, would require a thick CO2 blanket to keep its surface above freezing. But all that CO2 could present its own problems for life. Almost all forms of animal life on Earth, including sea creatures, die when placed in CO2-rich environments. This has led astronomer <a href="https://eschwiet.github.io/" target="_blank" rel="noopener noreferrer">Eddie Schwieterman</a> and colleagues to propose a <a href="https://iopscience.iop.org/article/10.3847/1538-4357/ab1d52" target="_blank" rel="noopener noreferrer">habitable zone for complex life</a>: A band of orbits where planets can stay warm without requiring heavy CO2 atmospheres. According to Schwieterman, animal life of the kind we know would only be able to form in this much thinner band of orbits. </p>
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