Tag: telehealth

A 45-year-old got pregnant in a state with a ban on abortions. She flew across the country to get one | CNN

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CNN
 — 

When 45-year-old Victoria realized she was five weeks late and the lines showed as positive on two pregnancy tests, the New Orleans resident dreamed up a plan to get an abortion.

Traveling out of state was the only abortion option for Victoria, who asked CNN to withhold her last name out of fear of backlash against her and her family. Louisiana is one of several states that have essentially banned all abortions.

“It was probably one of the hardest things I’ve had to go through, from the moment of discovering that I was pregnant at age 45 to actually having to have to take time off work, travel across the country, do a meeting with a doctor, and then take the pills and then skedaddle back home and then go to work like nothing had happened,” Victoria told CNN of her experience earlier this year.

Victoria’s story about the distance she traveled and the hardships she endured to get an abortion reflects a wider American reality, where women seeking the procedure must navigate through a patchwork of states with varying levels of access.

The average travel time to an abortion facility more than tripled, from less than 30 minutes to more than an hour and a half, after the US Supreme Court overturned Roe v. Wade in 2022, according to a November study in the Journal of the American Medical Association. And for women in Texas and Louisiana, average travel times to the nearest abortion facility were seven hours longer – almost a full workday in travel time to get an abortion.

Victoria says she was grateful she could drop everything and afford to spend $1,000 for the procedure, including same-week airfare with connections both ways and appointment and medication fees.

“It was so hard for me wrap my head around the fact that I was able to do this, but I’m one of the lucky ones and that there are so many women who are in much tighter positions,” Victoria said. “And, God, what are they going to do?”

Victoria says plans materialized quickly once she knew which states seemed more accessible.

She researched the parameters for abortion in a state, how long she would have to take off work, travel options and how soon she could get an appointment. She found abortionfinder.org to be a helpful and reliable source, she says.

“Because the situation is so fluid, it changes from day to day, that was really of paramount importance for me to be able to have a reliable source of information,” she said.

Driving to a neighboring state was not an option, as every state adjoining Louisiana has a similarly restrictive law that bans virtually all abortions. Victoria says she considered close states, like Florida, but she ultimately dismissed them because available appointments were farther out.

“Once I saw that Oregon was so, so protective of reproductive rights, I said, ‘Why would I think about going anywhere else?’” she said. “The second I got the definitive pregnancy result, I was like, ‘OK, let’s book a flight to Oregon. When can we do this?’”

She reached out to a friend from college and asked if she could stay with her, detailing the reason for her visit. She then made an appointment and booked a flight for that week, she says.

The provider sent instructions, including that the patient must be in Oregon for the telehealth appointment, according to documents provided to CNN. They contacted her within an hour of making the appointment to make sure she had proof of travel documents because she had made it from Louisiana, where the procedure is illegal.

Victoria planned to take a day off to fly across the country and work remotely for two days, which fits her hybrid work situation. She says she was grateful to have a supportive, female boss who showed understanding for why she had to take the unexpected time off.

“She was the only person I actually kind of broke down and cried for,” Victoria said. “I think it’s because I had been holding it back all week, and telling her was sort of the last thing that I needed to get in place before I could do everything.”

Victoria says the hardest part of her experience was telling her mother because she didn’t know how her mom would feel about it. Victoria and her siblings were raised Catholic. Her father had a strong faith and her mother was a non-practicing Catholic, her mother says. Victoria’s mom asked not to be named for privacy reasons.

Victoria’s mother says she wanted to support her daughter, even if she does not agree with what her daughter did. Victoria coming to her with tickets purchased and a full plan made it easy for her mother to support her, the mother says.

“I agreed to drive her to the airport and that that was the only thing I could do because this would be a real game-changing thing in her life,” her mother said. “I wanted to support what she wanted to do because she has supported me on several family crises. I just wanted to do it because I love her. “

Victoria said she appreciated her mom for being supportive in a way she didn’t expect. They talked about some of her mother’s friends who had abortions throughout the years, both say. Victoria’s mother even told her about when she tried to get her tubes tied, but her husband found out and she did not pursue it.

“I feel like, if anything, it’s made our relationship stronger,” Victoria said. “We already had a fantastically strong relationship, though. So, it’s another rock in the wall.”

After boarding early on a Wednesday in March, Victoria traveled for eight hours on two flights and landed in Portland, Oregon.

Victoria reunited with her friend, and they did the things that old friends do, from staying up late talking about college memories to talking about why Victoria was there. They both described the situation as surreal.

“The vast majority of reproductive conversations I have with friends at this point are people who are trying desperately to get pregnant,” said her friend, Emily, who asked that CNN not use her last name to keep Victoria’s privacy. “The sort of irony is that there could still be an unplanned pregnancy and it would still be just as devastating as it would have been when we were in our teens and twenties was kind of a shock to me.”

Emily, who has been friends with Victoria for about 25 years, says it took so little effort for her to drive to the airport and let her friend stay with her.

“I felt honored that she trusted me,” she said. “I was really proud of Victoria. I was impressed that she had taken this in stride and that she had reached out to someone she knew – I think a lot of people would have been ashamed or hidden it.”

After the telehealth appointment the next day, Victoria received an overnight package.

Victoria took two medications as part of a medication abortion. She took mifepristone at her friend’s home. The next day she took misoprostol before boarding her flight home – she was careful not to take them in her home state, where it’s illegal.

Misoprostol, taken after mifepristone, is a common combination prescribed for a medication abortion.

“It was like a heavy period,” she said. “I took some Aleve, had to get some extra jumbo pads, and I bled a lot on the flights home, but it was fine.”

Physically, she felt fine – it was more of what was happening psychologically that she noticed, she says.

“I had this feeling that I should be having some kind of deep, psychological moment of reckoning or something, but I didn’t really feel that,” Victoria said of the experience. “I’ve never wanted to have a kid. I wasn’t torn about this decision.”

When Victoria learned she was pregnant, a big part of the shock came from not thinking she could get pregnant at age 45, she says.

“You hear so much culturally out there about you’re in your forties, are told you’re too old to get pregnant and carry a child to term,” she said. “I feel like I had sort of a false sense of security.”

Victoria joked that she’s “careening toward menopause,” but she says she has not been diagnosed as perimenopausal.

Her pregnancy news came several months after she was treated for a uterine fibroid, a benign growth, in July 2022, according to medical records. Victoria also tested positive for a PALB2 gene mutation, which can lead to an increased chance of breast cancer, according to a study in the New England Journal of Medicine. She underwent a preventative double mastectomy and reconstruction earlier in 2022, according to medical records provided to CNN.

She says she got an excellent standard of care around her surgeries, but it felt dissonant with her state’s laws around abortion.

“It felt so surreal to get this really high standard of care around my secondary sexual characteristics, but then to have that freeze, slam shut when it comes to reproductive health, it just felt abrupt,” she said.

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Getting prescription meds via telehealth might change soon. Here’s how to prepare | CNN

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CNN
 — 

For three years now, the expansion of telehealth has made care more accessible for many people, especially those in rural areas. Patients have been able to receive prescriptions from providers without seeing them in person. But that may change come May 11 when the federal government is set to end the Covid-19 public health emergency declaration that made this convenience possible.

Before the pandemic, medical practitioners were subject to the conditions of the Ryan Haight Act, which required at least one in-person examination before prescribing a controlled medicine, said Dr. Shabana Khan, chair of the American Psychiatric Association’s Committee on Telepsychiatry.

“There are seven exceptions, and one of them is a public health emergency declared by the secretary of (health and human services), which is what we’ve had for the past three years,” Khan said. “It was immensely helpful … and allowed many Americans to get their medical care without having to come in person, so we could treat patients completely remotely.”

“The administration and HHS has put out a notice that they don’t intend to renew it any further,” Khan said, “so the federal public health emergency is going to be expiring May 11.”

Returning to pre-pandemic rules means people who were prescribed controlled medications via telehealth — such as stimulant medications for attention-deficit/hyperactivity disorder, benzodiazepines for anxiety, or medications for opioid use disorder, sleep or pain — will need one in-person medical examination to continue these prescriptions or start new ones.

The US Drug Enforcement Administration’s website has a general list of controlled substances, and an exhaustive list can be found here.

Patients will still be able to get prescriptions for non-controlled medications, such as antibiotics or birth control, via telehealth. The pre-pandemic rules also wouldn’t affect telehealth care by a practitioner who has already conducted an in-person examination of a patient.

To establish some flexibility in the telehealth framework moving forward, Khan said, the DEA has put forth proposals (PDF) that would allow telehealth practitioners to prescribe one 30-day supply of buprenorphine — a medication for opioid use disorder — or Schedule III-V non-narcotic controlled medications without doing an in-person examination first. A patient would have to do an in-person exam before the second prescription of either type of medication, according to those proposals.

But there’s no guarantee that will happen — public comment on the proposals was open through March; since then, the DEA has been considering comments before drafting final regulations.

“It is really important to start planning now,” Khan said. “For many medicines, it can be a risk to abruptly stop treatment.”

People who are on medications for opioid use disorder, ADHD or anxiety and don’t get an in-person exam between May 11 and the next time they need a prescription refill could experience withdrawal requiring a trip to the hospital, or negative effects on health, relationships, employment or academics, she added.

Here’s what else you should know about the changes and steps you should take, according to Khan.

This conversation has been lightly edited and condensed for clarity.

CNN: How should people prepare to ensure their prescription routine isn’t disrupted?

Khan: It’s important for patients who may be prescribed one of these types of medicines by a telemedicine physician or other practitioner to reach out to that practitioner to discuss this issue and make sure that they have a plan. And if it’s feasible to see that telemedicine physician in person, schedule that as soon as possible.

CNN: What if you can’t see your telehealth provider in person?

Khan: Let’s say a telemedicine physician practices completely remotely — then the patient would discuss with them what next steps would be.

In the proposed rule, the qualifying telemedicine referral may allow a patient to be seen by a local DEA-registered practitioner. So, for example, perhaps their primary care doctor or pediatrician — if they are DEA-registered — might be able to go through the qualifying telemedicine referral process so that they can see them in person and continue to be prescribed the medicine. Or patients can contact their health insurance provider to get a list of local referrals.

CNN: Are there any drawbacks to seeing general physicians or pediatricians for controlled medication prescriptions?

Khan: Some may say they aren’t going to prescribe certain medications, like psychiatric medications. Some may say they are comfortable with it, and some may say they will prescribe for a short period of time until you connect with a specialist. So there is variability.

CNN: Would the patient have to continue seeing the referral provider after that first in-person appointment?

Khan: In terms of what’s required at the federal level, if a patient has that one in-person exam with a provider through that qualifying telemedicine referral process, they wouldn’t necessarily have to see that provider again unless that’s part of their treatment plan that’s discussed.

With the qualifying telemedicine referral in the proposed rule, the way it’s written, it doesn’t necessarily have to be the referral practitioner prescribing the medicine; they just need to do the in-person exam. The referral practitioner can refer the patient back to the telemedicine doctor, who can prescribe the medicine.

The other factor that’s significant here is we discussed all the proposed rules and the status at the federal level, but there’s also the state level. States also have rules around controlled medicine prescribing, and they may not always align with federal law. Let’s say the DEA puts out their final rule, and there’s some flexibility — some states might adopt the older Ryan Haight Act language from the federal level, so they might actually be stricter than what we’ll be seeing at the federal level. When federal and state laws don’t align, providers generally have to follow whatever is stricter.

CNN: Will patients need to see their provider in person every time they need a prescription refill?

Khan: The DEA has indicated that the absolute requirement at the federal level is one in-person examination. Beyond that, it would be left to the discretion of whoever the patient is seeing.

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How safe is the abortion pill compared with other common drugs | CNN

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CNN
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A federal judge in Texas ruled on Friday to suspend the Food and Drug Administration’s approval of mifepristone, the first drug in the medication abortion process, nationwide by the end of this week.

The judge sided with the coalition of anti-abortion national medical associations that filed the lawsuit. He argued that the FDA failed to adequately consider risks associated with the drug, including “the intense psychological trauma and post-traumatic stress women often experience from chemical abortion.”

However, data analyzed by CNN shows mifepristone is even safer than some common, low-risk prescription drugs, including penicillin and Viagra. There were five deaths associated with mifepristone use for every 1 million people in the US who have used the drug since its approval in 2000, according to the US Food and Drug Administration as of last summer. That’s a death rate of 0.0005%.

Comparatively, the risk of death by penicillin — a common antibiotic used to treat bacterial infections like pneumonia — is four times greater than it is for mifepristone, according to a study on life-threatening allergic reactions. Risk of death by taking Viagra — used to treat erectile dysfunction — is nearly 10 times greater, according to a study cited in the amicus brief filed by the FDA.

“[Mifepristone] has been used for over 20 years by over five million people with the capacity to become pregnant,” said Ushma Upadhyay, an associate professor in the department of obstetrics, gynecology and reproductive science at the University of California, San Francisco. “Its safety is very well established.”

The Justice Department, the FDA, and Danco — a manufacturer of mifepristone that intervened in the case — have already appealed the ruling.

Within hours of the decision in Texas, a federal judge in Washington state issued a conflicting ruling that the federal government must keep mifepristone available in the 17 Democrat-led states and the District of Columbia that had sued in a separate lawsuit.

If the Texas ruling is allowed to take effect this week, 40 million more women of reproductive age would lose access to medication abortion care around the country, according to data from abortion rights advocacy group NARAL Pro-Choice America. That’s in addition to the 24.5 million women of reproductive age living in states with abortion bans.

“The court’s disregard for well-established scientific facts in favor of speculative allegations and ideological assertions will cause harm to our patients and undermines the health of the nation,” said Dr. Jack Resneck, Jr., president of the American Medical Association, in a statement. “By rejecting medical facts, the court has intruded into the exam room and has intervened in decisions that belong to patients and physicians.”

Medication abortion has become the most common method for abortion, accounting for more than half of all US abortions in 2020, according to the Guttmacher Institute.

The growing popularity of medication abortion is largely because of its accessibility, said Abigail Aiken, associate professor at the University of Texas at Austin who leads a research group on medication abortion.

“It reduces the cost, it reduces barriers where people may not want to go to a clinic,” she said.

It is also a safer option than both procedural abortion or childbirth. The rate of major complications — like hemorrhages or infections — for medication abortions is about one-third of a percent, according to a 2015 study conducted by Upadhyay. That means out of more than 11,000 cases, 35 experienced any major complications.

The likelihood of serious complications via procedural abortion — performed second-trimester or later — is slightly higher than medication abortion at 0.41%, according to the same study. And childbirth by far comes with the highest risk, at 1.3%.

If access to mifepristone is cut off, abortion clinics and telehealth organizations could pivot to misoprostol-only abortions, Aiken told CNN. Although misoprostol-only abortions are used around the world, they are less effective, associated with a higher risk of serious complications and often more painful than the mifepristone and misoprostol combination, she said.

In the latest study of self-managed misoprostol-only medication abortions in the US, Johnson found misoprostol-only abortions to be a safe alternative, though less safe than using both pills. The study, published in February, analyzed data from online telehealth medication abortion provider Aid Access from 2020. Nearly 90% of 568 users reported completed abortions and 2% experienced serious complications using only misoprostol.

Mifepristone and misoprostol together is still considered the gold standard, Aiken told CNN. People who used the two-pill combination were less likely to experience serious complications than those who went with the misoprostol-only regimen.

“It’s clear people can use these medications, mifepristone and misoprostol, at home even without the help of a medical professional very safely,” said Aiken.

Because misoprostol is used to treat multiple ailments including stomach ulcers, it’s readily stocked in pharmacies and unlikely to be taken off the market anytime soon, Johnson told CNN.

However, a lesser-effective method means more people will likely have unsuccessful abortions.

“It’s possible that it might not work for some people, and it will prolong their abortions,” said Upadhyay. “Then by the time they get back to the clinic, they’re seeking abortion later in pregnancy.”

Before the ruling, 19 states already restricted telehealth abortion care, limiting access to medication abortion. Nearly half of US adults were unsure whether medication abortion was currently legal in their state as of late-January, according to a survey conducted by the Kaiser Family Foundation. Experts say that confusion will only be exacerbated.

“People are not going to be sure mifepristone or misoprostol in fact, is available. I think it’s going to be confusing,” said Aiken. “As people look around for options or feel unsure about their options, they may end up delaying [care].”

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Maternity units are closing across America, forcing expectant mothers to hit the road | CNN

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CNN
 — 

In picturesque Bonner County, Idaho, Leandra Wright, 40, is pregnant with her seventh child.

Wright is due in August, but three weeks ago, the hospital where she had planned to deliver, Bonner General Health, announced that it would be suspending its labor and delivery services in May.

Now, she’s facing a potentially precarious drive to another hospital 45 minutes from her home.

“It’s frustrating and worrisome,” Wright said.

Wright has a history of fast labors. Her 15-year-old son, Noah, was born on the way to the hospital.

“My fifth child was born on the side of the highway,” Wright said. “It was wintertime, and my hospital at the time in California was about 40 minutes away, and the roads were icy, so we didn’t make it in time.”

By the time she and Noah got to the hospital, about 15 minutes after he was born, his body temperature was lower than normal.

“It worries me not to have a doctor there and worries me to have to go through that,” Wright said.

Residents of Bonner County aren’t the only ones dealing with unexpected maternity unit closures.

Since 2011, 217 hospitals in the United States have closed their labor and delivery departments, according to a report by the health care consulting firm Chartis.

A CNN tally shows that at least 13 such closures have been announced in the past year alone.

Services provided at maternity units vary from hospital to hospital. Most offer obstetrics care in which an obstetrician will deliver a baby, either vaginally or via cesarean section. These units also provide perinatal care, which is medical and supportive care before and after delivery.

Other services provided may include lactation specialists and private delivery rooms.

After May 19, Bonner General Health will no longer offer obstetrical services, meaning there will be zero obstetricians practicing there. Consequently, the hospital will no longer deliver babies. Additionally, the unit will no longer provide 24-hour anesthesia support or post-resuscitation or pre-transportation stabilization care for critically ill newborns.

Some hospitals that have recently closed their maternity units still offer perinatal care, along with routine gynecological care.

Bonner General is planning to establish a clinic where perinatal care will be offered. Gynecological services – such as surgical services, preventative care, wellness exams and family planning – will still be provided at a nearby women’s health clinic.

The Chartis report says that the states with the highest loss of access to obstetrical care are Minnesota, Texas, Iowa, Kansas and Wisconsin, with each losing more than 10 facilities.

Data released last fall by the infant and maternal health nonprofit March of Dimes also shows that more than 2.2 million women of childbearing age across 1,119 US counties are living in “maternity care deserts,” meaning their counties have no hospitals offering obstetric care, no birth centers and no obstetric providers.

Maternity care deserts have been linked to a lack of adequate prenatal care or treatment for pregnancy complications and even an increased risk of maternal death for a year after giving birth.

Money is one reason why maternity units are being shuttered.

According to the American Hospital Association, 42% of births in the US are paid for by Medicaid, which has low reimbursement rates. Employer-sponsored insurance pays about $15,000 for a delivery, and Medicaid pays about $6,500, according to the Health Care Cost Institute, a nonprofit that analyzes health care cost and utilization data.

“Medicaid funds about half of all births nationally and more than half of births in rural areas,” said Dr. Katy Kozhimannil, a public health researcher at the University of Minnesota who has conducted research on the growing number of maternity care deserts.

Kozhimannil says communities that are most likely to be affected by maternity unit closures tend to be remote towns in rural counties in states with “less generous Medicaid programs.”

Hospitals in larger cities are often able to offset low reimbursement rates from Medicaid births with births covered by employer-sponsored insurance, according to Dr. Sina Haeri, a maternal-fetal medicine specialist and CEO of Ouma Health, a company that provides virtual prenatal and perinatal care to mothers living in maternity care deserts.

Many large hospitals also have neonatal intensive care units.

“If you have a NICU, that’s a substantial revenue generator for a hospital,” Haeri said.

Most rural hospitals do not have a NICU, only a nursery where they care for full-term, healthy babies, he said. Due to that financial burden, it does not make financial sense for many rural hospitals to keep labor and delivery units open.

A low volume of births is another reason for the closures.

In announcing the closure, Bonner General noted that in 2022, it delivered just 265 babies, which the hospital characterized as a significant decrease.

Rural hospital administrators providing obstetric care say it takes at least 200 births annually for a unit to remain safe and financially viable, according to a study led by Kozhimannil for the University of Minnesota’s Rural Health Research Center.

Many administrators surveyed said they are working to keep units open despite low birth rates.

“Of all the folks that we surveyed, about a third of them were still operating, even though they had fewer than 200 births a year,” Kozhimannil said. “We asked why, and they said, ‘because our community needs it.’ ”

Another issue for hospital administrators is staffing and recruitment.

The decision to close Bonner General’s labor and delivery unit was also directly affected by a lack of experienced, qualified doctors and nurses in the state, said Erin Binnall, a Bonner General Health spokesperson.

“After May 19th, Bonner General Health will no longer have reliable, consistent pediatric coverage to manage neonatal resuscitations and perinatal care. Bonner General’s number one priority is patient safety. Not having board-certified providers certified in neonatal resuscitation willing to provide call and be present during deliveries makes it unsafe and unethical for BGH to provide these services,” Binnall told CNN by email.

The American Hospital Association acknowledges the staffing challenges some hospitals face.

“Simply put, if a hospital cannot recruit and retain the providers, nurses, and other appropriately trained caregivers to sustainably support a service then it cannot provide that care,” the association said in a statement. “Such challenges are only magnified in rural America, where workforce strain is compounded by aging demographics that in some communities has dramatically decreased demand for services like Labor and Delivery.”

Wright is considering moving because of the lack of maternity and pediatric care available in Bonner County.

More stringent abortion laws may be playing a role in the closures, too.

Bonner General said in a news release last month that due to Idaho’s “legal and political climate, highly respected, talented physicians are leaving. In addition, the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.”

According to the Guttmacher Institute, Idaho has one of the strictest anti-abortion laws in the country: a complete ban that has only a few exceptions.

Idaho requires an “affirmative defense,” Guttmacher says, meaning a provider “has to prove in court that an abortion met the criteria for a legal exception.”

No matter the reason, Kozhimannil said, closures in rural communities aren’t just a nuisance. They also put families at risk.

“That long drive isn’t just an inconvenience. It actually is associated with health risks,” she said. “The consequence that we saw is an increase in preterm births. Preterm birth is the largest risk factor for infant mortality. It is a huge risk factor for developmental and cognitive delays for kids.”

Haeri says the decline in maternal care also has a clear effect on maternal mortality rates.

The maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births in the US, compared with rates of 20.1 in 2019 and 23.8 in 2020, according to a report from the National Center for Health Statistics. In raw numbers, 1,205 women died of maternal causes in the US in 2021.

Conditions such as high blood pressure, obesity, and diabetes may raise a person’s risk of complications, as can being pregnant with multiples, according to the National Institutes of Health. Pregnant women over the age of 35 are at a higher risk of pre-eclampsia.

As labor and delivery units continue to shut their doors, possible solutions to the growing problem are complex, Haeri says.

“I think anyone that comes to you and says the current system is working is lying to you,” he said. “We all know that the current maternity system is not good.”

Kozhimannil’s research has found that many women who live in maternity care deserts are members of minority communities.

“When we conducted that research, we found the communities that were raising the alarm about this … tended to be Black and indigenous, or tribal communities in rural places,” she said. “Black communities in the South and East and tribal communities throughout the country, but especially in the West, Mountain West and Midwest.”

Haeri says one possible solution is at a woman’s fingertips.

“I always say if a woman’s got a cell phone, she should have access,” he said.

A 2021 study found that women who live in remote areas of the US could benefit from telehealth visits, which would decrease the number of “in-person prenatal care visits and increase access to care.”

The American College of Obstetricians and Gynecologists recommends 12 to 14 prenatal care appointments for women with low-risk pregnancies, and the study suggests that expansion of prenatal telehealth appointments could help women living in remote areas better adhere to those guidelines.

Ouma works with mothers who are typically remote and high-risk, Haeri says.

He also believes that promoting midwifery and doula services would help bolster maternity care in the US.

Certified nurse midwives often assist remote mothers who are high-risk or who decide to give birth at home, he says.

Midwives not only deliver babies, they often work with medical equipment and can administer at-home physical exams, prescribe medications, order lab and diagnostic tests, and assess risk management, according to the American College of Nurse Midwives. Doulas – who guide mothers through the birthing process – are often present at home births and even hospital births.

“That midwifery model shines when it comes to maternal care. [And] doula advocacy involvement leads to better outcomes and maternity care, and I think as a system, we haven’t made it easier for those two components to be really an integral part of our maternity care in the US,” Haeri said.

After living in Idaho for 10 years, Wright says, she and her fiancé have considered leaving the state. The lack of maternity and pediatric care at Bonner General Health is a big reason why.

“I feel safe being with [my] doctors. Now, I have to get to know a doctor within a couple of months before my next baby is born,” Wright said.

As she awaits the arrival of her new son, she feels doubtful that there is a solution for mothers like her.

“Everywhere – no matter what – everybody has babies,” she said. “It’s posing a problem for people who have babies who don’t have the income to drive or have high risk pregnancies or first-time mothers who don’t even know what to expect.”

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Will Telehealth Save Patients Money or Drive Up Costs?

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April 5, 2023 — Barbara Rosebrock was heading to the doctor’s office to learn how to use her 8-year-old daughter’s new insulin pump when health care as she knew it forever changed. 

It was March 11, 2020. With a mysterious new virus entering the U.S., vulnerable patients like Aubrey — recently diagnosed with type 1 diabetes — were advised to stay home.

Her doctor canceled the appointment and suggested a remote video visit instead.

Rosebrock was skeptical.

“I didn’t want to do something wrong and end up hurting my kid,” she said.

But the virtual visit went well and set a pattern. Three years later, all of Aubrey’s doctor’s visits are done from home unless lab work or a physical exam is needed. Mom avoids an hour of driving and saves on gas and childcare for Aubrey’s younger brother.

“It’s pennies here and there, but it all adds up,” said Rosebrock.

Telemedicine became routine for the Rosebrocks and tens of millions of others during the pandemic. Among Medicare patients, remote visits increased from 840,000 in 2019 to 52.7 million in 2020, a 63-fold jump. Doctors had shut their doors to only the sickest of patients, and insurers agreed to temporarilyreimburse audio and video visits at the same rate as in-person ones.

Usage has come down substantially since. But patients continue to demand remote options, with 70% of younger generations (Generation Zers, millennials, and Generation Xers) saying they prefer telehealth to in-person visits, and 44% saying they’ll switch providers if it isn’t offered, according to the American Hospital Association. 

But despite the demand, there remain long-run questions of cost, effectiveness, and choice of provider.

Some pandemic-era exceptions, including state-level rules allowing patients to see doctors across state lines, have already been scaled back. Other rules, like those allowing doctors to prescribe drugs for ADHD or opioid addiction via telehealth, are set to be rolled back May 11. And by December 2024, thanks to a 2-year extension,  lawmakers must decide whether to continue covering telehealth visits via Medicare. That decision will inevitably impact what private insurers do.

A key question: Does telehealth save money? 

“It depends,” said James Marcin, MD, director of the University of California Davis Center for Health and Technology. The answer depends on how it is used, by whom, and whose money you’re talking about.

“It is not a panacea,” Marcin said. “But COVID has definitely enabled us to realize its potential.”

Real Savings for Patients

When it comes to out-of-pocket savings, the benefits are clear, said Stephanie Crossen, MD, a Sacramento-based pediatric endocrinologist. Many of her patients, including quite a few from low-income, rural populations, travel several hours to see her. 

“My patients would pretty much always say that telemedicine saves them money,” Crossen said. And regaining that kind of lost time in your day has value, too.

One recent study of 3 million outpatient telemedicine visits in California found that, on average, patients avoided a 17.6-mile, 35-minute commute, saving about $11 in transportation costs per visit. 

Throw in lost wages or child care costs and the savings are likely higher, especially where travel distances are farther, the authors said.

In-person visits often also come with extra facility fees not charged for telemedicine appointments, Marcin said. And doctors tend to order more scans and tests when a patient is on site (some necessary, some questionable), driving up costs. 

Telemedicine can also save tens of thousands in helicopter flights, such as when a stroke patient or child with a complicated medical history shows up at a rural emergency room lacking specialists. 

“We get a lot of patients transferred between hospitals that don’t necessarily need to come to us,” said Marcin, a pediatric critical care doctor who frequently patches in via video to evaluate and suggest treatments for young patients in distant hospitals.

In-person visits are usually ideal, but cars break down, buses don’t come, and family members get sick. In such cases, telemedicine can avert a cancellation, saving money in the long run, said Crossen.

“We know that if our diabetes patients are seen more often, they are at lower risk for long-term kidney damage and all kinds of other issues,” Crossen said.

In this respect, more visits can mean more cost to insurers in the short term, while in the long term it could avoid more expensive treatments.

That poses a dilemma for payers.

“The problem in our system is that the insurer who covers their costs now is not necessarily the same one who’s going to cover their dialysis in 40 years. So it’s hard to make the case that it’s saving them money,” she said.

More Access Means More Visits 

In December, Congress extended Medicare coverage of telemedicine for 2 years, giving everyone time to decide how to handle the practice permanently. If telemedicine makes it so easy to see a doctor, will it be overused?

Ateev Mehrotra, MD, a professor of health care policy and medicine at Harvard Medical School, says he has seen no research to convince him that telemedicine saves the health care system money.

“From my perspective,” he said, “the real question is: Does telemedicine increase health care spending, and if so by how much?”

In one 3-year study of people who went to the doctor for acute respiratory illnesses, he found that only 12% of telehealth visits replaced what would have otherwise been an in-person visit. The other 88% were “new utilization,” meaning that had telehealth not been available, the patient probably would have just ridden out their cold and not gone to the doctor at all. In the end, telehealth increased net annual spending on colds by $45 per telehealth user. 

Another recent study by the Rand Corporation showed that in the arena of mental health, telemedicine visits more than made up for a drop in in-person visits during the pandemic, with treatment of some disorders up 20%. 

“If you make care more convenient, more people get care,” Mehrotra said. 

Whether that is good or bad depends on lots of factors, including who is paying.

In the case of a cold, “if they are paying out of their own pocket to be reassured, more power to them,” Mehrotra said.  “But if we as a society are paying for all those visits, we do worry because a lot of people get colds.” 

Increased utilization could drive up premiums for everyone.

Doctors also may be more likely to prescribe antibiotics via telehealth, boosting costs and potentially promoting antibiotic resistance, suggests a 2022 review in Clinical Infectious Diseases. 

While research on return visits is mixed, another study, published in 2021 by University of Michigan researchers, found that patients who had their initial visit via telemedicine were significantly more likely to come back for a second visit within a week.

The authors said that “potential savings from shifting initial care to a direct-to-consumer telemedicine setting should be balanced against the potential for higher spending on downstream care.”

Worth the Cost?

Mehrotra, a practicing doctor, contends that the question of whether telemedicine saves money is not a fair one.

“When a new drug or procedure or MRI machine comes out, we never say, ‘Does it save money?’” he noted. “Instead, we ask whether the improvement in health we’re observing is worth the cost.”

Policymakers must assess how telemedicine affects patients and look specialty by specialty to see if it’s cost-effective.

“For instance, from my research and what I see clinically, I think telemedicine for the treatment of opioid use disorder is a great idea. For telestroke, I’m sold,” he said. “But if we’re talking about telemedicine for colds, I’m not so sure.”

He envisions a system in which visits deemed to be of “lower value” (like that reassuring video call for a cold) might come with a higher co-pay for the patient or a lower reimbursement for the doctor than an in-person version. 

Who is using telemedicine also matters.

Notably, during the pandemic, research found that white patients in urban areas were most likely to use telehealth for outpatient visits, while people in low-income and rural areas and racial minorities used it less, in part due to connectivity issues. 

Doctors say that addressing those access inequities could go a long way in getting telemedicine to the people who need it most and who will financially benefit from it most.

Priceless Care

For some patients, the benefits are hard to put a price on. Francis Richard, 72, who lived in Mendocino County, CA, took a 2-hour shuttle (one way) to visit a doctor for his late-stage type 2 diabetes and kidney disease. 

“My husband was not tired,” said his wife, Marie. “He was tired of the transportation.” She says wait times for an in-person visit were often weeks or months.

His nephrologist suggested Francis start seeing him via telemedicine.

He’d Zoom in for consults when Francis needed in-person care at a smaller hospital closer to home and was working to set up at-home dialysis.

Often their visits included Marie seated next to Francis in bed at home, holding the phone as the doctor looked him over, asking questions and exchanging the occasional joke.

She never met the man on the screen, Jose Morfin, MD, in person, and her husband met him only once. 

But she considers him family now.

“I wish my husband was still alive and he could tell you this himself,” said Marie, who lost Francis in January.  “But this prolonged his life. They made us feel so supported.”

That kind of care, she said, is priceless.

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Ozempic prescriptions can be easy to get online. Its popularity for weight loss is hurting those who need it most | CNN

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CNN
 — 

Telehealth and social media are playing a significant role in driving demand for Ozempic, a prescription drug that treats Type 2 diabetes, experts told CNN. The current drug shortage has limited access for patients with diabetes who rely on it to control their blood sugar.

Digital health companies make medications like Ozempic easier to get by providing prescriptions online. Many advertise quick and easy — sometimes same-day — access.

“Anecdotally, it’s almost easier to get medication [via digital health companies],” said Dr. Disha Narang, endocrinologist and director of obesity medicine at Northwestern Medicine, Lake Forest Hospital. “But not always the safest.” People who put in average weights on the online intake forms were still offered the antidiabetic drug, Narang told CNN.

In part because of Ozempic’s popularity, the prescription weight loss drug market has grown significantly, according to MarketData Enterprises, an independent market research and consulting firm. The market surpassed forecasters’ expectations for 2022 and is expected to become a nearly $2 billion industry in 2023.

WeightWatchers is also tapping into the telehealth prescription drug space. Last week, the company bought telehealth subscription service Sequence, which helps connect patients to doctors who can prescribe weight loss and diabetes drugs.

“At the start of 2022, these companies weren’t marketing this stuff,” Narang said, noting advertising around Ozempic took off in 2022. “I think we really need to start questioning our ethics around this.”

There are few across-the-board requirements when it comes to digital health companies’ intake processes, Dr. Bree Holtz, an associate professor at Michigan State University studying telemedicine, told CNN. Once a patient fills out the required forms online, information gets transferred to an in-state provider who can write the prescription. Some companies require that the patient hop on a video or phone call with the provider — others don’t require either.

“It’s a little scary that you can just wake up and get these appointments in — or these pharmaceuticals — and you’re not being cared for,” said Holtz.

Telehealth has been a game changer in providing access to health care, particularly during the pandemic. And especially for people living in places where high-quality primary care is not available, direct to consumer telehealth services can help fill a gap, said Dr. Laurie Buis, associate professor in the Department of Family Medicine at the University of Michigan, whose research focuses on digital health.

When patients begin to seek selective treatment from selective providers, however, Buis says it opens the door to problems like fragmented care or abuse. Telehealth providers may not have access to a patient’s full medical history and may be less able to provide holistic care that a primary care physician otherwise could.

“I have no doubt that some of these services are doing a good job,” said Buis. “There are also services that don’t take it quite as seriously. And that’s of concern.”

The US Food and Drug Administration first announced that Ozempic was in shortage last August. Supply will likely be strained through mid-March, according to the FDA drug shortages database.

Ozempic prescriptions in the US reached an all-time high in the last week of February, with over 373,000 prescriptions filled, according to a J.P. Morgan analysis of IQVIA data shared with CNN. That’s an increase of 111%, compared with the same week in 2022.

Of these, more than half were new prescriptions, according to a CNN review of J.P. Morgan’s analysis.​​

With many patients relying on Ozempic for diabetes treatment, providers like Narang are scrambling to figure out what alternatives to put their patients on.

“We’re getting messages daily about patients not being able to get their own medication,” Narang said. “It’s been tough for patients and providers alike.”

Ozempic currently holds more than 40% of the US market share of glucagon-like peptide 1 (GLP-1) agonists — a class of drugs that mimic an appetite-regulating hormone — according to analysis from J.P. Morgan. These drugs work by stimulating the release of insulin, which helps lower blood sugar. They also slow the passage of food through the gut.

Ozempic has grown quickly in popularity since it was first put on the market in 2018. The drug has safely and successfully been used to help diabetics improve blood sugar levels and put diabetes into remission, Narang told CNN. Ozempic is the most potent of all the GLP-1 medications, she said.

Behind the brand name Ozempic is the medication semaglutide. While Ozempic is used primarily to treat Type 2 diabetes, another drug by the name Wegovy — also semaglutide — is approved specifically for chronic weight management.

Although approved by the FDA in 2021, Wegovy was not readily available through most of last year, according to Narang, so people turned to Ozempic. According to the FDA drug shortages database, Wegovy was undersupplied starting at the end of last March but came back in stock earlier this year.

Social media buzz around the two drugs took off at the start of 2023. Celebrities shared their testimonies about how semaglutide helped them shed unwanted pounds. Elon Musk, for example, publicly credited Ozempic and Wegovy in part for his weight loss.

#Ozempic and #Wegovy have been “extremely popular” over the last few months on TikTok, according to company analytics.

The use of Ozempic and Wegovy for short-term weight loss has resulted in real consequences for patients who need the drugs most for diabetes treatment and chronic weight management, said Narang. For example, some insurance companies in the past have reportedly refused to cover Wegovy, one calling it a “vanity drug.”

Both drugs are intended for long-term use, not for short-term weight loss. Their appetite-regulating effects wear off quickly after you stop taking them.

“This is not meant to be a medication to take off your last five or 10 pounds to get ready for an event or something like that. It’s not for use of three or four weeks,” Narang said. “When we think about weight management, we’re thinking about the next 25 years of someone’s life.”



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How Treating Psoriatic Disease Has Changed

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By Nilanjana Bose, MD, as told to Susan Bernstein

I am an adult rheumatologist, so I see patients who are 18 and above, with the whole gamut of rheumatologic conditions. Every patient I see is different. For patients with classic psoriatic disease, skin psoriasis symptoms often occur before their arthritis symptoms happen. These two conditions could even develop years apart for some people. But that’s not absolute. You can develop arthritis, or joint pain and swelling, first and then later develop psoriasis.

Patients typically first come to see us for their joint swelling. Usually, psoriatic arthritis causes a peripheral joint swelling. They’ll have swelling of your fingers and toes, which can look similar to rheumatoid arthritis (RA). We do an initial workup and examine their skin, too. If they have psoriasis, including nail pitting or psoriasis plaques, or if they have a family history of psoriasis or psoriatic arthritis, this may suggest that they may have psoriatic arthritis.

COVID: Hello, Telehealth

Once the pandemic hit last year, for the first couple of months, we had to go into retreat mode at our clinic. We really had to scramble to adapt. We moved quickly into using telehealth to treat our patients. We didn’t have some of the telehealth technology, but once we understood that there were resources out there, like telehealth portals and online platforms we could use, we started adopting them.

I think our patients also adapted to telehealth fairly quickly. There were some challenges with older folks. Some didn’t have internet access or found it harder to work out the logistics of telehealth. But for those patients, we were able to conduct regular telephone visits as well.

Telehealth came with its own challenges. We had to learn how to “examine” a patient over the internet. It’s not easy, and it’s not optimal for joint or skin conditions. But a telehealth visit is any day better than a patient missing their appointment altogether and not accessing medical care.

For follow-up visits, telehealth is easy and works well. You can check in with patients and see how they’re doing on their current medications. Some of my patients really prefer telehealth for the convenience. Again, it’s not optimal. We still encourage our psoriatic disease patients to come into the office. It can be tough to see everything using the camera.

Overall, telehealth has been a fun experience, but if a patient needs to be examined in person, I ask them to come in. We’re all still masked up, practicing social distancing, and taking every precaution. We are very committed to the whole aspect of infection control with our patients.

I’ve even seen new patients using telemedicine, especially during the worse phases of the COVID pandemic. If they were referred to me by another physician because they have psoriasis, I can do the initial consultation remotely, but I still try to have them come in. Just getting in and seeing a rheumatologist to begin your treatment is ultimately the most important step with psoriatic disease. You can establish a rapport with your doctor and get the information you need.

Biologics: Game Changer for Psoriatic Disease

Biologics have totally changed the way we manage this disease. Once you’re diagnosed with psoriatic arthritis, there are great treatment options out there. In the past, we had steroids, DMARDs (disease-modifying antirheumatic drugs), and TNF inhibitors, but now, we have IL-17 and IL-23 inhibitors, and JAK inhibitors, too.

Initially, we evaluate our new patients with lab tests and joint imaging and go over all of their symptoms. Some people will have milder psoriatic disease, and some will have more systemic symptoms. With younger patients, we may try to be more aggressive at controlling their disease, because they’re at greater risk for joint damage.

When we go over treatment options, it’s really a two-way, fluid discussion. I talk with my patients about all the risks and benefits of each treatment. If my patient is doing better after a few months, we talk about it and may re-assess the treatment plan.

It’s very rare to see people with psoriatic arthritis these days who develop chronic joint deformities. It may happen if someone was diagnosed a long time ago, before there were better treatment options, or if they were unable to access care before they came to us. The improvements are mainly due to advances in drug treatment, but also because people are more conscious of rheumatic diseases. They Google it. They just have more awareness of rheumatic conditions and that they need to see a rheumatologist.

We screen every patient. Some of them have a true inflammatory, psoriatic disease, while some do not. They may have osteoarthritis or fibromyalgia causing joint pain. Every patient deserves a thorough, complete examination. We want to diagnose these patients as early as possible to begin treatment to control their disease and prevent damage.

COVID and Other Infections: Take Extra Precautions

We were having this exact discussion with our patients before COVID, too. They are at higher risk for serious infections – not just COVID, but also other types of pneumonia and other infections. We had already been encouraging these patients to wash their hands often, take commonsense precautions, avoid close contact with sick people, and to get all their vaccinations.

Once the COVID vaccines became available, I told them, “Please get vaccinated and keep wearing your mask.” People who are on a biologic to treat their psoriatic disease are by default more cautious. For new patients who were just starting their biologics, I advised them on how to take precautions to prevent infection. We told many of our psoriatic patients, “Stay home as much as you can right now, and avoid close contact with others.” Patients do listen to this advice because they trust us as their doctors.

Making Psoriatic Patients Feel Safer

Always have a backup plan with telehealth technology! Also, I have encouraged all of my patients to enroll in our online patient portal, so we can stay connected. They can send me messages, I can update their prescriptions, and we can share test result with them.

Technology is a beautiful thing. We need to use it to the fullest advantage in modern medical care. Technology can make it easier to stay in touch with patients with psoriatic disease, who need ongoing care. But some patients may not be used to telehealth, so they can experience some frustration at first. Be patient, take your time to learn to use these tools, and help your patients adapt. Don’t give up if something doesn’t work right at first.

Face-to-face interaction is still very important when you are working with patients with psoriatic arthritis. It can be difficult to form a new patient/doctor relationship without any in-person component.

After they’re diagnosed, some patients continue to see me virtually, and it seems like we are really able to get to know each other well. Telehealth is a safe, secure environment for patients. They’re in their home or office, or even in their car. Sometimes, when I’m talking with a psoriatic patient over telehealth, I see them taking notes. That’s good! Some people find that they’re less anxious when they’re in a telehealth appointment instead of being in their doctor’s office.

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