Lisa Jarvis: Telehealth should stick around. Teens need it

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The COVID pandemic seemed to worsen teems’ and adolescents’ mental health, according to several recent studies. But now, new research shows a reason for hope: Telehealth seems to be giving many more kids access to support. That’s a win worth celebrating. And it should push us to ensure virtual care is more permanently and equitably integrated into mental health services for minors.

The worrisome gap between kids who need help and those who get it predates the pandemic. For example, the rate of major depression among kids doubled between 2009 and 2019, and an estimated 1 in 5 kids have experienced a mental, emotional or behavioral disorder. Yet the Centers for Disease Control and Prevention estimates that just 20% of them get help from a specialized provider.

The new study, conducted by the public policy research group RAND Corp., found that telehealth use, which had been negligible among kids before spring 2020, did far more than simply fill the void of in-person mental health visits that were suspended during the early COVID shutdowns. Once telehealth became an option, use of mental health care rose — a trend that has persisted even as the pandemic has faded. Although in-person services were back up to 75% of their prepandemic levels by August 2022, telehealth visits were 2,300% higher. Overall, that translated into nearly 22% higher usage than in January 2019.

The study has some limitations. The data only captures children with private insurance, and it’s hard to know whether those with public insurance benefited equally. Most mental health providers don’t accept public insurance. And the researchers can’t parse whether many more people got care, or if existing patients were more consistently seeing their therapist — that’s something the team hopes to disentangle in future studies.

But the magnitude of the increase does suggest that more children had access to care than before the pandemic, says Mariah Kalmin, the RAND health policy researcher who led the study. Meanwhile, she notes, rates of usage and spending went up in lockstep, meaning this wasn’t a more expensive form of care.

A cynic might worry that insurers will look at this data and decide telehealth is making it a little too easy for people to get needed care. But insurers should remember that an investment in mental health care today can translate into savings tomorrow. As I’ve written in the past, untreated anxiety can snowball into larger issues later in life; failure to address behavioral health issues can disrupt a child’s education and diminish their future success in the workforce.

Data has long suggested that phone or virtual appointments are just as effective as in-person visits, and that a telehealth option makes patients more likely to consistently connect with their therapist. During the pandemic, no-show rates dropped markedly.

And while some adults might consider a virtual appointment less intimate than a face-to-face meeting with a therapist, it probably doesn’t feel weird to teens — so many of their interactions already happen through devices. “They’re comfortable through that space, so trying to provide behavioral health services adapted to the generation we’re trying to serve makes a lot of sense,” says Warren Ng, president of the American Academy of Child and Adolescent Psychiatry.

Nor do adolescents and teens have to miss big chunks of their school day, or lose a whole afternoon of sports or activities, to travel to an appointment.

For parents, telehealth makes it easier to participate in their children’s plan of care. Every caregiver knows the challenge of juggling a job (or two) with daytime appointments. It’s much easier to briefly duck out of the office for a virtual check-in with a child’s therapist.

None of this means that telehealth is always the best option for struggling kids. Schools are still an essential place for adolescents and teens experiencing anxiety or depression to be identified and treated.

And there are other challenges to accessing telehealth that must be addressed. Some of the pandemic-era services that might have made it easier to access, regardless of socioeconomic status, have been lost. For example, many kids received free devices and access to the internet so they could participate in remote school — something that also opened the door to virtual visits with a therapist.

And another recent paper from researchers at Harvard Medical School found that Black and Latinx adolescents were less likely to be transitioned from in-person to virtual appointments during the pandemic than their white peers, a disparity the researchers think could be managed by a combination of better funding and clinician education.

The Harvard paper reiterated a point that has become abundantly clear in the past year: All kids, regardless of race, ethnicity, socioeconomic status, are struggling, and all groups are experiencing a gap in care. Given the enormous need and the critical role telehealth could play, every effort should be made to ensure all kids can be met where they are.

There are plenty of changes from the pandemic we can happily toss; readily accessible mental health services are among the things we should keep.

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.

 

Jaden McDaniels will miss Timberwolves’ regular-season opener

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The Timberwolves will be down a starter when they opens the NBA season Wednesday night in Toronto against the Raptors.

Jaden McDaniels, who signed a five-year extension worth $131 million on Monday, will miss the regular-season opener with the calf strain suffered in Abu Dhabi that has kept him out of much of training camp.

The 23-year-old defensive stopper resumed 5-on-0 work this week. The team said McDaniels’ status “will be evaluated day-to-day” moving forward. Minnesota’s home opener is Saturday against Miami.

Either Kyle Anderson or Nickeil Alexander-Walker is likely to start in McDaniels’ place against the Raptors.

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Biden won’t appear on New Hampshire primary ballot

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President Joe Biden’s name will not appear on the New Hampshire Democratic presidential primary ballot, as the state moves forward with an unsanctioned nominating contest in 2024.

In a letter to New Hampshire Democratic Party Chair Ray Buckley on Tuesday, Biden campaign manager Julie Chavez Rodriguez wrote that “while the president wishes to participate in the Primary,” he is “obligated” to comply with the Democratic National Committee’s presidential nominating calendar. He will “refrain from submitting a Declaration of Candidacy” ahead of Friday’s filing deadline, she wrote, though he will appear on the general election ballot in November 2024.

Withholding Biden’s name from the New Hampshire ballot caps a yearlong effort by the DNC to reorder the 2024 early state lineup, in which Iowa and New Hampshire lost their influential perches atop the calendar. New Hampshire, however, is moving forward with its first-in-the-nation primary, potentially triggering more sanctions against the state from party leaders.

Top Democrats in New Hampshire are expected to lead a write-in effort on behalf of Biden.

Buckley, in a statement posted to X, said Biden “will win the NH FITN Primary in January, win renomination in Chicago and will be re-elected next November.”

Even as Biden’s name won’t appear on the ballot, another Democrat may. Rep. Dean Phillips (D-Minn.) is expected to launch his presidential campaign on Friday morning in Concord, N.H. If he gains any traction, that could, at a minimum, result in an embarrassment for Biden there.

Lisa Kashinsky contributed to this report.

Justin Fox: How we got COVID’s risk right but the response wrong

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Early in March 2020, I decided to write about the risks posed by COVID-19. I have no background in epidemiology or even health journalism, but I can multiply, divide and make charts and was frustrated with the lack of quantification in most reporting and public-health messaging on what was soon to be declared a pandemic.

In the resulting column I took what seemed to be the most authoritative estimate of COVID’s per-infection fatality rate, 1%, and noted that this was about 10 times the 0.1% fatality rate of seasonal influenza, then conservatively multiplied a CDC estimate of 61,099 influenza-associated deaths in the U.S. in the pretty bad flu season of 2017-2018 by five and 10 to get a range of “300,000 to 600,000 deaths.”

Over the 12 months that followed, about 550,000 Americans died of COVID according to according to the CDC’s provisional estimates and 490,000 according to its tallies of the “underlying cause of death” listed on death certificates. Both are almost certainly undercounts, because in the early days the lack of testing meant many COVID-caused deaths were attributed to other maladies. My guesstimate was also more lucky than good in that actual seasonal flu fatality rates may be closer to 0.04%, and the 2017-2018 influenza toll has since been revised downward to 52,000. Still, it was in the ballpark.

I was reminded of all this while reading a passage in a new book on the history of the pandemic, “The Big Fail: What the Pandemic Revealed About Who America Protects and Who It Leaves Behind.”

In March 2020, the authors write, Stanford University health policy professor Jay Bhattacharya “coauthored an article for the Wall Street Journal questioning the validity of the scary 2 to 4 percent fatality rate that the early models like Neil Ferguson’s were estimating — and that were causing governments to panic. He believed (correctly, as it turns out), that the true fatality rate was much lower.”

Well, my 1% fatality rate estimate came from a Feb. 10 paper out of the MRC Centre for Global Infectious Disease Analysis at Imperial College London, then led by none other than Neil Ferguson. The March 24, 2020, Wall Street Journal op-ed by Bhattacharya and Eran Bendavid appropriately took aim at the 2% to 4% fatality rates that the World Health Organization was calculating using confirmed cases as the denominator, but ignored Ferguson’s estimate and went on to propose that the actual fatality rate might be as low as 0.01%, “one-tenth of the flu mortality rate,” and that in the U.S. COVID might be “a 20,000- or 40,000-death epidemic.”

Studies based on antibody testing later found that, in the early days, among hard-hit, immunologically-naive populations with age distributions like those of East Asia, Europe and North America, COVID killed close to 1% of those infected. Fatality rates seemed to be lower where incidence of the disease was lower (although measurement was less reliable there too), and they have certainly declined over time, especially since vaccines were introduced. But the very early estimate by Ferguson and team, described as “approximately 1%” in the summary of their paper but either 0.9% or 0.8% (depending on assumptions about how long people with COVID kept testing positive for it) in the text, appears to have been quite accurate, and certainly much closer to the mark than Bhattacharya and Bendavid’s spitballing.

It was also not an outlier in early 2020. “The data so far suggest that the virus has a case fatality risk around 1%,” well-informed amateur epidemiologist Bill Gates wrote on the New England Journal of Medicine’s website on Feb. 28. On the same day and in the same place, National Institute of Allergy and Infectious Diseases director Anthony Fauci and the heads of the National Institutes of Health and the CDC wrote that the “case fatality rate may be considerably less than 1%,” and on March 11 Fauci testified before Congress that it was “somewhere around 1%.” A study published March 30 in Lancet Infectious Diseases, again co-authored by Ferguson, put it at 0.66% overall, albeit much higher for those 60 and older and much lower for those under 50, with the fatality rate for children under 10 estimated at less than 0.002%.

So it wasn’t a faulty expert consensus on the risks posed by COVID that drove the reaction to it. The expert consensus turns out to have been eerily on-target.

But as “The Big Fail” makes maddeningly clear — and no, I didn’t stumble over any other mischaracterizations in it like the one described above — the U.S. did an awful job of balancing COVID’s risks with the costs of fighting the disease. (I should disclose that the authors, Joe Nocera and Bethany McLean, are former colleagues of mine and current friendly acquaintances, although we’ll have to see if the latter holds up after they read this column. Something I wrote comparing COVID mortality in California and Florida is cited approvingly in the book.)

The “lockdowns” at the outset of the pandemic — which in the U.S. were mostly not literal lockdowns but did involve strongly urging people to stay home — seem to have saved lives when implemented early enough. It is also undeniable that staying away from other people is an effective way to avoid catching or spreading COVID.

But public policies aimed at encouraging and even requiring such behavior over extended periods were extremely costly and disruptive, and appear to have had at best a modest impact on COVID mortality.

The biggest mismatch between risks and costs in the U.S. involved schooling, as many urban districts did not offer in-person classes for much or all of the 2020-21 school year, with dire consequences for student performance.

How much of a role did misrepresentations of COVID’s mortality rate play in this faulty decision-making? It can’t have helped that the WHO and other data compilers continued throughout the pandemic to report fatality rates based on confirmed case numbers, which the news media usually passed on without adding context. But I also think that a disease with a mortality rate of a bit under 1% is just really hard for people, myself included, to get their heads around. It’s in an uncomfortable middle ground between seasonal viruses that we’ve all grown accustomed to living with (as now seems to be happening with COVID) and high-fatality-rate ones such as Ebola and the original SARS virus that no one would encourage allowing to spread. The conservative meme that “COVID is 99% survivable” — as if that made it a mere trifle — was one indication of this confusion, but Fauci’s waffling over the course of summer 2020 on whether schools should reopen probably was too.

It didn’t help that some of those clamoring loudest for school reopening, such as President Donald Trump, so clearly underestimated COVID’s risks. An underappreciated reason why the October 2020 ” Great Barrington Declaration” calling for an end to lockdowns generated such an allergic reaction in public health circles is that two of its three authors, Bhattacharya and University of Oxford epidemiologist Sunetra Gupta — who in May 2020 argued that COVID “has largely come and is on its way out” in the U.K., with a fatality rate between 0.1% and 0.01% — had been so spectacularly wrong in their early risk assessments. These were not people who had earned a lot of credibility on COVID.

It seems telling — or at least ironic — that Sweden, where public health officials greatly overestimated how quickly COVID was spreading early on and thus underestimated its fatality rate, ended up with one of the most successful and sustainable COVID management efforts among Western countries.

Sweden’s approach was never as laissez-faire as sometimes portrayed — high schools and universities were closed early in the pandemic and large gatherings banned — and the initial increase in deaths there was even sharper than in the U.S., but over time the country’s light-touch policies were accompanied by excess mortality only moderately higher than in neighboring Denmark and Norway and much lower than in the U.S. and the rest of Europe. Getting the risks right may not have been essential to getting the response right.

Justin Fox is a Bloomberg Opinion columnist covering business. A former editorial director of Harvard Business Review, he is author of “The Myth of the Rational Market.”