This is a writing sample by “nycghostwriter,” AKA Barbara Finkelstein. It is a “book on managing chronic disease,” a ghostwritten self-help book for a vice president of clinical transformation at a large U.S. regional healthcare system. You can get professional ghostwriting services from a published non-fiction writer. Email me or fill out the short form on my contact page.
Chapter 1: Chronic Disease Is an Epidemic and It’s Killing Us
Dr. Craig Spencer came down with fever and gastrointestinal problems when he completed a medical mission in Guinea. His symptoms pointed to Ebola, a lethal virus that killed 11,284 people in the West African countries of Guinea, Sierra Leone and Liberia in 2014 alone. The 33-year-old volunteer with Doctors Without Borders spent twenty days in a specially designed isolation unit at New York City’s Bellevue Hospital. After Spencer’s healthcare team declared him virus-free, Mayor Bill de Blasio applauded Bellevue for implementing a perfectly executed treatment strategy that stopped the disease from infecting anybody else.
When it comes to fighting acute diseases and public health threats such as Ebola, the American healthcare system has few equals. A culture of innovation and product development has improved life measurably for millions of people. For at least seventy years, public and private funding has helped eradicate epidemics and acute disease that once shortened Americans’ lives. Indeed, when HIV-AIDS began infecting and killing gay men in the early 1980s, medical researchers could largely rely on a scientific and governmental infrastructure to start working on a cure. In mid-1995, the U.S. Food and Drug Administration approved a three-drug cocktail that suppressed replication of the HIV virus. By 1996, the number of new AIDS cases diagnosed in the U.S. declined for the first time since the beginning of the epidemic.
We take for granted that most of us will never suffer from acute diseases such as smallpox and polio. If we have access to regular medical care, we also no longer fear conditions that killed our parents and grandparents: Hepatitis C, kidney infection, pneumonia, pancreatitis. We are all beneficiaries of the vaccines, drugs and devices that have extended the lives of people suffering from some kinds of cancer and congenital heart disease. If you have to cope with an acute condition, better to live in 2015, not 1915.
But the healthcare narrative in America and other developed countries takes a different turn when we talk about chronic disease. Diabetes, hypertension, coronary heart disease, stroke, hyperlipidemia, gastric ulcers, arthritis, osteoporosis, chronic obstructive pulmonary disease, depression and back pain are coming at us from every direction. Thirty percent of all chronic disease is genetic and we probably can’t blame anything but our inherited biology. Most chronic disease, however, strikes us because of how we eat, how we spend our time and how our healthcare system addresses our problems. In fact, medical researchers attribute forty percent of chronic disease to our behavioral patterns; fifteen percent to social circumstances; ten percent to healthcare and five percent to environmental exposure.
Yet it’s too easy to say that we are making ourselves sick. The 117 million Americans — about half of all adults — who have at least one chronic health condition are not totally to blame for OD’ing on foods high in sugar, salt and fat. Our supermarkets are temples to this stuff. Primary care doctors — the mules in our healthcare system — aren’t to blame for their patients’ poor health either. As soon as they begin their clinical practice, doctors are whipped and beaten into treating patients with six or seven chronic conditions in a ten- or fifteen-minute office visit. This schedule alone is a sure-fire recipe for poor health outcomes. Doctors don’t have enough time to understand their patients’ problems. They haven’t been taught how to help patients change their behavior. They don’t have an effective model to monitor patient progress. Plus, they’re expected to document every patient visit, comply with federal regulations, adhere to privacy laws and keep up with peer-reviewed papers on primary care topics.
When it comes to chronic disease, what is the central problem?
Patients and doctors alike participate in an outmoded healthcare system designed to treat acute disease — such as Ebola, myocardial infarction or upper respiratory infections, to name a few. The reality is that millions of us are struggling with chronic disease: Obesity, diabetes, high cholesterol, high blood pressure, etc. Our healthcare system is simply not set up clinically, financially and administratively to treat them.
We’ve known since 2001, when the Institute of Medicine, a division of the National Academies of Sciences, Engineering, and Medicine, reported that the delivery of care is “overly complex and uncoordinated, requiring steps and patient ‘handoffs’ that slow down care and decrease rather than improve safety.” We can all attest to the IOM’s diagnosis. Like many twentieth-century systems, our healthcare organizations, medical centers and physician groups function as separate silos. A patient’s cardiologist and neurologist probably don’t know of each other’s existence. It’s as if the Internet technologies that dramatically transformed our economy over the past twenty years have had little impact on the healthcare industry at all.
Maintaining a badly functioning healthcare system has had severe consequences on our personal health and on the health of our society. In 2013, the year for which we have the most recent data, the U.S. spent $2.9 trillion on healthcare, or about $9,255 per person. That’s tantamount to 17.4 percent of Gross Domestic Product (GDP). By 2024, the healthcare share of GDP is expected to rise to 19.6 percent.
There’s no lack of mind-blowing statistics on the amount of money that we — households, governments, private business and other entities — spend every year on healthcare. For all the trillions we’re spending, though, shouldn’t we rank higher than eleven of eleven industrialized nations when it comes to healthcare outcomes? A Commonwealth Fund study found that we’re also last or near last on health system quality, efficiency, access to care and equity. By comparison, the United Kingdom, which spent $3,406 per capita in 2011, ranked first on the same metrics based largely on national mortality data (although it too lagged on health outcomes).
The data show a great disconnect between the money spent on healthcare and outcomes: Of that $2.9 trillion spent on healthcare, $1.65 trillion, or 75 percent of all healthcare spending, goes to treating patients with one or more chronic diseases. The annual economic impact on the U.S. of the seven most common chronic diseases: Approximately $1.3 trillion.
So, how’s this system working out for us?
Not so good. Chronic disease is responsible for seven out of every ten deaths in the U.S. (as of 2010). Heart disease, cancer, stroke, diabetes, kidney disease and other chronic conditions kill more than 1.7 million Americans every year.
Primary care doctors — the first responders in the chronic disease epidemic — can tell you that their middle-aged and older patients are coming in sick with diabetes or pre-diabetes and high cholesterol; and their young patients — roughly one in six children between six and nineteen — are overweight. You cannot see a steady stream of chronically sick patients, month after month, year after year, and feel that you are truly helping people get healthy. In fact, only 36 percent of physicians are satisfied with the care they give these patients — as compared to 54 percent who are satisfied with the care they give their general patients.
What primary care physicians also recognize is that the prescription pad is a limited healthcare tool. For every individual helped by the ten highest-grossing drugs in the U.S. to control cholesterol, diabetes, asthma, Crohn’s Disease, arthritis and other chronic conditions, between three and twenty-five people report no benefit at all.
An equally serious problem is the lack of patient adherence: Medical researchers in 2011 learned that even when medications are effective in combating disease, their full benefits are not realized because some fifty percent of patients don’t take their medications as prescribed. Once again it makes no sense to blame the patient. Who wants somebody to shove a prescription down their throat and say, “Take this drug or else you’re going to die!” Scaring people into going straight has never worked and never will.
If you’re on a leaky ship, putting up a new mast won’t keep it from taking on more water. Likewise, a new insurance carrier or a new low-level “care manager” is not going to reverse the physiological, social, psychological, financial and organizational deficits spawned by chronic disease. A healthcare system that cannot prevent 1.7 million new diagnoses of diabetes a year or help contain the $245 billion for the total cost of the disease in diagnosed patients alone is a system that is listing toward an unsustainable future. Writing out more prescriptions, warning people that smoking is bad for you, restricting wellness visits to once a year to keep healthcare costs down, certifying support staff as chronic disease case managers — trying harder in these ways to change individuals and systems isn’t much of a solution at all.
A system that should be keeping us healthy is keeping us sick.
I have seen this assertion borne out in my own practice as a cardiologist.
Eighty percent of the cardiovascular conditions I have observed as vice chairman of the department of cardiology in the Ochsner Health System in New Orleans, and as Ochsner’s chief clinical transformation officer, stem not only from unhealthy lifestyle habits, but also from a wrongheaded systemic approach to disease prevention. What typically happens is you or a loved one comes to us after having a heart attack. Once we’ve got you stabilized, you enter into a three-month rehabilitation program. We’re not talking cardiac rehab boot camp here. We’re talking about you coming in three times a week for “education.” We’ll “teach” you about your risk factors if you continue to smoke cigarettes or eat a diet rich in Big Macs, or if your idea of exercise is typing your Amazon Prime password into your smart TV. You’ll also join a cohort of patients with the same health and lifestyle problems you have. You’ll exercise “x” amount of minutes on the treadmill or elliptical. We’ll put you on a healthier diet — and presto change-o — you’ll leave a changed man or woman.
Two flaws in this well-intentioned therapeutic plan: First, you will likely resume the very habits that gave you a heart attack or stroke in the first place. Not because you’re bad or weak willed, but because you no longer have the support of your group. Second, you can’t stick with the program because we’ve compelled you to participate in a cart-before-the-horse plan. We should have enrolled you in a cardiac health program three months ago. But who in the American healthcare system reimburses you for preventive care? We’ll spend a gazillion dollars on you after you get sick, but not before when we can really help you. Sadly, the only behavior-change tool we have in our healthcare doctor’s bag is too little too late.
A hopeless situation, right?
It’s not!
The Internet of Things — the connection of devices to the Internet and to each other — has given us an arsenal of behavior-change tools. Wearable technology, like a Fitbit, theoretically could help your primary care physician infer from weekly, monthly or quarterly data why your cholesterol or blood pressure is high.
At Ochsner we initiated a hypertension digital medicine program in April 2015 that uses an Apple Watch, as well as other wireless devices, to help patients measure their blood pressure and heart rate at home. The numbers are sent automatically to Ochsner-affiliated pharmacists so that they — not low-level “care managers” — can inform patients about necessary medication or lifestyle adjustments. Patients also get medication reminders, clinical feedback, prescription renewals, activity trackers and other relevant info. Best of all, we have data to show that patients and doctors are benefiting from our program, primarily because that data is continuous. We’re not just looking episodically at information we gather three or four times a year during short office visits.
We have to talk about a reformed healthcare system that can respond almost instantly to patients before they suffer a heart attack or stoke — a system that may even reduce the number of times patients have to come in for a check-up. Fewer appointments also reduce daily patient caseload, freeing up physicians’ schedules for bigger emergencies.
I don’t want to minimize the wicked problems that come along with digital data collection. We have to ensure patient privacy. We have to work with insurance companies so they don’t use personal data to penalize patients or doctors. But the potential benefits of health-related data collection are too great to dismiss. Technology is valuable because it lets patients interact with each other as well as with their physicians. Changes in patient behavior do not come from me telling a patient what to do. They come about in a dynamic way when technology helps human beings learn tactics and strategies from each other. Get an encouraging word from each other.
#
I started this chapter by talking about Ebola, an extreme disease as similar to chronic disease as laser tag is to hopscotch. But chronic disease and Ebola actually have something in common with each other. They are both communicable diseases. Research shows that if you associate with people who make unhealthy food choices, you’re likely to make that same choice. Connecting with people similar to you, in real life and on social networks, appears to force less healthy individuals to interact primarily with one another. The people most in need of a health innovation that could alter their behavior may be among the least likely to adopt it.
Yet some studies show that in certain controlled situations, people with the same social contacts can be influenced to adopt a new health behavior. Anecdotally speaking, we see that happen all the time in online and real-world support groups. Even if it turns out that there’s a genetic component underlying the tendency for obese people, for example, to cluster in large social networks, we now have technologies that will let us investigate the legitimacy of this assertion.
Healthcare organizations, such as the Centers for Disease Control, the World Health Organization and numerous nongovernmental organizations understood (some right away, some eventually) that letting Ebola run its course could result in the deaths of thousands, perhaps hundreds of thousands, of people. Poorly managed chronic disease is having a comparable, albeit less sensational, impact on millions of people in the U.S. and elsewhere.
We already know a lot about the root causes of our chronic disease epidemic. We know the bad news:
- Chronic disease is responsible for 75 percent of health care costs and the majority of deaths in the U.S.
- Existing delivery models are poorly constructed to managed chronic disease, as evidenced by low adherence to quality and control indicators.
But we know the good news too:
- New technologies have emerged that can engage patients and offer additional modalities in treating chronic disease.
- Modifying health care delivery to include team-based care combined with patient-centered technologies offers great promise.
In the next ten chapters, I’ll talk about how each one of us, physicians, administrators and policymakers, must help our patients become active partners in their own healthcare. Thanks to smart phone apps and wearable technology, we can make this happen. Popular technologies and structural fixes in our healthcare delivery system give us the power to design a cost-effective non-pharmacological scheme that will encourage people to change their negative behaviors. I believe that a reengineered healthcare system has the power to extend people’s lives.
What do we do first?
For starters, we have to stop blaming the patient and the primary care physician for systemic problems that put all kinds of strain on patients, families, hospitals and workplaces.
Next we’ve got to transform the current care delivery model so that we can manage chronic disease — the medical crisis of the twenty-first century. The model we develop must include integrated units of pharmacists, advanced practice clinicians, nurses, health educators, dietitians, social workers, counselors and therapists who can competently take up the job of managing chronic disease where the physician has to leave off.
Finally, the healthcare industry has to avail itself of the same just-in-time technologies that have reshaped other sectors of the economy. These will put people in touch with each other, deliver services at the tap of an app and lower the cost of delivering care.
This country is facing huge challenges in education, homeland security, cybersecurity, climate change, employment and infrastructure. We can’t afford to be distracted by diseases that we can prevent. We can’t afford to tax a shrinking workforce population of Millennials, GenXers and Baby Boomers so that we can keep putting Bandaids on a societal wound that needs major surgery. A healthy healthcare system isn’t just a nice to have. It’s a need to have.
When you come to a fork in the road, take it.
That’s where we’ve got to start.
