HJNO Jul/Aug 2025

WHAT’S WRONG WITH HEALTHCARE patients per day than he does) while also or- dering significantly more tests, and who have much lower thresholds to refer to specialists. Many providers may not realize that pay- ers have quite a bit of data on them that gets generated through a combination of claims and clinical data. A small portion of my career was spent working for a commercial payer where I had access to this data on provider ef- ficiency and effectiveness through a contract with an advanced analytics consulting group. During my time working for this payer, the internist described above was ranked first in efficiency and effectiveness out of over 2,000 primary care providers in his state. However, he practiced that way to his own financial detriment, but out of deference to his moral compass so that he can look in the mirror and feel good about how he practices medicine. A few years ago, he and I were having drinks at a local restaurant, and we engaged in a discus- sion about quality measures in medicine. Like many physicians he was very passionate about quality, but he was also bemoaning the chal- lenges of satisfying a plethora of quality metrics that may not directly correlate with the best clin- ical outcomes. Sometimes these quality metrics can feel more like “checking a box” than doing what is in the best interest of every patient. I asked him his opinion about if he had only one measure of quality to track, what would it be? He responded without hesitation, “to- tal cost of care.” I agree with him. The best primary care physicians are the ones whose patients are least likely to suffer a heart at- tack or a stroke or end up with an avoidable emergency room visit or hospitalization. Granted, there are nuances and complexi- ties that sometimes render adverse health events, emergency room visits, or hospitaliza- tions unavoidable, but the very best physicians are the ones who figure out how to keep their patients as healthy as possible for as long as possible. And healthier patients are just plain less expensive. There are actuarial challenges to measuring total cost of care at the individ- ual physician level (because of relatively small panel sizes), but these challenges are not in- surmountable if we devoted the right statisti- cal and analytical resources to solving them. Multiple Variations If there were one word that best sums up what’s wrong with healthcare in this coun- try, I believe that word would be “varia- tion”: variation in practice patterns, varia- tion in utilization, variation in outcomes, variation in cost of care, variation in quality, etc. My earliest experience with practice pat- tern variation came in dramatic fashion back when I was in residency at one of those public hospitals. A specialist from a private hospital found himself caring for a patient without health insurance and called the resi- dent on call at the local public hospital, in this case me, to transfer the patient. He went on to tell me that this patient had a specific rheumatologic condition that would war- rant an extensive evaluation that would need to be treated with blood-thinning medica- tion, along with immunosuppressive therapy. Fortunately, we were taught in our training to approach each patient with a fresh set of eyes and obtain our own history, perform our own exam, and come up with our own diagnostic and treatment plan. And again, since we were closely supervised by a group of excellent phy- sicians, we knew that every question we asked, every physical examfinding we found, every test that we ordered, along with our own diagnosis and treatment plan, would come under scrutiny. For this patient, the diagnosis given to me by the private practice specialist was nowhere near accurate, and the treatment plan he sug- gested would have been potentially harmful to the patient. After all, there are clear risks to being on blood-thinning medication and sup- pressing one’s immune system unnecessarily. My attendings agreed completely with the less-intensive diagnostic evaluation and treat- ment plan and simply commented that this pri- vate practice specialist was known in the com- munity for being overly “aggressive” in their care. However, the prevailing culture of medi- cine is very hesitant to confront fellow physi- cians for these variations in practice patterns. After entering private practice myself, I very clearly remember discovering these practice pattern variations across the medi- cal community. While I tried to never criticize a fellow physician directly to a patient (be- cause that is frowned on within the medical community), I do remember advising pa- tients to see specific specialists who I knew tended to follow evidence-based practices. For example, I remember trying to guide patients with chest pain or suspected cardiac pathology to certain cardiologists, telling them, “If this cardiologist tells you that you need a heart catheterization, then you really do need a heart catheterization,” which was not the case across all cardiologists in the community. Indeed, the cardiologist to whom I referred most frequently followed evidence-based guidelines almost exclusively, resorting to pro- cedures such as angioplasty and stent place- ment only when meeting clear indications ac- cording to well-established medical evidence. And as this new presidential administration attempts to tackle this beast we call healthcare, they would be well served by lessening their at- tacks on scientifically proven preventive tactics, such as vaccinations, and diverting their atten- tion to real examples of “overmedicalization” as mentioned in their recent MAHA report. To that end, they would do well to learn some of the lessons taught by Drs. Libby and Lown. Lessons from Libby and Lown William Besterman, MD, is one of the fin- est internists and human beings I know. He is one of those physicians who would have thrived in an academic setting, but ulti- mately devoted his life to private practice. I came to know him during the period of time that I spent working on the payer side. The commercial payer where I briefly worked was so invested in attempting to improve car- diovascular outcomes within their state that they contracted with him to help teach other pri- vate practice physicians how to do a better job of managing cardiometabolic conditions such as hypertension, hyperlipidemia, obesity, and diabetes, so as to better prevent heart attacks and strokes. He recently published an article where he touted the heroics of two physicians who served on the Harvard Medical School fac- ulty, Peter Libby, MD, and Bernard Lown, MD. He described Libby as a giant in the field of cardiovascular medicine, one of those academically oriented cardiologists who is among the leading authorities on atheroscle- rotic vascular disease. Libby literally wrote the chapter on atherosclerotic cardiovas- cular disease in the pre-eminent textbook, “Harrison’s Principles of Internal Medicine.” He also wrote an article titled the “Molecu- lar Basis of Acute Coronary Syndromes” in a 1995 issue of the American Heart Association journal Circulation that changed — or should have changed — cardiology practice forever. Up until that time, we thought that opening 56 JUL / AUG 2025 I  HEALTHCARE JOURNAL OF NEW ORLEANS