HJNO Jul/Aug 2025

HEALTHCARE JOURNAL OF NEW ORLEANS I  JUL / AUG 2025 57 heart arteries with stents and bypasses pre- vented heart attacks and sudden death. It made perfect sense, but Libby said flatly that opening arteries relieves symptoms, but it does not prevent heart attack or sudden death. Libby outlined a new understanding of the pathophysiology of acute coronary syndromes based on episodes of plaque disruption and thrombosis, rather than gradual progression to complete occlusion of fixed coronary ste- noses or blockages. Bypass surgery or trans- luminal angioplasty with stents provide ra- tional and often effective therapies for fixed, high-grade blockages such as what occurs when a patient is experiencing an acute heart attack or is experiencing angina that is refrac- tory to treatment with optimal medical therapy. However, these interventions do not ad- dress the non-stenotic but vulnerable plaque that many of us can develop as we age, es- pecially those of us who have multiple risk factors for coronary artery disease. And yet many people, including physicians, still think that bypass surgery and stents (also known as revascularization) prevent heart attacks. But that is simply not the case, as has been demonstrated in numerous trials over the past 20 years, including the COURAGE trial from 2007, the ISCHEMIA trial from 2020, and the REVIVED trial from 2022. To reduce the risk of acute myocardial infarction, one must stabilize lesions to prevent their disruption, particularly the less stenotic plaques, using medications rather than procedurally oriented interventions. In other words, opening arteries does not protect you, while best practice medical treat- ment to stabilize soft, inflamed cholesterol de- posits so that they don’t rupture and cause a clot does. Unfortunately, practice patterns that favor intervention over medical therapy still predominate in many institutions. One has to wonder if finances play a role in these practice patterns, since procedural interventions are so much more richly reimbursed than office vis- its where doctors sit and discuss medications. Another prominent academic cardiologist was Bernard Lown, MD, who also served in the Harvard faculty and who had preferentially recommended medical treatment — rather than interventional treatment — for heart ar- tery disease long before 1995. In addition to being a pioneering cardiologist, Lown was also a Nobel Peace Prize co-recipient and the inventor of the direct current defibrillator. He has laid bare some of the deepest tensions in modern cardiology and, more broadly, healthcare delivery. He founded the Lown Cardiovascular Research Foundation to study alternatives to routine revasculariza- tion for patients with coronary artery disease. Initially, he tried to launch a randomized trial comparing medical therapy to surgery after angiography, but the study failed because once patients saw their angiograms and were told — in dramatic, fear-inducing language — about their blocked arteries, they all opted for surgery or procedural intervention. Angiogra- phy, he realized, functioned less as a diagnostic tool and more as a pipeline to intervention. To avoid this bias, Lown’s team began man- aging patients without relying on angiogra- phy. Over 35 years, they published studies on about 1,000 patients with multivessel disease, most of whom had been told elsewhere they needed a stent or bypass. Yet fewer than 30% ended up needing revascularization, and out- comes were excellent — with about a 1% an- nual mortality rate. Lown’s experience led him to a strong conclusion: Most patients recom- mended for stents don’t actually need them. He spent his career challenging a health- care system prone to overtreatment, where procedures often follow fear, not evidence. Better Spending to Improve Health Libby and Lown are both brilliant men who elucidated what works most effectively to treat heart artery disease and stood by their convictions in the age of “money medi- cine” where profit-driven motives often influ- ence the practice patterns that dominate our healthcare industry. Lown also authored a book titled “The Lost Art of Healing,” which I can personally attest is an excellent book. The Lown Clinic ultimately evolved into the Lown Institute, which among other things studies variation in appropriateness of care for coronary artery disease. According to a re- port published by the Lown Institute on Oct. 31, 2023, unnecessary coronary stent proce- dures cost Medicare approximately $800 mil- lion annually. (These massive expenditures do not include commercial plans, so the to- tal costs are actually much higher.) Between 2019 and 2021, over 229,000 stents were placed unnecessarily in Medicare patients, accounting for more than 20% of all stent procedures during that period. That’s nearly $1 billion spent just on unnecessary stents. If we started to tally up all of the other ar- eas in medicine where there is an opportu- nity to divert healthcare dollars to areas that actually improve health, we might be able to achieve a point where we get closer to be- ing able to insure everyone and maybe even come to regard healthcare as a human right. The “overmedicalization” that is being described in the recent MAHA report does indeed exist. And ultraprocessed foods, chemical exposures, lifestyle factors, and overprescription of certain medications all do contribute to some of what is wrong with healthcare. The report is right to call them out, because at least then we can at- tempt a healthy debate in this country about the root causes of dysfunctional healthcare. But moving forward, we need to also under- stand the role of clinically unwarranted practice pattern variation and its role in causing some of the quality and affordability challenges of healthcare. We could probably spend sev- eral more articles exploring practice pattern variation and how this can lead to overdiag- nosis, overtreatment, overmedicalization, and overutilization, all of which drive up medical expenditures for us as a society and is one of the principal reasons why the controversial payer practice of prior authorization exists. So, while the health insurance industry clearly plays a role in what is wrong with healthcare, we will not completely solve all of healthcare’s woes until our profession looks at itself more closely in the mirror to scruti- nize our own contribution to these problems. Only then — and only once we stop point- ing the finger at each other with blame, thus fostering adversarial relationships across payers, policy makers, and providers — will we successfully come up with collabora- tive, proven solutions that will “Make Amer- ica Healthy Again” while making health- care more available and affordable for all. n REFERENCES 1 Bell, D.; Clarkson, J.; Jensen, B.; et al. “Milliman Medical Index: 20th Anniversary Edition.” Milliman, Inc, May 27, 2025. https://www.milliman.com/en/ insight/2025-milliman-medical-index 2 Institute of Medicine (U.S.) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (Washington, DC), 2001. DOI: 10.17226/10027