When I was an emergency medicine resident twenty years ago, some doctors would pre-write opiate pain medication prescriptions ahead of a busy shift to keep up with the demand.  Knowing what we know now about the dangers of opiate addiction, many may wonder why on earth would doctors do that?

At the time, a growing movement in medicine decried the undertreatment of pain as unethical while downplaying the addictive properties of opiate pain medication.  Hospital systems were expected to comply with better pain management, and the American Medical Association (AMA) threw its clout behind the effort to establish pain management performance measures.  The subjective sensation of pain was reframed as an objective measurement and, through implementing pain scales, was deemed on par with literal measurements of temperature, blood pressure, heart rate, and respiratory rate.

The “pain as the 5th vital sign” campaign was incorporated into pain management standards, and linked to reimbursement from the Center for Medicare and Medicaid Services (CMS) for in-hospital care through patient surveys that included three questions about pain treatment.  When patients reported unrelenting pain despite non-opiate therapeutics, the next alternative to adhere to pain management policies and avoid a cut in reimbursement was an opiate prescription.

Now, as the opioid epidemic rages, the AMA has since dropped “pain as the 5th vital sign” from its professional standards, and the three questions posed to patients about pain management on post-treatment surveys have been replaced with questions about “pain communication” instead.

Doctors were never mandated to use opiates to treat pain.  But the pressure to aggressively treat pain likely resulted in the increased rate of opiate prescriptions, a peak of 81 prescriptions for every 100 persons in 2012.  

Medicine’s contribution to the opioid crisis reveals the hidden dangers of targeting -- and reimbursing for -- subjective benchmarks in health care.

Financially incentivizing soft metrics has the potential to yield unintended results because the endpoints are ill-defined.  Unlike objective measurements like blood sugar levels in diabetic patients, the zeal to reach subjective, lucrative goalposts can promote variable patient care.  And, in a system that seeks to maximize profits, doctors can be prodded into making decisions that instinctively don’t always feel right.

Like the pain campaign, fresh incentive payments from CMS aim to push forward a movement in medicine aspiring to achieve the equally broad and complex goal of social justice.  A new Improvement Activity, to “Create and Implement an Antiracism Plan,” will be added to a list of options influencing incentive payments for 2022, contributing to a score that can increase or decrease reimbursement by up to 9 percent.

The rationale for this initiative is to “address systemic inequities including systemic racism” as stated in President Biden’s executive order released in January 2021, to confront racial and ethnic health disparities.

CMS references a toolkit to implement strategies that addresses these disparities using root cause analysis.  It uses as an example the rates of diabetic foot exams to evaluate complications of diabetes, which are noted to be lower in black versus white patients.  The data analysis ultimately reveals that accessibility to podiatrists’ offices is a major impediment to exams, and referrals to offices serviced by public transportation reduce the disparity. While CMS’s definition of “antiracism” is left up to interpretation, this model demonstrates the power of objectively pinpointing the cause of disparity to create positive change.

The AMA goes a step further, however, in favor of making race and ethnicity a bigger factor in patient care decisions.  In May it released “Organizational and Strategic Plan to Embed Racial Justice and Advance Health Equity,” with the objective to “Embed racial and social justice throughout the AMA enterprise culture, systems, policies and practices,” through the implementation of “Health Equity performance metrics” and “consistently using lenses of racial, gender, LGBTQ, disability, class and social justices…”

The AMA defines racism as “a system of structuring opportunity and assigning value based on phenotype (‘race’)…” and prejudice as “An unfavorable opinion or feeling formed beforehand or without knowledge, thought, or reason.”

Yet, in the same document, by calling out a segment of the population by race -- whites -- as perpetrators of a current political and financial power imbalance, the same principles of racism and prejudice are injected into the physician-patient encounter.  The AMA demands that race-blindness and equality take a back seat in favor of viewing patients through a racial lens, advocating for reparations to “end health inequities and restitution for past and present injustices.”  The idea is that equality of care will only perpetuate systemic oppression, ushering in a new ideology to which medicine should aspire to address social justice. “Seeking to treat everyone the ‘same,’” the publication reads, “ignores the historical legacy of disinvestment and deprivation…” The document implies that care should be allocated differently based on immutable characteristics such as race and ethnicity to make up for historical wrongs, by viewing patients not as unique individuals, but instead as members of social cohorts.

What might health care through a racial lens look like?

Using the AMA’s analogy that “equity is a precise scalpel,” one can’t help but wonder how aggressively the scalpel dissects.  Will patients be steered towards certain care plans based on the amount of melanin in their skin?

This is not beyond the imaginable.  In their strategic plan, the AMA positively references two Boston physicians who credit Critical Race Theory as their inspiration in advocating the use of race and ethnicity to guide patient care.  Undeterred by Title VI of the Civil Rights Act of 1964, they describe “medical restitution” by offering “preferential care based on race or ethnicity,” pointing to instances where they believe racism yielded unequal health outcomes.

A reshuffling of patients by skin color is not only a missed opportunity to uncover root causes of disparity, but it also perpetuates the evils of racism it aims to address at a potential cost of quality health care for all.  Perhaps CMS’s new Improvement Activity will spark methodical and unbiased evaluations that bring about positive change; but with a prejudicial approach lacking objectivity, we face the danger of creating a new “5^th vital sign”: race.

Image: CMS