Somewhere along the way, the patient stopped being the point.
A patient who was stable
A year ago this month, 74-year-old Martha was stable. She lives with osteoporosis, osteoarthritis, degenerative disc disease, multiple joint replacements, and chronic anxiety. Even so, she was functioning. Her pain was controlled on a low, unchanged dose of oxycodone that she had taken responsibly for more than five years.
At her annual visit, everything changed. Her primary care physician told her he would not renew her prescription because she was “becoming dependent.” He referred her to pain management.
“The pain specialist only wants to give prednisone and cortisone shots,” she told me. “Gabapentin made me dizzy. Cymbalta didn’t help. Pregabalin made me nauseous.” She kept exercising as much as she could. Then she fell and dislocated her knee, and still no pain medication was offered.
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“I haven’t slept good since,” she said through tears. “I have pain head to toe.”
She worries about liver damage from acetaminophen and stomach problems from NSAIDs. She is doing everything she can, and she is suffering. Her disease did not change. The system did.
What a program measures versus what a patient lives
I spent more than three decades working in nearly every corner of health care: the ICU, oncology, geriatric primary care, home health, and eventually the executive suite, where I built programs such as the first home-based heart failure program in my region and a post-acute brain injury center. In every one of those settings, I watched the same tension play out. There is what a program can measure, and there is what a patient actually experiences. We often treat those two things as if they were the same. They are not.
The last prescription is not the finish line
I was reminded of this recently while watching a county board presentation by a vendor that sells opioid prevention programs funded through opioid settlement dollars. The program director said something I have not been able to shake: “What physicians don’t know is when to write the last prescription.”
It was offered as the core insight behind the entire program. It should trouble anyone who hears it, because it treats stopping a prescription as the outcome itself rather than as the beginning of a much harder question. Stopping in favor of what? When a patient has an incurable, chronically painful condition and is stable and functional on an opioid, what is the risk of taking it away?
The vendor’s presentation answered a different question entirely. It was full of numbers, including claims of a 75 percent reduction in high-risk prescriptions, a 56 percent reduction in cost per member, a 41 percent reduction in emergency department visits, and 99 percent provider adoption of Centers for Disease Control and Prevention (CDC) guidance. On paper, that looks like success.
Nowhere, however, was there any mention of what happened to the patients behind those numbers. Were they connected to physical therapy, injections, non-opioid medications, or behavioral pain management, the actual alternatives to an opioid prescription? How well did those interventions work? Did their pain, function, or quality of life improve once the prescription stopped, or did they simply go without?
A program that can tell a county board exactly how many prescriptions it eliminated but cannot say what happened to the pain those prescriptions were treating has answered only the easy half of the problem. The hard half, the half that matters to the patient, goes unmeasured and unreported. The system rewards reductions, not improvements, and treats the last prescription as the finish line instead of the starting point.
A pattern, not an exception
Others are noticing the gap. In Livingston County, Michigan, commissioners recently weighed paying a vendor to comb through county employees’ health insurance claims, including those of their family members, for early signs of opioid misuse. Critics raised concerns about privacy and about duplicating the state’s existing prescription monitoring system. Their objections point to the same blind spot: a program can be designed to find and reduce prescriptions without ever asking whether the people behind them are in less pain.
This is not unique to one vendor or one crisis. It is a pattern across modern health care. Value-based care metrics, readmission penalties, and quality measures tied to reimbursement are too often built to be defensible in a board meeting or an audit rather than to reflect whether someone’s life actually got better.
I have sat on both sides of that reporting relationship, building programs that had to satisfy accreditation bodies and outcomes committees. The difference between a program that serves patients and one that merely reports on them is not whether it measures things. It is whose definition of success gets measured, and who was in the room when that definition was written.
That question deserves to be asked about any program before it receives public dollars, especially settlement dollars that exist because patients were harmed in the first place. Whose voice was in the room when success was defined? Was it a patient, or a family member who lived through the condition being treated? Or was it exclusively actuaries, technologists, and executives building something that would look good in a quarterly report?
Measuring what matters
None of this means metrics are the enemy. Metrics are how we hold ourselves accountable. But a metric that counts only what is cheap and convenient to count, such as prescriptions written, dollars saved, and encounters avoided, will always miss what matters most: whether the person is doing better by their own account, not just by the account of the system managing them.
A program built the other way around is not hard to imagine. It would:
- Define success together with the patients it serves before choosing a single metric.
- Require patient-reported outcomes on pain and function, not just claims data.
- Track what happened to people after their last prescription, not just log its absence.
- Report patient outcomes alongside financial outcomes, in the same report, every time, rather than treating one as the deliverable and the other as an afterthought.
What happened to the pain?
Counties are sitting on billions of opioid settlement dollars right now, deciding which programs deserve that funding. Every one of those decisions is an opportunity to ask the question the vendors themselves are not asking: What happened to the pain?
Until someone insists on an answer, we will keep funding programs that can prove they reduced a number while the people behind that number go unheard.
Heidi Sykora is a retired nurse practitioner, former health care executive, and the volunteer chief scientific officer of the International Plant and Herbal Alliance. Her writing and advocacy focus on evidence-based interventions that improve patient outcomes and experiences.
Her career has encompassed clinical education, public health policy, and regulatory reform, with special emphasis on misinformation, caregiver support, and safe access to plant-based and alternative therapies. She has also written policy advocacy articles through the American Kratom Association.
Her published work spans clinical research, continuing education, book chapters, and public health commentary, with recent contributions appearing in Home Healthcare Now, the Chicago Daily Herald, and Nursing CE Central. A representative sample includes “The case for regulating, not banning, kratom,” “A custodian helped this nurse manage a patient with hospital delirium,” and “Rural Family Caregiving: When Resources Are Scarce,” her chapter in 10 Nursing Interventions for Family Caregivers: Guide to Best Practices in Adult-Gerontology Patient Care.
Professional updates and advocacy work are available on LinkedIn.
