By Jessica Schorr Saxe, M.D.
The Charlotte Observer, April 9, 2015
“Skin in the game.” The phrase pops up frequently in health insurance discussions, as it did twice in the recent Charlotte Observer article about high deductible policies (“A Growing Risk: High Deductible Health Plans Can Ruin Finances,” April 9).
In finance, the phrase refers to high-level executives investing their own money in stock in their company, so that they have a stake in its performance.
In health care, it refers to “consumers” having financial responsibility – in the form of high deductibles and co-pays in their insurance plans – for their health care so that they will be “smarter shoppers.” This raises a number of questions.
What problem is it solving?
The call for skin in the game implies that Americans are profligate over-users of health care. In fact, we have fewer doctors, see them less frequently, and spend less time in the hospital than residents of most other developed countries.
According to the Commonwealth Fund, more than one-third of Americans missed medical care because of cost in 2014. And more than one-third of non-elderly adults have a problem with paying their medical bills or debt. It seems we already have plenty of skin in the game.
Does it promote smarter choices?
Cost-sharing does decrease medical expenditures in the short term. But, according to the Robert Wood Johnson Foundation, “patients do not accurately discriminate between essential and nonessential services when responding to changes in cost-sharing.”
Avoiding a doctor visit to check your high blood pressure or skimping on a recommended medication because you have a high deductible might not turn out to be such a smart decision.
Does it save money? And, if so, for whom?
It certainly saves money for private health insurance companies: if patients don’t get care, insurers don’t have to pay for it. Healthy families who manage to avoid seeking medical care might see savings. But most people who have the misfortune to get sick are likely to find deductibles of thousands of dollars hard to pay. Such families have other losses in income, such as missed days of work for the patient and the caretaker, exacerbating their financial hardship.
With regard to national health care expenses, almost half are incurred by the 5 percent of people who are seriously ill. These people will not save money by putting skin in the game – they are likely already down to the bone. Robert Wood Johnson notes that increased cost-sharing will likely have no impact on national health spending.
Are patients the major drivers of excessive procedures?
Almost everyone knows someone who had an unnecessary MRI. But does that impetus come strictly from the patient? Medical device makers and pharmaceutical companies invest a lot of money in making us think we need more procedures and drugs. As a practicing physician, I noted that it was faster to order a test or lab than to do a meticulous exam. Our fee-for-service system has provided many people (other than patients) incentives for excessive spending.
Is this how we want medical decisions made?
A recent Medical Economics article about dealing with high-deductible plans tells doctors that they need to adjust their care by discussing costs and options as defined by the patient’s insurance plan. As a patient, I would like my doctor to let me know what recommendations are optional. Even if fully covered by insurance, I might prefer to spend my afternoon somewhere other than in a radiology waiting room or in a lab. Shouldn’t doctors be advising everyone on what is medically indicated – and not spending precious, limited time with patients discussing cost?
Whom is insurance supposed to protect, anyway?
Do we evaluate the value of fire insurance by whether people who don’t have fires feel secure in having it? Or by whether it protects those who actually have house fires?
Maybe health insurance is the wrong model after all. It differs from other insurance programs. Everyone needs health care, whereas not everyone needs fire care. Insuring against only catastrophic events (which high deductibles do) will ensure more catastrophic events, because of the resulting avoidance of primary and preventive care.
Americans need health care, but not private health insurance. We need accessible, affordable care without high deductibles or other barriers. Let’s drop the “skin in the game” cliche like a hot potato and use constructive language and thought to move toward a single-payer health care system – with real savings in administrative and drug costs – that would provide care for all.
The writer is a Charlotte physician and chair of Health Care Justice-NC, a group of health professionals and non-medical providers pursuing a single-payer, universal healthcare system.