The term “skin in the game” is often used, to the point of obnoxiousness, to describe the concept of making patients pay more of their own money to turn them into thriftier consumers of healthcare services. It's the central idea behind “consumer-directed” health plans with high deductibles and personal health savings accounts.
Many healthcare providers and consumer advocates—and even some health insurance executives—say the skin-in-the-game model has been taken too far in the U.S. and is getting in the way of patients receiving appropriate care.
Now physicians are finding themselves being held financially accountable for their medical choices, and they don't much like the skin-in-the-game model or metaphor.
Employed hospitalists at PeaceHealth Sacred Heart Medical Center in Springfield, Ore., have joined the American Federation of Teachers union partly in response to the hospital's use of financial incentives to get them to achieve performance targets such as reducing length of stay and improving patient satisfaction scores, the New York Times reports. The doctors are negotiating with the hospital to try to make the incentive system more consistent with what they see as their professional standards.
The skin-in-the-game metaphor had already become so widespread by 2006 that New York Times language columnist William Safire wrote a piece trying to trace the origins of the term.
He cited then-Sen. Tom Coburn, who used it in connection with health savings accounts, and billionaire investor Warren Buffett, who used it when he raised his first investment fund from doctors and kicked in his own money. Buffett's office denied he was the coiner.
Another possible source is Shakespeare's “The Merchant of Venice,” in which the moneylender Shylock requires Antonio to promise “a pound of flesh” as collateral for his friend Bassanio's loan. Health policymakers will certainly distance themselves from that practice.
Yet the skin-in-the-game philosophy in U.S. healthcare has become so widespread that at least 38 states are charging prison inmates co-payments for healthcare services.
“We do it for the same reason your insurance company does, to eliminate abuse by making the inmates put a little skin in the game,” Tommy Thompson, jail administrator at the Rutherford County Sheriff's Office in Tennessee, told the publication Stateline.
In the Times piece about the hospitalists union, Dr. David Schwartz recalled that he first heard the expression at a meeting with the hospital's board of directors, when a local businessman on the board stressed the need to establish strong incentives for doctors.
“It really took all of my self-control to not say, 'What the hell do you mean skin in the game?' ” he said. “We have our licenses, our livelihoods, our professions. Every single time we walk up to a patient, everything is on the line.”
Schwartz wasn't finished. “My thought was, I'll put some of my skin in the game if you put your name on that chart. Just put your name on the chart. If there's a lawsuit, you're on there. You come down and make a decision about my patient, then we'll talk about skin in the game.”
Don't be surprised if you see this reaction more often from employed physicians, said Dr. Stuart Bussey, president of the Oakland, Calif.-based Union of American Physicians and Dentists. He turned the skin-in-the-game metaphor around on hospital administrators.
“The administrator's role to make as much money off patient interactions without any skin in game or liability,” Bussey said. “That's what skin in the game is, taking liability and accountability for decisions foisted on doctors.”