Skin In The Game

April 8, 2012

We’ve all heard the saying “you get what you pay for.”  But in medicine, where the laws of economics don’t work like they do everywhere else, this maxim is essentially meaningless.  Thanks to our national health-insurance mess, some people pay very little (or nothing) out-of-pocket for a wide range of services, while others have to fork over huge sums of money for even the most basic of care.

Good arguments have been made for health insurance to become more like automobile or homeowners insurance.  Car insurance doesn’t cover oil changes and replacement tires, but it does pay for collisions and mishaps that may result if you don’t perform routine maintenance.  Homeowners insurance doesn’t pay the plumber, but might reimburse you for a flood that results from a blown valve on your water heater.

In medicine, we’ve never really seen this type of arrangement, apart from the occasional high-deductible plans and health savings accounts.  If you have a typical employer-sponsored health plan, not only do you pay little or nothing for your basic, routine care, but your insurance company has probably added even more services (massage, discounted gym memberships, “healthy eating” classes) in the name of preventive medicine and wellness.  (It’s almost as if your auto insurance paid for exactly what you’d do if you wanted to hang on to your car for 500,000 miles.)  When faced with this smorgasbord of free options, it’s easy to ignore the true underlying cost.  One way to reverse this trend is to ask for patients to put some “skin in the game.”

This might happen in Medicaid, the insurance plan for low-income persons.  California Governor Jerry Brown, for instance, proposed that patients receiving Medi-Cal (the California version of Medicaid) should pay higher co-pay amounts for care which is currently free (or nearly so).  A $5 co-payment for an office visit, or a $50 co-pay for an emergency room visit might sound hefty, but it’s a bargain—even for a poor family—if it means the difference between life and death… or even just sickness and health.

Unfortunately, California’s proposal was shot down in February by the Obama administration on legal grounds: the co-pays “are neither temporary nor targeted at a specific population.”  There are other legitimate questions, too, about its feasibility.  Would people forgo routine checkups or neglect to fill prescriptions to save a few dollars, only to cost the system more money down the road?  Would doctors and hospitals even bother to bill people (or send accounts to collections) for such low sums?  Is it fair to charge people money for what some people think is a right and should be free to all?

Without commenting on the moral and political arguments for or against this plan, I believe that this is a proposal worth testing—and psychiatry may be precisely the specialty in which it may have the greatest promise.

Psychiatric illnesses are unique among medical conditions.  Effective treatment involves more than just taking a pill or subjecting oneself to a biological intervention.  It involves the patient wanting to get better and believing in the path he or she is taking to achieve that outcome (even if it violates what the provider thinks is best).  Call it placebo effect, call it “transference,” call it insight, call it what you will—the psychological aspect of the patient’s “buying in” (pardon the pun) to treatment is an important part of successful psychiatric care, just as important—perhaps more so—as the biological effect of the drugs we prescribe.

Like it or not, part of that “wanting” and “believing” also involves “paying.”  Payment needn’t be extreme, but it should be enough to be noticeable.  Because only when someone has “skin in the game” does he or she feel motivated to change.  (Incidentally, this doesn’t have to be money, it could be one’s time, as well:  agreeing to attend an hour of weekly psychotherapy, going to self-help groups 2 or 3 times a week, or simply driving or taking the bus to the doctor’s office can mean a great deal for one’s recovery.)  It’s more than symbolic; it can mean a lot.

In my own life, I’ll admit, I took medical care for granted.  I was fortunate enough to be a healthy child, and had parents with good jobs that provided excellent health insurance.  It wasn’t until my mid-20s that I actually had to pay for medical care—even my co-payments seemed shocking, since I had never really had to pay anything before then.  Over the years, as I struggled with my own mental health needs (which were, unfortunately, not covered by my insurance), I had to pay ever-larger amounts out of my own pocket.  I honestly believe that this was a major contributor to my successful recovery—for starters, I wanted to get to a point where it didn’t make such a huge bite out of my bank account!

The absence of a “buy-in” is most stark precisely where Governor Brown wants to change it:  in Medicaid patients.  In the community clinics where I have worked, patients can visit the office with zero co-payment (and no penalties for no-shows).  This includes medication and therapy visits.  Prescriptions are often free as well; some patients take 4 or 5 (or more) medications—at zero out-of-pocket cost—which can set the government back hundreds of dollars a month.  At the same time, patients with no health insurance (or even with insurance, like me) can’t access the same drugs because of their prohibitive price tag or byzantine insurance restrictions.  It’s nowhere near a level playing field.

To make matters worse, patients on Medicaid generally tend to be more medically ill and, almost by definition, face significant environmental stressors that detrimentally affect their physical and mental well-being.  In these patients, we give psychiatric diagnoses far too liberally (often simply to give patients the opportunity to keep coming to see us, not because we truly believe there’s a diagnosable “mental illness”), and allow them to keep coming in—for free—to get various forms filled out and to refill medications that cost a fortune and don’t treat anything, perpetuating their dependence on an already overburdened health care system.  In fact, these patients would be much better served if we expected (and helped) them to obtain—and yes, even pay for—counseling or social-work assistance to overcome their environmental stressors, or measures to promote physical and mental wellness.

In the end, the solution seems like common sense.  When you own something—whether a home, an automobile, a major appliance, whatever—you tend to invest much more time and money in it than if you were just renting or borrowing.  The same could be said for your own health.  I don’t think it’s unreasonable to ask people to pony up an investment—even a small one—in their psychological and physical well-being.  Not only does it make good fiscal sense, but the psychological effect of taking responsibility for one’s own health may result in even greater future returns on that investment.  For everyone.

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