Skin In The Game

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.

33 Responses to Skin In The Game

  1. I once thought it was self serving when the analysts used to say that patients who pay little or nothing for therapy won’t work hard in treatment because they think it’s only worth about what they pay for it.

    But then I found out the analysts were right about many patients.

    BTW, psychotherapy involves the patient being willing to work hard to deal with difficult issues, which is not the same as a placebo effect.

    • stevebMD says:

      “psychotherapy involves the patient being willing to work hard to deal with difficult issues, which is not the same as a placebo effect.”

      You’re right, the two are not the same. But they both share the fact that the patient believes in treatment as a way to achieve whatever goal(s) he or she wishes to achieve.

      Paying for treatment is simply another way to strengthen that belief. Or to put it another way, not paying risks making treatment a wasteful endeavor.

    • I think the underlying idea of the analysts’ admonition is not the placebo effect, but “cognitive dissonance,” the idea first propounded by Leon Festinger in 1957 that we humans naturally aim to keep our beliefs consistent. Thus, if we don’t pay for a good or service, we tend to believe it isn’t worth much; conversely if we pay, we tend to value it more.

  2. Terri says:

    Terri Squires, LPC, FNP-C, PMHNP-C; What a difference of opinion with the interview of the Psychiatrist in wherein she is quitting her private practice to move to New Zealond because the United States has no SENSE OF FAIRNESS when it comes to medical care and mental health care. She talks of America looking at healthcare as a corporate business and you can’t take good care of people in all fairness when you are looking at a profit. Like Bill Mahr pointed out–look at all the countries with a single payor system and it’s working for them–the rich get scared about having to wait on a list for their operation and that’s what essentially has fueled the propaganda in our country. Other countries, Finland, Sweden, Austria, New Zealand take care of their own in all FAIRNESS because it’s the fair and just, social just thing to do. My goodness what’s wrong with our people????

    • stevebMD says:


      Thanks for your comment. My post has nothing to do with the provider making a “profit.” In fact, I say nothing about the provider’s motivation. The issue here is simply that anything we can do to strengthen a patient’s motivation/belief/desire in treatment will result in a more positive outcome. One important element of that (which I have experienced first-hand) is to make an investment in one’s treatment. It needn’t be so much as to bankrupt the patient (or to make the provider wealthy); in fact, even a token amount can have a powerful effect.

      One might ask why a single-payer system works in Finland, Sweden, Austria, and New Zealand, but is met with such resistance here. I think it’s more than just the “rich getting scared.” But that’s a topic for another post.

      • Terri says:

        I agree with you that your post said nothing about you making a profit. I was reacting to numerous issues and your post activated me! So thank you and I agree with most of what you say and I don’t agree. I enjoy immensely your posts and I want you to continue! I want to get people activated to rethink our corporate take on healthcare. I want to have single payor system like other countries. I feel very very sad about our America and how we treat other human beings. I’ve watched poor people not able to get the operation they need and it is State by State as California is one of the better states for the poor and Arizona is horrible for the poor and Colorado can be very tough if you are indigent without coverage; you die. This is not right. So, this has to change.

  3. Terri says:

    I wanted to add I work in community mental health and talk to my patients everyday about psychotherapy as important as the pill, xanax, they believe helps so much as psychotherapy does change the neuronal pathways in the brain much like vigorous exercise. I literally sound like a broken record as I repeat this with excitement and vigor as how important it is for their happiness, well being and the patients that get better are the ones that participate in therapy and exercise. I tell them the meds are the kick in the butt to get them out the door to do the rest which is very very important. Of course, my group home patients struggle with this however I encourage them to sit on the porch, look at the trees, take a walk around the block and I have to tell you some of them tell me they actually feel a little better.

    Anyways, I am so disappointed and saddened by Americans not having a sense of fairness about our people, people in general and caring enough to cut out the corporate profit from medical care and develop a system which is in place in many countries with success. We don’t have to redevelop the wheel folks, it’s being done–what is wrong with American??? Bill Mahr asked the question, the Psychiatrist who is moving to New Zealand and coming back to attack single payor system in America for 6 mos out of the year is asking the question and I am asking the question What is wrong with Americans??????

    • doctorz says:

      By the way, this self-righteous psychiatrist is working only 6 months out of the calendar year in New Zealand because if she worked longer, she’d have to pay income tax. Instead, she sanctimoniously portrays herself as an advocate for reforms to our health care system in this country, which will require an equal amount of her time. I suspect she believes our system is unfair because her income potential has been limited.

  4. Hawkeye says:

    “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)”

    This may not be just a placebo effect. It is possible that the patient really does know better. This is especially true in an age when the internet provides useful information, if one is careful. Further, in the era of the fifteen minute med check, even well intentioned and capable physicians may not have the time to deal with patients, completely and effectively.

  5. Nathan says:

    As someone who did not have coverage of mental health care when I thought I needed mental health services, was basically bankrupted by pursuing care, and had my concerns and disagreements with parts of my treatment experience construed as “not believing enough” or not “wanting help enough” to a point where I felt aggressively pressured to continue what was ineffective and eventually harmful treatment, all the while coupled with fear tactics used to think stopping treatment would be worse than continuing, I find the the setup of this post a little difficult to get behind.

    To be clear, I think having a stake in your own care/health is vitally important, regardless of health care services sought or wellness behavior initiated. I agree with Dr. Balt that there can be a lot of proportionality in what someone’s financial stake in their care can be, where people who cannot afford care paying very little and people who have the means can pay more. I don’t think this even has to be considered a placebo effect, but one of agency/empowerment/responsibility/mastery, which may already be a goal for many treatments and meaningful/helpful to a client/patient.

    I do think it is a dangerous and ultimately wrong path to double down on the belief part of “believing in the path he or she is taking to achieve [a better] outcome.” Placebo, and even transference and insight, may be on the more benign side of the spectrum that has a more insidious part that includes manipulation and coercion. These tools are still used (some might say with convincing rationale like in some aspects of involuntary hospitalization) to promote health outcomes. Enhancing belief and trust in treatment I believe is only worthwhile if the treatment itself has already been shown to produce good outcomes beyond the extent people believe in it. Otherwise, all of the tools on this spectrum can be used for provider benefit (even regardless of whether a provider thinks it is ultimately self-serving) at the expense of patient health. While I think having a stake in treatment can demonstrate agency/mastery, the flipside is that patients can be manipulated and have that agency stripped/used against them, as well as decrease belief (which may decrease chances of robust outcomes) in the benefit of further/additional treatment.

    Instead of focusing on just enhancing/manipulating commitment/belief in treatment, why not rigorously gather evidence to show robust benefits and limited risks of treatments and sharing that evidence with patients? I think showing evidence for treatment effectiveness is pretty convincing in itself and doesn’t require any further intervention in someone’s beliefs. I also don’t like this focus on manipulating placebo/transference through structuring economic relationships without being upfront about it with patients. I don’t think it is a difficult concept for people to understand why paying an amount of money meaningful to them for treatment could be helpful, as the phenomena of taking anything more seriously when having financial resources on the line is not limited to health care. Even more, rigorously study the effects of belief/trust/motivation, and use results from study to design reliably and robustly helpful treatments.

    If belief in treatment, regardless of what the treatment is, is what produces strong outcomes, then I think we can devise a better healthcare delivery system that is cheaper, more effective, and risks less harm than current practices today, and frankly, would mean taking a lot of mental health care providers and treatments off the table. I think if treatments and doctors are there just so people can “believe” in treatments and doctors so that they can feel better, then we have to recognize it is the power, credibility, respect, wealth, and reverence we give provders/treatments that is helpful, not the method/treatment or skill/education of the provider. I believe (emphasis please) we can put our money and respect where it can do more good instead.

    • stevebMD says:

      “Instead of focusing on just enhancing/manipulating commitment/belief in treatment, why not rigorously gather evidence to show robust benefits and limited risks of treatments and sharing that evidence with patients?”

      Nathan, this, I think, is the million-dollar question. Unfortunately, it is difficult to separate “commitment/belief” from outcome, particularly when we’re talking about disorders/conditions/complaints that involve the human psyche. Perhaps this is a wake-up call that practicing “evidence-based medicine” (which is what you’re asking for) is simply impossible in psychiatry. (Sort of like religion, actually.)

      If I’m right, then we might see a day very soon when, as you say, we “tak[e] a lot of mental health care providers and treatments off the table.” (I can already think of some places to start the process!) Who will remain? For starters, those who work collaboratively with patients and who earn credibility and respect by the way they interact with them (and, for better or for worse, by what they ask their patients to pay for their service), not simply by their ability to diagnose and prescribe. Those days may be coming to a close.

      • Nathan says:

        Dr. Steve,

        Taken further, I think your argument against evidence-based medicine in psychiatry, ends the relevancy/belief of/in psychiatry. Our long history of medical shows that non-evidence based medicine is not medicine (practices that reduces ill health and promotes health outcomes). Medicine not informed by science did not produce reliably good outcomes for people, and likely led to a lot of poorer health (argument against the science of germ theory, amputations to prevent infection that caused infection, maternal/child mortality based on physician refusal to wash hands, lobotomy, more contemporary medications approved for use despite inaccurate/underwhelming data, etc.) I think “evidence-based medicine” is a redundant concept, because the profound value of contemporary medicine has been its systematic collection and application of evidence. If seeking mental health outcomes does not require specialized intervention based on knowledge produced from accumulated evidence, and perhaps may be harmed by the reliance on specialized faux-medicine, there are no reasons to have psychiatrists in the first place.

        There are many systems of mental health/well-being throughout human histories/cultures that do not rely on doctor-patient model of care. Some require specialized/differentiated roles of (ex. shamans, priests) in order to increase belief in engaging in a ritual relationship will be helpful. Some involve individual introspect and mutual validation/compassion in intentional communities. Some involve intense belief in a direct relationship/intervention with the divine. What I think you are ultimately envisioning of psychiatry is just another component of a particular cultural framework that explains health/pathology in a particular way in order for a particular intervention, consultation with psychiatrist in a special kind of relationship, to be helpful for people moving form particular notions of pathology to particular notions of health. The problems I see with all of these models is that they tend to be over-determining, and lose their effectiveness when having to compete with other ones. In particular with psychiatry, I think it is dangerous that it is guised in medicine/science, leading to false beliefs that diagnosing and treating are based rational decision-making. It also leads to a needed great divide in knowledge/power between patients and doctors in order to create a belief/trust in a doctor’s ability to be helpful. While I think specialization is not necessarily a bad thing, historically and now in psychiatry, we pay psychiatrists (money, prestige, trust) for actually having useful/helpful knowledge experience , not for inhabiting a particular social role that both causes/filters particular kinds of distress and allows for the relief from that distress.

        For me, “evidence-based practice” at least allows for the potential of new knowledge to permeate through how we view our health and caring for our health that if not more valid, at least is reliably more helpful/less harmful, as opposed to relying on pre-science tropes of wellness/pathology coupled with capitalist exploitation of distress-at least the vast majority of shamans and Catholic priests don’t make six figure salaries for supporting healing without evidence.

      • stevebMD says:


        Thanks again for a thoughtful comment. Of course, I do not mean to throw out the baby with the bathwater when I suggest that evidence-based medicine is impossible in psychiatry. Evidence is the foundation upon which we practice, and I absolutely agree that “evidence” can be as simple as knowledge gained from personal experience.

        But it’s hard to standardize that knowledge. And that, in a nutshell, has been my beef with psychiatry. Not only have we been led astray by our leaders (see my post “I Don’t Know What (Or Whom) To Believe Anymore”), but even when we do collect and disseminate information in good faith and without bias, the premises (eg, DSM-IV diagnoses, screening tools in clinical trials, patient rating scales) upon which the “evidence” is based, are questionable from the outset. As they say: garbage in, garbage out.

  6. Nathan says:

    I guess the flipside is having to believe in treatment/provider/experience/relationship/medicine in order for treatment to work. Why not enhance belief in something else, like you own personal efficacy, the power of exercising, ability to do well without professional help, etc? Many people have “evidence” of personal experience of them doing just that and perhaps have some expertise in shaping beliefs for particular benefits. In fact, much distress is also probably caused by people trying to alter someone else’s beliefs for reasons both helpful and malicious.

    Dr. Steve, I agree with you that the pillars from which to frame mental health care are commitment to patients’ well-being and strong evidence. I don’t see these pillars framing your current argument in regards to this current post.

    I care about evidence because I think engaging in ways that are shown to be generally helpful for particular people/concerns and that helpfulness outweighs the risks of harm for engaging also puts patients’ well-being front and center. I have written exhaustively about my critique of the ways mental health care researchers and clinicians theorize health, conduct research, interpret results, and apply findings (and I apologize for taking up so much space on your blog recently). I make no claims that evidence in mental health research/practice is easily standardized (or possibly standardized at all) or that “evidence-based treatments” are helpful for everyone in all situations, even if indicated. I do say, we do have the tools to engage people in ways where quality research, experience, and client values can guide treatment in ways that maximize likelihood of helpfulness and minimize risk and severity of harm, are transparent and respectful to clients, and allow for personalized decisions/changes to be made as both clients and providers get more experience working with each other.

    I will counter-argue to not throw out the usefulness of quality research (and it could be research related to the benefits of client/provider interaction, hopefulness/belief, etc.) because several decades of psychiatric research has been profit-driven at the expense of patient care, poorly theorized and conducted, and applied in inappropriate ways. I think you concerns about evidence are better directed towards your teachers, researchers in psychiatry, your professional organizations, and the schools/residencies that perpetuate belief in dismissing usefulness of quality research (which may have helped a lot of people based on their belief and experience), undermine scientific processes for their own benefit, and leave value of patients’ integrity out of their frame of interest.

  7. Terri says:

    A N=1 IS POWERFUL for the 1 and for me–again it’s so linear to believe we have to have evidence based proof in order to feel okay about what we are doing–I see people get better or not—that’s powerful and enough—if they don’t get better–go to the plan b, c, d, whatever; of course our plans are based on current research and our own clinical experiences. If a single payor system can help many many more people than our current system–isn’t this the fair, just, social justice thing to do?????? We get caught up in these idealogical, moral, religious arguments which by the way are created by the left and right to impede our progress for human beings in America—social justice—do we care anymore and if so how are we challenging our values and beliefs with regards to the millions of people in our country suffering from poor healthcare–California sounds like a better place for the poor however there are other states that are not giving care, not allowing the people to have medications that don’t make them fat, cognitively dull, TD sx out the whazoo, hair fall out–I mean really—–really??????

  8. mara says:

    As someone who is on MediCal (and who also has Medicare and a private health insurance), I think Jerry Brown’s idea is nuts. Personally, I never used MediCal, though I have had it for years, just because I found out very quickly that doctors hate it with a fiery, fiery passion. And I don’t see why patients would like it either. It is a morally bankrupt form of insurance that most doctors will not accept. I think I only used it to get a new pair of glasses once and to pay for some medications. I always paid the doctors and I usually paid for the meds. It was hit or miss what meds MediCal would cover. But most people who are disabled do not have that option. My father has awesome insurance and he is allowed to keep on any of his kids if they are disabled (no matter what the age). I JUST, this last month and after having MediCal for 7 years, switched to a MediCal GP because I got really sick and could no longer afford the copays to see my old GP. I swear I was at the doc’s office every week for a while. I’m still not totally well and I really don’t think I could afford all the copays…even at 5 dollars.

    We have already cut so much from MediCal. They don’t pay for glasses anymore. So all those patients with vision impairments are screwed. I bought my glasses from WalMart and it was still a financial hardship. They also don’t cover dental for anyone over 24 unless it’s an extraction :/ However, they will give you pain killers so you don’t have to feel your teeth rotting out of your mouth. They won’t even pay for dentures for the elderly. I could go on and on.

    If they have taken away dental almost completely, and only cover the exams for vision, then I think everything else needs to be free. That way people can at least attempt to save for dental and glasses. Though I don’t know how you could do that when SSI is only like 850 a month for a lot of people and they already have rent, food, and (if their lucky) a phone bill to cover.

    Wanna hear something that will really bother you, Steve? I always pay for my psychiatrist with private health insurance. I always pay a copay. I could go to one for free with MediCal. But that’s not what will bother you. The psychiatrist prescribed a generic medicine, and MediCal would not cover the medicine. They said I had to go to a psychiatrist who accepts MediCal, or they would not cover the medicine. Usually, MediCal does not investigate who did the prescribing unless it requires a prior authorization. If it’s a really expensive antibiotic or a stimulant then they want to know who the doctor is.

    Weirdly, anyone can prescribe me a benzo and they don’t investigate. They just pay for it automatically, regardless of whether the doc accepts insurance of any kind or not. But if it’s a stimulant, the doctor actually has to call it in if your an adult. And they won’t approve anything your doctor prescribed unless he has a contract with them. It could be a five dollar bottle of adderall, and they will not approve it. Xanax is okay though :/

    I actually think it’s sad they force people to use their doctors. If it’s so much money to support MediCal, then I would think they would encourage people to use non-MediCal docs and pay a copay.

  9. The idea of insurance is to spread the risk of an expensive outcome to a larger population who can absorb the associated costs. Buying insurance is “gambling against yourself”: If you don’t suffer a mishap, you’ve wasted your money. In the case of auto or homeowners insurance (or malpractice, personal liability, etc), insureds are motivated to avoid/prevent covered losses — the insurance money isn’t worth the entirety of the loss. And when exceptions arise, e.g., when arson makes economic sense, the threat of prison keeps the balance tipped against cashing in.

    Health insurance isn’t like this at all. As commonly construed, it makes about as much sense as “food insurance.” Health services and food are necessities, not rare expenses suffered by an unfortunate few. Our society’s discomfort with letting people die in the street of starvation, illness, or injury calls for a basic level of health care, analogous to food stamps, to prevent that. No apologies, no shrill accusations of socialism, no drama. We need it just like we need police and fire stations.

    As for skin in the game, I agree completely. Psychotherapy (for example) is valued more, and in my experience helps more reliably, when paid out-of-pocket. When a treatment is psychological by nature, there is no meaningful distinction between the “active ingredients” and fuzzy interpersonal influences such as transference, halo effects, and cognitive dissonance. In part, and perhaps sometimes in whole, they ARE the active ingredients.

    How to combine guaranteed basic health care and “skin”? It may take some finessing. Sliding scale co-payments are one possibility. Exploratory/analytic forms of psychotherapy may unfortunately never work well as safety-net care because nominal co-pays sap too much of its psychological influence. That remains to be seen, though — an experiment well worth doing.

    • Terri says:

      Again, repeatedly, we don’t have to reinvent the wheel. Healthcare is working in 50 other countries good enough people, Americans. Why is it rednecks, pharmacists, physicians and especially specialists, wealthy people in America are sooooooo against a socialist medical system????

    • mara says:

      Kind of a tangent, but that was a good point about “food insurance.” I’m not a Bill O’Reilly fan, but a while back, when Rush (he is a moron) called that law student woman a whore because she thought Georgetown should pay for contraception for students, Bill weighed in on it. Someone sent Bill a comment saying that contraception is essential to a woman’s health and it should be covered by the university. And then he said that nutritious food is also essential to health. Shouldn’t nutritious food be covered for everyone. That was totally unrelated to contraception, but it did make me think. Isn’t that why so many people are obese in this country? They are filling up on 1 dollar cheeseburgers and burritos. Nutritious food is expensive and bad food is all some people can afford. Maybe there should be “food insurance.” I’m not a puritanical woman, but I kinda don’t wanna cover contraception before covering nutrition. Maybe it’s time to have publicly funded healthy food in the same way that we have police and fire stations. We can have food stations with fruits and vegetables and whole grains. Free apples, quinoa, broccoli, etc. Everything essential to nutrition is free. Things that are not essential, like candy and cheeseburgers, can be paid for out of pocket. McDonalds can still exist, but poor people don’t have to live off of it.

      And trust me when I say that we with MediCal do not need to put anymore skin in the game. Our skin is already in the game enough as it is. We can barely afford food, shelter, and clothing. If it is true that psychotherapy is more effective when the patient is paying, then maybe a barter system for people who really cannot afford to pay. Though what would we barter? Hmmmm. Maybe offer to be part of a research study for free?

  10. Duane Sherry says:

    Dr. Balt,

    The taxpayer already has plenty of “skin in the game”.

    Vera Sharav with the Alliance for Human Research Protection put out a good idea a while back…

    No more federal money for drugs that were illegally researched and/or marketed (scroll down once the page opens to read the article) –

    This would not only put a stop to the fraud in Pharma, but would go a LONG WAY toward searching for safer, more effective (non-drug) research and care for people who are suffering and searching for answers.

    Duane Sherry, M.S.

    • Duane Sherry says:

      This would include Medicaid, Medicare, Veterans Affairs (VA)..
      And would work with ANY healthcare system we come up with where federal dollars are involved.


  11. catsrgreat says:

    I wish I wish I wish I remembered more, but there were a couple times in the past 40 years where studies were done comparing program costs before and after copayments from poor people were required, and what happened is that some of the poor people did not have a couple of bucks, so they did put off medical care, and there were many more hospitalizations as a result. Both those studies concluded that it was cheaper to have zero copays. But I cannot remember where I read that, or in what states this research was conducted in 😦

    You have to be careful to remember that not every poor person will make medical decisions like YOU would. It doesn’t take many screw ups to increase Medicaid costs. One extra hospitalization wipes out a thousand peoples’ copays. I can’t say as to whether or not a person will work harder in therapy if they have to pay for it.

  12. mara says:

    I’m gonna add one last comment. I walked into an urgent care one weekend a couple months back. There was a young couple with a baby there. They have their own insurance and MediCal. MediCal just pays their baby’s copays. The primary insurance covers everything else. The Urgent Care covered by the primary insurance did not accept MediCal. The copay was 20 dollars. The man went to his wife and said, “We’re going to the hospital.” They then walked out. Obviously, that cost taxpayers way more money than if MediCal had covered the 20 dollars on that visit. But no one wants a contract with MediCal, so there it is…

    Again, MediCal is a morally bankrupt insurance that most doctors will not accept for a reason. The reason people do not want universal healthcare is because they are afraid it will look like MediCal: a system where psychiatrists don’t get paid unless they prescribe medication; where you cannot be prescribed medicine by a doctor who doesn’t accept the universal coverage because the government only covers medicine prescribed by doctors who work for them, or even get a second opinion from a non government doctor. I can just see it now. Someone goes to a specialist, paid for out of pocket, and is told they might have cancer. You’re going to need a biopsy, sir! My Goodness! When? I’m sorry, but maybe never. I don’t accept government health insurance, so the government doesn’t care what I think. I can tell the government you need a biopsy, but they will request that you see one of their doctors first. If he agrees with me, you will eventually get a referral for a biopsy. The whole process should take a couple of months :/ If he disagrees with me, then you will pursue a second opinion, prolonging diagnosis by another couple of months…

    The focus should be on getting MediCal to pay for more and not less. If they agreed to pay for any urgent care visit copays or accept a diagnosis and prescription from someone who does not contract with them, that would also probably save lots of money.

    • stevebMD says:

      “MediCal is a morally bankrupt insurance that most doctors will not accept for a reason”

      Mara, I appreciate your comments. Your use of the phrase “morally bankrupt” is apropos. Medi-Cal reimbursement for services is low, patient volumes are (necessarily) high, and complicated regulations stifle good care. This, combined with inconsistent access to services, means that patients on Medi-Cal (and their providers) are almost required to act in ways that defy logic, cost much more money in the long run, and make it virtually impossible for patients to make rational health care decisions for themselves.

      I would opt out of Medi-Cal for precisely this reason– namely, that despite my (and my patients’) best efforts and intentions, it is a nonsensical entity which is hard to navigate or understand. Sure, we complain about private insurance and its faults, but if we look at insurers simply as businesses looking out for the bottom line, at least we can make some sense of why they do what they do. Not so for Medi-Cal.

      If universal health care means everyone has something like Medi-Cal, then maybe it would work because there would be a level playing field. But I’m certainly not holding my breath.

  13. Anonymouus says:

    Skin in the game! Geez! Not many have more skin in the game than I do. I pay “out of pocket” for my annonymity. When one submits anything to their “top shelf” insurance company….nada (this is a DSM serious disorder). There simply is not parity for any other physical disorder, I still think the brain is part of the body. Take a bus???? I know you have seen mental illness and taking a bus is ridiculous. Can you imagine, I could not see my MD because I was too depressed to go. Can you imagine dropping 15lbs (seriously do not need to be thinner) out of the blue, because you are once again in a down time. Again, I say Geez! If you are speaking of the “worried well”, or disability abuse or any other socio-economic misfortune, I can almost agree. Most especially because we somehow pay for it and I am of the mind for serving and funding those less blessed and continue to do so of my own volition. I have lived and worked in Europe for 11 years and you pay dearly. My take-home was 37% of what I earned. Sorry, this really caught me in the throat and I was treated well there because of some notoriety. Yes, even if it is a buck, one should know they are somewhat responsible. And, when one is capable, they should participate in their own health responsibilites when able. Have a heart. I could be barking up the wrong tree, but real mental illness is not so hard to spot………..I’m pretty sure, at times, no one wants to get on a bus with me!

    I would like to say you get what you pay for, but you just don’t. I know why I pay “out of pocket” and so does my MD and I realize not everyone is in this position. I see terrible mental disorders in my volunteer work and they are also not getting on a bus. It would be a bus to nowhere! Some folks afflictions are so awful that riding a bus would be a dream. I often wish I could rent a boat as in “One Flew Over the Cukoos Nest”, and show everyone a great time!

    So sorry not to agree with you on this one, but appreciate your insight and courage. I realize it is no picnic to be a psych and when you are reimbursed, it is probably as dismal as when I worked in Europe.

    Thanks anyway for the consistent good work.

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