Opinionator | Bedside: Saving Your Own Skin

Bedside is a series about health care from a nurse's-eye view.

Pittsburgh

The visceral phrase "skin in the game" keeps popping up in discussions of American health care policy. It's the idea that if patients spend their own money on care, they will spend it more carefully, and health care costs will go down. Conservatives worry that as the government becomes more involved with health care, patients will become less responsible about costs because the money being spent — their "skin" — is not their own.

The phrase reminds me of a patient whose skin was literally in the game, despite having good insurance. He had been off and on the hospital floor for so many months that we all knew about his fondness for '60s rock 'n' roll, his perceptive and stalwart wife, the dearly loved young children he so rarely got to see, the outside work he kept up with in the hospital. First there had been a diagnosis of leukemia. Then he'd relapsed, telling me with a resigned shake of the head, "Well, that leukemia came back, Theresa." His only option for a possible cure was an allogeneic stem cell transplant — a donation of cells from another person — and he got one.

Then he developed graft-versus-host disease of the skin. In a reversal of the kind of rejection that can happen with solid-organ transplants, where a patient's immune system attacks the new organ, with graft-versus-host the donated stem cells, called the graft, attack the patient's body. The condition is not uncommon, but it comes in grades. The patient had Grade 4, the worst, which was typically fatal.

His skin sloughed off. Desquamation is the medical term, but it doesn't capture how horrid the patient's situation was. Areas of skin on his face and legs essentially disappeared, leaving raw patches dark with blood.

We changed his dressings twice daily. It took four nurses, each of us murmuring, at different times, "Now we're doing your face," "Now your left leg," "Last one — we're almost done," and we told him these things because the pain caused by the dressing changes was obviously excruciating. Those days he rarely talked or even woke up, but the pain roused him. He moaned, then apologized for bothering us. That's the kind of guy he was.

We couldn't premedicate him with narcotics before the dressing changes; his status was so fragile that the medical team feared opioids would slow his respiratory function enough that he would have to go to the intensive-care unit, and they wanted him to stay on the floor.

He would die, and did, after several weeks of treatment. Before he died, I talked with his wife about whether to bring the kids in to see him one last time. She worried that he looked so grotesque it would be better for the children not to see their father.

The man had good insurance, and he and his family used it freely to provide him with as much comfort and care as possible. I can't imagine they'd have acted differently were they paying out of pocket. It may sound macabre, even perverse, to link a man losing his skin to the policy-inflected term "skin in the game," but I tell the story because people who use the term are willfully ignorant of what it actually means. Patients don't act according to market models when the "skin in the game" is, well, their own skin.

That distinction underlines the stark differences between the two parties on health care. If re-elected,President Obamawould finish implementing Obamacare, the goal of which is to make health insurance affordable for all Americans and to make health care cheaper.

Conversely, according to Mitt Romney, "The private market and individual responsibility always work best." He has specifically taken "skin in the game" as his approach to correcting our growing health care costs.

The problem is, Mr. Romney's market-based approach fundamentally misunderstands the nature of health care as a commodity. Health care choices made by patients only rarely resemble a penny-wise buyer who, say, needs a car and must choose between a used Buick, a new Hyundai or a shiny new Mercedes.

Those three cars offer different levels of comfort and status, and they obviously vary widely in price. But all will travel from point A to point B. In contrast, and despite what conservatives assert, when patients need care there are rarely low-, medium- and high-cost options; the choices tend to be black and white.

Consider a patient who falls and badly breaks a kneecap. Presumably he wants to walk again. His choice is between, on one hand, surgery, a cast and physical therapy, or, on the other, forgoing care completely and remaining lame for the rest of his life.

For heart attack victims, the first stop is a cardiac catheterization lab to have blocked arteries opened. Bypass surgery might be needed, and a stay in the intensive care unit. The lower-cost option is not getting care at all and living ever after with a damaged heart.

When these patients think about their personal health care costs, they all have skin in the game: their own skin. Or their own bones, their own heart muscle, brain cells, lung tissue, spinal cords, blood.

In dire situations of illness and injury, there isn't an old Buick alternative. There's care that can fix what's wrong, and anything less is about the same as doing nothing. People typically don't think about financial incentives, or frugality, when their very well-being is at stake. They just want to get better.

For my patient, when he first received his diagnosis, there was essentially one chemotherapy regimen that had the potential to save his life: a cocktail of drugs given at precise intervals and a long hospital stay. First-line therapy, we call it. There is no low-cost option, because there aren't any other options that work as well for the largest number of patients.

My patient knew from the start that his life was on the line. Could anyone have had more skin in the game?

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