Helping patients understand the rules of the game

  | August 11, 2017

Many hospital leaders are saying that patients need "skin in the game." Usually, what they're talking about is money: copays and deductibles.
But the real "skin in the game" issue for high-cost, vulnerable patients is health literacy. You can't have skin in the game, after all, if you don't understand the game that's being played. This lack of understanding could be a vocabulary issue, a language issue, a discrimination issue, or a cultural issue.
Or it could simply be that the game has never asked players to understand the rules.
As recently as 10 to 20 years ago, healthcare providers had the unquestioned authority to tell patients what to do, which prescriptions to take, which foods to avoid, and so on. What the patients wanted — or even what they knew or didn't know about their health — wasn't part of that conversation.
That is no longer the case. As our industry shifts to accountable care and a population health model of care delivery, patients now need to take more responsibility for their own health. That means we have to fundamentally rethink the relationship between providers and patients.
Having spent most of my career in urban safety net hospitals, including as the CEO of Sinai Health System in Chicago, I have witnessed extremes of both kinds when it comes to the provider dilemma: How to offer meaningful care that addresses the root cause of symptoms, even as our time and resources are severely restricted. On one end, providers take a paternalistic view of their patients and communities. On the other, providers are willing to spend time making sure patients understand what something like “sugar" can mean to their health.
This shift away from paternalistic behavior is long overdue. As professionals, we tend to fall back on jargon, abbreviations, and other mysterious language to show patients how smart we are and how little they know. We provide handouts, then check the little box that says patient education took place. But how can we expect a 50-year-old diabetic patient to change his lifestyle if he doesn't have a clue about what we are telling him?
One caring and patient-sensitive provider recently told me what scant education her diabetic patients had received before she saw them. This physician had to spend time explaining not only what “sugar" meant — and why it was something that could be controlled — but also how to shop, prepare food, and find a friend to walk with.
Indeed, "skin in the game" goes beyond just understanding the chronic disease process. At one Chicago safety net hospital, a team of epidemiologists and patient educators used HgA1c, a measure of blood glucose levels, as the benchmark for measuring a successful diabetes intervention. They found that patients were able to absorb basic information about blood sugar and health. But mere information did not yield any behavior change on an individual level.
Outcomes didn't change until a supermarket opened in the neighborhood — eliminating a food desert — and partnered with the hospital to identify fresh foods, especially fruits and vegetables, which might be new to patients. The hospital created a demonstration kitchen in partnership with WIC-Women Infant Children, a federally funded program implemented by the City of Chicago Department of Public Health. The diabetes team created community partnerships to reinforce the need to exercise and eat correctly.
The combination of community health workers, the new supermarket, neighbors supporting neighbors, and health education yielded a statistically significant reduction in HgA1c — “sugar."
The shift toward population health will help make this happen more and more. Providers are joining in new organizational structures that support team-based care. Insurers are offering more economic incentives via shared savings or capitation payments. The delivery side of the healthcare equation will surely benefit.
And as we do the smart thing for patients, they'll have the opportunity to truly have “skin in the game."
Alan Channing is a consultant and the former CEO of Sinai Health System in Chicago. Illustrated by Anat Evan-Or.

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Excellent article and so true. I would take one step further and state that the information a patient receives should presented simply and holistically to their entire health eco-system.
Name: 
Bonnie Kotz
Email: 
bonnierkotz@gmail.com
Mr. Channing's article is "on target". The "successful" patient encounter mentioned where a patient with limited health literacy can see a Provider who has "skin in the game" is predicated on the patient being able to see the Provider - which emphasizes the importance of continuing Medicaid support for the uninsured and continued funding for Community Health Centers, as well as community improvements such as having a supermarket available.
Name: 
Harry Ginsberg
Email: 
hlginsberg@gmail.com
I agree. Patient literacy is critical, but so is cultural competency and diversity awareness. Health education and preventative medicine should be the focus in this shift to a "population health model" because if the population is not aware of what is healthy and how to prevent chronic illness, then failure is imminent.
Name: 
Carriann Mulcahy
Email: 
caremulcahy@gmail.com
Spot on, Alan! Underlying this is the need for extensive and meaningful community partnerships (examples of which are mentioned in the piece). While healthcare providers must play a key role in this, I believe the key to long term and sustainable change is community support, activation and partnerships. Great examples from Sinai and others across the nation.
Name: 
Christopher Cornue
Email: 
ccornue@gmail.com
In my 40 + years experience, education is a relatively critical component to change, but without motivation, an ineffective component. Motivation generally comes as a response to either financial incentives, or more commonly fear after either a personal or an observed crisis in a family member or friend. In other words, the folks who see someone they know have a devastating stroke are more likely to take a sudden interest in applying all the education and motivation enhancers I have showered them with for years. That's when they realize that their skin has been in this game all along. My estimate is about 10-15% of folks get motivated as a response to my efforts in the exam room and their patient portal; 85-90% do so from external experiences that slap them up on the side of their head with their mortality. They come back to the office to partner in their lifestyle and diet modifications, as they are well aware of the resources they've declined up to that point. The rules of the game are that we are all mortal, and ignoring common sense and health maintenance will encourage an early demonstration of mortality. Excuses do not protect you from the grim reaper.
Name: 
Robert D Peterson MD
Email: 
rpeterson@suddenlinkmail.com

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Helping patients understand the rules of the game