Skin in the Game

Pharmacy Practice in Focus: Health SystemsMay 2012
Volume 1
Issue 2

There is an old adage that says if you put "skin in the game," you will be more willing to participate in an activity or take responsibility for an outcome.

There is an old adage that says if you put "skin in the game," you will be more willing to participate in an activity or take responsibility for an outcome.

This idiom is commonly ascribed to Warren Buffett, who requires the executives of the companies he manages to have a financial investment in their own organization.1 If you personally have something at stake, you will be more motivated to achieve results. The same is true for airline pilots. If they make an error when flying an aircraft, their outcome will be no different from that of the passengers on that plane. If, however, a surgeon makes a mistake when operating, only the patient suffers the poor outcome.

In pharmacy, there are many applications for this adage. If a patient receives medications at a reduced cost or for free, will they be less likely to have lower adherence as opposed to those who had to pay a portion of the cost of the medication? Some might argue that if a patient has complete knowledge about their disease state, understanding and recognition about the benefit of drug therapy, and they can comfortably afford it, the “skin in the game” concept should be nullified. This means that whether a patient has paid for their medication or received it for free, adherence should not differ.

Noncompliance is a major issue in health care today. Studies have shown that patients with chronic disease states are noncompliant half the time and one-third of prescriptions are never filled.2 It is recognized that there are many factors that influence adherence, including cost of medications, patient understanding of their disease state and how medications can improve their health, and daily pill burden.

Studies have evaluated this concept of whether reduced copays lead to improved adherence. A study tested adherence rates when 1 group received 50% price reductions for brand name copays.3 In patients with diabetes, adherence improved by 7% to 14% in the lower copay group, demonstrating that a reduction in the amount that patients pay out of pocket can be a factor in improving their adherence rate.

Another study eliminated copays for statin drugs for patients with diabetes or vascular disease and found that adherence to statins improved by 2.8% compared with a control group.4 Interestingly, they also studied a group that was on clopidogrel who received copay reduction (not elimination). This cohort had an increase in adherence of 4%. While this study was not focused on evaluating whether paying a modest amount or none at all is better, it is interesting to note that both were deemed effective.

This leads to a study released in late 2011 that evaluated patients who had had a prior myocardial infarction.5 They were randomized to either copayments for statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or beta-blockers of $13 to $25 or no copayment at all. The primary outcome was determining whether no copayments would lead to a reduction in the first major vascular event or revascularization (presumably because adherence would improve). Even though adherence improved 4% to 6%, overall costs were no different between the groups and there was no difference in overall outcomes.

What do these studies mean for health-system pharmacy? They suggest that adherence is impacted by factors other than money and knowledge of disease state. In the most recent study, every enrolled patient had had a cardiovascular event in the previous year. If any patient would have a first-hand understanding about the need to take their medications, these would. When you couple that recent experience with free medications, adherence should soar and patient outcomes should improve. Unfortunately, this was not found.

Health-system pharmacists interact with patients throughout the course of their event and have a unique opportunity to educate them about the need for medications and the value of adherence. How can we blame the rest of the health care system if we are unwilling to do our part?

If we had some “skin in the game” as it relates to the outcomes of the patients we serve, we would be more motivated to work with patients to improve their health. The tide is starting to turn and health care is starting to incentivize us more. But there is a lot that can still be done—and we are better positioned than anyone else to take advantage of it. Let’s begin thinking like an airline pilot and start taking these outcomes personally.


1. Language: Who’s got a skin in the game? International Herald Tribune. Editorials & Commentary. The New York Times website. Accessed February 19, 2012.

2. O’Reilly KB. Tactics to improve drug compliance. American Medical Association website. Accessed February 19, 2012.

3. Health Affairs. 2008;27(1):103-112. Accessed February 19, 2012.

4. Health Affairs. 2010;29(11);1995-2001. Accessed February 19, 2012.

5. N Engl J Med. 2011:365;2088-2097. December 1, 2011. 6. Wall Street Journal. November 15, 2011.

Stephen F. Eckel, PharmD, MHA, BCPS, FASHP, FAPhA, is the assistant director of pharmacy and residency program director of UNC Hospitals and director of graduate studies in the Division of Pharmacy Practice and Experiential Education at the University of North Carolina Eshelman School of Pharmacy and is in charge of the 2-year masters of science in hospital pharmacy administration. He has been elected as the chair of the Acute Care Practice Forum and board member for the North Carolina Association of Pharmacists. He has served for many years in the American Society of Health-Systems Pharmacists (ASHP) House of Delegates and was the chair of the ASHP Council of Pharmacy Practice from 2009 to 2010. Dr. Eckel has been recognized as a Fellow of ASHP and the American Pharmacists Association.

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