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.