I had an exchange of opinions (respectful, I think) on Twitter with a Georgia-based consultant who says he has run many practices. He's very pro High Deductible Health Plans, and talks about how patients only value what they pay for, along with advancing the old "skin in the game" argument.
It then struck me -- so many of my patients were Medicaid and didn't have "skin in the game." Yet I think we had an excellent relationship and I have no doubt about their appreciation.
It seems to me that it's the relationship, and the patient's understanding that you care, and that you are trying, and that you have respect for them, that is the crucial element. The patient's paying is like another way of attacking it, that substitutes for that relationship. Because if you pay for it, there's a cognitive incentive for you to value something, because you figure if I paid for it I had better value it or it's wasted money.
So looked at that way, the skin in the game argument is taking advantage of the cognitive error of sunk costs (I think that's what it's called) in lieu of establishing a caring relationship.