Delivery of Care

Facts, nuance, and narrative

What is the news media’s role in reporting on health care?

Photo by Richard Asinof

The first Rhode Island baby born to welcome in the new decade at Women and Infants Hospital was Stephania Michelle Escobar Orellana, daughter of Katerin Oviedo Orellana, and Luis Escobar, of Providence, weighing 6 pounds, 5 ounces, their first child.

By Richard Asinof
Posted 1/6/20
The health care industry is the largest private employer in the state of Rhode Island, and spending on Medicaid, including federal and state funds, represents a third of the state budget. Yet no reporters other than ConvergenceRI reported on the first or second meeting of the legislative commission focused on reimbursement rates.
Why has there been so little media attention focused on the evidence being presented at the Senate Commission studying insurance reimbursement rates in Rhode Island? How important is it to include information about a massive corporate lobbying campaign to discredit “Medicare for All” health plans when Lifespan seeks to make further cuts in its operating budget, blaming it on the potential threat of such an all-payer plan? Is there a health care reporter in Rhode Island who is willing to collaborate with ConvergenceRI on making a presentation to the Commission? Why has the R.I. General Assembly chosen not to increase reimbursements to skilled nursing facilities based upon the inflation index, as required by law, for eight years? Should a member of the R.I. Attorney General’s legal team be attending the Commission hearings? How much money will the Governor include in her proposed budget for Health Equity Zones in Rhode Island?
It is hard to separate out issues surrounding rates of reimbursement from demographic changes underway in Rhode Island. Residents are becoming older, more racially diverse, and more divided by wealth and health disparities. The current crises in education and affordable housing reflect those changes; so, too, does the increase in concentrated poverty in urban core cities.
The leaders in the Rhode Island General Assembly can attempt to stonewall the need for more revenue to address these urgent needs, saying increasing taxes on the wealthy is a non-starter, but the lessons of the UHIP disaster and its false promise of future cost savings appear not to have sunk in.
The problem is related to narratives around cultural assumptions. In a recent TEDMED talk, Dr. Mitchell Katz said: “Health care is built on a middle-class model that often doesn’t meet the needs of low-income patients.” He continued: “The right prescription for a homeless patient is housing. The starting point has to be to meet patients where they are, provide services without obstacles, and provide patients what they need…and not what we think they need.”

PART TWO

PROVIDENCE – The efforts being undertaken by the R.I. Senate Special Legislative Commission To Study the Impact of Insurer Payments on Access to Health Care keep unearthing disturbing evidence of rate disparities in reimbursements that reflect the growing wealth and health disparities in health outcomes. [See links below to ConvergenceRI stories, “Open wider,” in this edition, and “Will anecdotal and data evidence converge into legislative health remedies?”]

At the most recent hearing held on Tuesday, Dec. 17, 2019, testimony by Dr. Andrew Gazerro III, D.M.D., chair of the Council on Dental Benefits for the Rhode Island Dental Association, and by Susan Storti, president and CEO of the Substance Use and Mental Health Leadership Council of Rhode Island, revealed the ways in which low reimbursement rates have become the crucible in which health inequities and poor outcomes are forged.

For many, the testimony may not come as a big surprise, particularly for patients navigating the rocky shoreline of dental care  or mental health care in Rhode Island. Still, the news that the two major dental health insurers had not raised their reimbursement rates for dental providers in 11 years, since 2008, should have raised alarm bells for legislators and perhaps for the R.I. Attorney General Peter Neronha to look at pricing disparities and market constraints.

However, the testimony by Gazerro and Storti was not reported by any other news media in Rhode Island, making it the proverbial tree in the forest that falls, unheard and, for the moment, un-heeded. The Commission is scheduled to meet two more times in 2020. Were the economics of health care related to reimbursement rates deemed too wonky to cover? Good question.

The answer is: maybe, maybe not. The next day, on Wednesday, Dec. 18, 2019, WPRI reported that Lifespan, the state’s largest health care system, which lost some $35 million during its last fiscal year, was planning to make further cuts in its operating budget, as part of a restructuring effort “to manage what if Medicare for All does come to fruition,” with the goal of achieving sustainability, according to Lifespan CFO Mamie Wakefield, speaking on a conference call with bondholders, as reported by WPRI’s Ted Nesi.

The way in which Lifespan injected concerns about proposed future Medicare for All health plans into its conversation about the health system’s future financial sustainability seemed somewhat curious, in ConvergenceRI’s opinion.

Why not talk about decreasing executive compensation as a more pragmatic response to reducing current operating costs, when the president and CEO currently makes a reported $2.5 million a year? Or, investing in proven community programs such as the one developed by Clinica Esperanza to keep people out of the emergency room and reduce uncompensated charity care, by providing primary care to the uninsured? Both actions would appear to produce immediate cost savings on the health system’s bottom line.

What was missing for the WPRI story, it seemed, was the larger context: a nationwide corporate lobbying effort being undertaken by the Partnership for America’s Health Care Future, “a multimillion-dollar cooperative designed to overwhelm not just the swelling Medicare for All movement, but every single Democratic proposal that would significantly expand the government’s role in health care,” according to a recent story by Politico, written by Adam Cancryn, entitled “The Army Built To Fight ‘Medicare for All,’” published on Nov. 25, 2019.

The new lobbying group has brought together what Cancryn described as “the warring corporate tribes” to help preserve their disproportionate fair shares of the $3.6 trillion annual in annual health spending.

“The Partnership officially launched in June 2018 with five founding members: [the] Federation of American Hospitals, AHIP and fellow insurer lobby the Blue Cross Blue Shield Association, drug industry giant PhRMA and the country's premier association of physicians, the American Medical Association,” the Politico story reported. [The AMA later withdrew its membership in August of 2019 from the lobbying coalition.]

The story continued: “It’s since expanded at breakneck speed, signing up the influential American Hospital Association and some of the nation’s largest individual hospital systems; the biotech trade group BIO; the health care executive roundtable Healthcare Leadership Council; and a series of trade associations representing smaller slices of the industry like insurance brokers and financial advisers, generic medicine manufacturers and radiologists. Recently, the Partnership branched onto the state level, adding local Chambers of Commerce, industry groups and private companies.” The Partnership currently has some 92 corporate partners, according to Politico.

The messaging being put out by the Partnership, the story continued, was this: “Health care reform will take away Americans’ “choice” and “control” and empower government “bureaucrats” by forcing everyone into a “one-size-fits-all system.” Sound familiar?

The Politico story also provided the counter-argument in a parenthetical graph: “Medicare for All proponents would counter that few Americans have choice or control now, since insurance is largely managed by their employers, and health care decisions are currently made by insurance, hospital and drug company bureaucrats, with little transparency or accountability.”

That is a big nuance to leave out of the narrative in a story reporting “just the facts” about what Lifespan said to bondholders, in ConvergenceRI’s opinion.

High cost of preserving the status quo
The Politico story also provided the financial rationale behind the corporate desire to keep any Medicare for All health plans at bay: “The current health care setup is good business for many of the companies represented by those in the coalition,” Cancryn wrote. “Insurance industry profits ballooned to $23.4 billion in 2018, up from $10 billion a year before Obamacare went into full effect in 2014. The hospital industry has consolidated, vacuuming up physicians and strengthening the nation’s largest systems’ abilities to negotiate higher rates for care, even as enrollment gains mean they’re treating fewer uninsured Americans for free.”

Is Medicare for All a legitimate, realistic concern for Lifespan as it seeks to restructure its finances? Why bring it up in a conversation on a conference call with bondholders, with reporters listening in? When the news media report on such conversations without providing a larger context, are they serving, unwittingly, as a mouthpiece? All good questions.

What is the role of the news media in covering health care?

In a world of increasing corporate consolidation of health systems, insurers, pharmacy benefits managers and newspaper platforms, understanding the changing role played by the news media in covering health care becomes a critical nexus.

At the end of the hearing on Dec. 17, 2019, ConvergenceRI spoke briefly with Sen. Josh Miller, the chair of the Commission and the chair of the R.I. Senate Health and Human Services Committee, inquiring about the possibility of journalists testifying before the Commission, based on their reporting on health care in Rhode Island, as a way to move the conversation in a different direction, away from technical “experts” and data and more toward the day-to-day encounters of everyday people trying to navigate through the labyrinth of the health care maze, often at the mercy about how decisions are made about reimbursement rates.

From “surprise” emergency room bills to “hidden” FDA databases about medical device failures, from analyzing the DEA data for prescription painkillers distribution to covering the daunting pollution problems posed by PFAS, from covering the global health consequences from man-made climate change to the persistent toxic presence of lead in our housing and our drinking water, health care reporters in 2019 have been on the front lines, capturing the patients’ often unheard and un-heeded voices.

[Editor’s note: The idea is also, in part, an outgrowth of ConvergenceRI’s own jarring personal experiences with the health care industry, including complex neck surgery in September that required a week in the hospital and two weeks in a skilled nursing facility, providing an unexpected opportunity to be on the inside looking out, as an “undercover reporter” on assignment.]

Miller was intrigued by the suggestion; he encouraged ConvergenceRI to write something and to find other health care journalists to collaborate on possible testimony.

Of course, finding other health care reporters in Rhode Island was the first challenge; there are so few. I reached out to one veteran health care reporter to see if she would be interested in collaborating on such a project.

In an email, I wrote: “Sitting through another commission meeting to study reimbursement rates in Rhode Island, the thought struck me that what was missing from the conversation was the way that journalists might parse the questions. I asked Sen. Josh Miller, who is the chair of the commission, if he would be willing to entertain testimony from the journalists' perspective. He said to write him something, suggesting that such testimony should be not just from me.”

My email continued: “Feeling optimistic, I thought that I would reach out to you to see if you would be interested in having a conversation about potential collaboration on a presentation that looks at the issue of reimbursement rates from a journalist’s perspective. It may not be feasible, and you may not be interested, but I figured I would at least make the suggestion that we could meet for coffee to discuss further.”

In closing, I wrote: “Essentially, I believe that there is a value in having journalists to ask questions about future policy considerations when it comes to health policies.”

The health care reporter responded, declining my invitation, saying it was an intriguing idea but that she was much too busy: “This is an interesting proposal, but I don’t totally understand it. What would the presentation consist of? I’m not sure what you mean by “how journalists would parse the questions.” How we come up with our questions? Why do they need a presentation to know that? We can just ask the questions and they'll find out.”

The reporter continued: “I think reporters are responsible for understanding what’s going on, and as long as officials make themselves available on the record to fully answer questions and clarify the arcana, I can’t complain. That’s the only perspective I would have to offer, and it’s pretty obvious.”

I thanked the reporter for her prompt response and attempted to answer her questions about the purpose. “I guess what I am proposing represents a disruptive challenge to the flow of information and the role that we play as reporters – something that has been part of the disruptive model of ConvergenceRI in breaking down silos around reporting the news.”

I continued: “The origin of the idea was prompted, in large part, by being both a participant and an observer at the recent education confab held by the Rhode Island Foundation, an all-day extravaganza, to develop a consensus position about strategies being pursued by a statewide stakeholder group in formulating a 10-year plan.

“There are, as I have reported, two competing narratives [at least] about public education reform in Rhode Island. The question is: where do they intersect and when do [the ways that they diverge] get talked about, even in the coverage by the news media? Not all voices are easily heard and included in the decision-making process.

“When it comes to rates of reimbursement, [I believe] it is a similar story. As usual, I was the only reporter covering the first two meetings of the commission [a sign, perhaps, of the lack of health care reporters in Rhode Island].

“So, at one level, there is the narrative of the study commission, which has had some fascinating presentations using the APCD database, detailing the 10 most expensive diagnoses in RI, and another on the current rates surrounding dental care, where Dental Dental and Blue Cross, the two dominant dental health insurers, have not raised rates since 2008.

“The kinds of questions that I, as a reporter, want to ask, are around more details around the actual costs: how and where does the money flow?”

In sharing my exchange with a reporter whom I greatly respect as a colleague and competitor, the purpose is to make the exchange of ideas transparent. The reporter always always asks good questions.

Editor’s Note: In PART THREE of this story, ConvergenceRI will detail the topics that could be addressed in a presentation by journalists before the Commission.

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