Never Overlook the Bottom Line When Covering Health Care

American health care is all about business. Almost every story written or aired about health and medical topics has a business overlay. Unlike health systems of other countries, ours is market-driven. We rely on the market to provide health care, improve it and deny it to those who cannot pay. Whether it's a story about a new, hyped-to-the-hilt drug, a medical error, a family struggling to pay off medical debts or a politician pooh-poohing a proposal to help the uninsured, there is always a business or financial angle often left unexplored and unexplained. Why is this so?

Most health reporting tends to fall into distinct buckets -- consumer tips for better health, traditional business stories about hospital and medical stocks and fraud when "good" companies go astray, clinical stories often promoting unproven or ineffective treatments and policy stories seen as boring and something to be avoided if an editor wants to keep his or her job. It is this silo thinking that keeps us from seeing the underlying financial issues so crucial to public understanding of a system that consumes one-seventh of the U.S. economy and is in desperate need of repair. Almost all the stories pigeonholed into health journalism's buckets would profit from reporters casting a keen eye toward the business and economic overlay and how it intersects with the public policy issues at stake. Recently, several reporters interviewed me about health savings accounts, a new type of insurance arrangement touted as the solution for the uninsured and authorized by the new Medicare legislation. Their major question: Were these accounts good for consumers? (Which, for the most part, they are not.)

No reporter asked whether these accounts are good for the small number of insurance companies that can sell them to healthy people who are unlikely to use the policies, thus allowing the carriers to make a tidy profit since they won't have to pay claims. Insurers pushed hard for these accounts. But when Congress was debating the bill, few stories discussed the insurance industry's self interest or examined whether these accounts would really help improve access and care for millions of people. And judging from reporters' questions to me, the stories they are writing now won't delve into this subject either. That is a mistake. Pursuing this line of questioning leads to a discussion of whether these accounts are really a viable solution for the uninsured and why other options have been ignored.

Our own preconceived assumptions about medical care are also at work. Sometimes that means we look for the business angles in the wrong places, resulting in misleading coverage. Media coverage of Health Maintenance Organizations during the past decade is a case in point. When managed care first emerged, its purpose was to wring excess costs and waste out of the system. HMOs did this by imposing controls, such as referrals and reviews of medical procedures, in an attempt to ensure that care was really necessary and treatments were effective. But those tools impinged on what many consumers and yes, reporters, came to believe was their god-given right to receive all the care they wanted any time they demanded it.

Greedy HMOs were the bad guys depriving people of needed care so they could make a profit. The press accused them of managing costs, not care. Never mind that hospitals and doctors, who saw their incomes shrink during managed care's heyday, were only too happy to see the media focus on insurance profits and not their own. But by doing so, the media missed another business angle of a very complex story. Eventually, managed care responded to what the marketplace seemed to want and pulled back from cost control and efforts to improve quality. In the end, the public lost. Now there's no way to control costs, there's less emphasis on providing quality care and few organized systems are willing to make the financial investment in such technology as electronic medical records, which are vital for improving care. By failing to consider all the financial stakes surrounding managed care, the media helped keep the public in the dark.

It's too simplistic to say that we should report only on financial winners and losers in health care. If we do, we will begin to ape the political press, whose stock in trade has become winners and losers in political battles, but with little illumination of the substance behind the politics. An analysis of winners and losers must be carried beyond the mere fact that some people will benefit and other people won't from any given health issue. The U.S. health system revolves around protecting the financial turf of its many stakeholders. Making sure their bottom lines are untouched is what keeps real reform at bay. Most health and medical stories afford an opportunity to carry the analysis much deeper. These stories need a makeover. The sooner, the better.

Copyright © 2008 Donald W. Reynolds National Center for Business Journalism