Steven Brill, the journalist, entrepreneur, and founder of the Yale Journalism Initiative, shook up the healthcare establishment last March with his 36-page expose, “Bitter Pill: Why Medical Bills are Killing Us,” published in Time. The piece, which closely examined the reasons that US healthcare costs so much, has reverberated far and wide. Recently I sat down with Brill to talk about the reaction to his story, the state of healthcare journalism, and where the discussions about our healthcare system should go.
Trudy Lieberman: What has been the journalistic reaction to “Bitter Pill?”
Steven Brill: It’s been a mix of sour grapes and praise. Some reporters wrote that this is a creative and new way to look at an old problem, and others wrote articles saying there’s nothing new here. A reporter from the Springfield, MO, News-Leader, Sarah Okeson, challenged me on a number and she was right; I had multiplied a profit margin incorrectly. So I asked Time to run a correction. I really respected the way she asked the question and did the work.
TL: What reaction did you get from the hospitals?
SB: Not much. Their response has been muted. The American Hospital Association did a hilarious Web page. An association of hospital finance administrators said they had been working for years to eliminate the chargemaster [an internal price list for medical services kept by hospitals, which Brill characterized as a list of extremely high prices “devoid of any calculation to cost.” ]
TL: And what has been the public’s reaction?
SB: The public’s reaction was not like anything I have seen in response to something I have written. People are really interested in this. I get 30 emails a day from the public.
TL: If the public appears to be interested in healthcare costs, judging from the reaction you’ve had, why do journalists have such a tough time interesting editors in health policy stories especially those dealing with costs?
SB: There’s a thinking that some people don’t care about healthcare costs. That’s increasingly untrue. People really do care, because with co-pays and deductibles rising they increasingly have to pay for it themselves.
TL: How did the doctors react?
SB: Of all the problems in healthcare, the fact that doctors’ salaries are pretty high—though they are maybe half the salaries of decently successfully lawyers—is not high on my hit parade. What doctors do takes brainpower, and they should be paid for it. The fundraising director at Sloan-Kettering makes two or three times as much as the average doctor.
TL: If journalists haven’t done this story in such a comprehensive way, why is that?
SB: They are given assignments to produce every day. They are on a treadmill and don’t have the time to spend all day deciphering CPT codes like I did. Or at least that is what they’ll tell you.
TL: In other words, what you did is hard work.
SB: It’s a ton of work. Most journalists feel intimidated by codes and documents and language they don’t understand. If I have one strength, it’s that I don’t get intimidated. For me getting a 48-page bill from MD Anderson [the Houston cancer center] that was unintelligible was like being in heaven. There was all this stuff to unravel.
TL: How is healthcare being covered, generally?
SB: Often, because healthcare reporters cover a beat, they can’t find stories that are hidden in plain sight. As a general matter, beat reporters take the state of play as it is. They get caught up in the prevailing debate and the four corners of the system rather than looking beyond it.
TL: Can you give an example of what they miss?
SB: All the debate on Obamacare was about who should pay for the high cost of healthcare, not about the more fundamental issue: Why does it cost so much? Reporters, like the policy makers they were covering, simply accepted the ridiculously high cost as a fact.
TL: When you were an editor, how did you encourage reporters?
SB: I pushed reporters not to take stories on the terms they were give. Always to ask more fundamental questions. Always to stretch further. Otherwise, why bother being a reporter?
TL: How do we break through the healthcare narrative reporters keep passing along?
SB: You should scramble beats. Change reporters every two years so they don’t become part of the process.
TL: Does the failure to do that explain why we keep seeing the same sources quoted over and over, with little new thinking brought into the story?SB: That explains a big part of it. Really, who needs to hear Peter Orzag yet again talk about how fee for service drives up healthcare costs?
TL: What’s a good hospital story a reporter should dive into?
SB: If I’m a reporter in any city and covering healthcare, why haven’t I gotten a hold of the hospital chargemaster and written about it? Why haven’t I looked at the probably oppressive non-compete contracts they force on their doctors? There are all these great stories out there….
TL: Why haven’t reporters tackled more of the healthcare business angle?
SB: In some cases they are intimidated.
TL: Reporters sometimes complain about lack of access to top hospital officials, and in your Time piece you noted many of those high officials did not talk. How much is this a barrier to good reporting on hospitals?
SB: You are mis-defining access. Access isn’t, in this case, about talking to the CEO of a hospital. It’s about getting the bills. It’s about getting their publicly available financial reports. About getting the insurance companies’ explanations of benefits that they give to patients. Or the cost data the hospital has to file with CMS. In that sense, I got all the information I wanted. I was buried in access—three file cabinets full by the end. If a reporter says, ‘Gee, I emailed the president of a hospital and he didn’t answer my email,’ that’s not the kind of reporter you want on your staff.
TL: Where should reporters take the healthcare story now?
SB: A story like the one I wrote can and should be written in every community in the US. For example, I just scratched the surface on lab fees and diagnostic tests. Why do we order so many tests? You can’t do enough of this kind of reporting. Journalists have been derelict, but there also great opportunity. Every hospital, every lab, every drug company has a story, and the data are accessible if you’re willing to spend the time and play with it.
TL: You note in your piece that hospital consolidation will end up raising the cost of care. How would you push back against the market power of the hospitals, the way governments in countries with national health systems do?
SB: There are lots of ways. First is complete transparency, so you know what you’re arguing over. You could simply say all prices have to be transparent, and no provider could vary the price by more than 10 percent. You could require all hospitals to charge the same prices for the same procedures. You could allow them to charge 140 percent of what Medicare pays. You could divide healthcare services into two types—voluntary and involuntary. Voluntary services would be things like Lasik or cosmetic surgery. Involuntary services are those you wouldn’t choose to do unless you have to. The prices for these things have to be regulated.
TL: What about regulating profits?
SB: You could limit their profits to five percent, and anything more than that, they would have to put back in the system by providing more free care, or paying a tax. Once you realize that the price of care is too high, you can regulate the prices you can charge.
TL: What are the chances of this happening?
SB: I can say now they are slightly more than nil. It can become a significant issue politically. There will be some change because the healthcare industry has priced itself into the political arena.
TL: Can states lead the way?
SB: Yes. Maybe there could be 46 or 50 Marylands, a state with price regulation.
TL: How far can transparency go to move the needle?
SB: It can only go so far. It’s good that chargemaster prices have now been made public by Medicare. Knowing what hospitals charge insurance companies would also go a long way. There’s no reason why a state can’t disclose those charges. Once you have that information, that’s good. But it’s only the beginning of the conversation. Transparency and skin-in-the-game is a way to begin the conversation, but it’s not the answer. Until patients have leverage—which they never will—you’re not going to change medical pricing. The only way to control medical prices is how every other country does it. The market can’t work without government regulation.
TL: What are the shortcomings of the Affordable Care Act, in your view?
SB: It nips at the edges but doesn’t address the basic problem of the cost of healthcare. It deals with who pays the costs, not what the costs are. The law passed precisely because it doesn’t solve the problem
Healthcare reporters who are in New York on June 11 are invited to the New York chapter meeting of the Association of Health Care Journalists, at which Steven Brill will speak. It will be held at 6:30 at the office of the New York State Health Foundation, 1385 Broadway.