The Media and Change in Health Systems

Since the Foundation emerged as a national philanthropy a quarter century ago, research has been one of its strategies for helping the nation (albeit indirectly) improve the health and health care of Americans. The logic of the investments in research presumes that more-reliable information can be the basis of more-informed public debates and decision making about health care.

However, the Foundation's interest in research has always been an applied one: it is funded to the extent that it advances--even if in the long run--the goals that are the cornerstones of the Foundation's grant making. However, for research to have an impact, it must be disseminated. Traditionally, research findings by grantees have been communicated through articles in peer-reviewed academic journals.

Although not deemphasizing the importance of peer-reviewed publications, in recent years the Foundation has recognized the importance of getting information to audiences other than academics and policy experts. Chapter Five describes one experience with an ambitious effort to communicate research findings to a wider audience. The Local Media Education Project was a program to transmit to journalists the latest research on the changing health care system in their communities and to explain what it meant for their readers.

Even though the idea of getting findings to local journalists is easy to state, implementing it turned out to be time-consuming and difficult. The chapter takes the reader behind the scenes of one such effort, conducted by the authors, Marc S. Kaplan, a senior communications officer at The Robert Wood Johnson Foundation, and Mark A. Goldberg, a distinguished fellow at the Yale University School of Management and a senior fellow at the Carnegie Foundation for the Advancement of Teaching. It provides insights about how foundations can work to ensure that findings from their grant-supported research reach diverse audiences.

Health care in the United States has increasingly become managed care, and just about everybody is perplexed about the pace, the direction, and the implications of the change coursing through their local institutions and markets. Yet, despite their confusion, people must make decisions: patients about their selections among health care plans, providers, and courses of treatment; providers about their responsibilities as professionals in a shifting environment; employers about the extent and the types of health care insurance to buy or subsidize for employees; managers of health care organizations and insurers about their strategies for survival and success; and public officials about how to manage and adjust government health care programs in the midst of change.

Change seems to characterize health care everywhere: in large cities and small towns, in every region of the country. But that change is not uniform. Every local market is distinctive in its history, its set of health care institutions and players, its demographic and health profile, its culture, and its competitive dynamic. Much of what can be done to explain health care change, therefore, has to be done at a local level--in the idiosyncratic markets where people live and work and where each group must make decisions about care and its financing and delivery. That is why The Robert Wood Johnson Foundation funded the Local Media Education Project. This project had two components: briefings of print journalists in fourteen cities and briefings of broadcast journalists in four of those cities.

Our briefings proceeded from four premises. The first was a broad conception of the potential audience for health systems research. We believed that the results of some (though certainly not all) such research would interest not only analysts and public policy makers but also the consumers of health services, whose well-being and finances could be affected by changes under way in health systems, and a range of key actors in the private and nonprofit sectors.

The second premise was that journalists are themselves a crucial audience for the results of research about health system change, because they inform and help shape the understandings of other audiences. Journalists alert consumers to developments and potential developments that involve their interests. They also apprise key health care decision makers of developments in and outside their particular segments of the system. Key health care players pay close attention to the major newspapers in their communities, as sources of information about what other players are doing or planning to do and for insights into the perceptions and concerns of consumers.

A third basis for our briefings was that the Center for Studying Health System Change had generated a body of research that could be extraordinarily useful to journalists as they reported on changes in local health care markets. The Center, which is based in Washington, D.C., was established and funded by The Robert Wood Johnson Foundation to track and analyze health systems changes around the country. In its first phase of work, the Community Snapshots Project, the Center assembled brief profiles, or "snapshots," of developments in fifteen markets, selected to represent a range of regions, population sizes, and stages of development. Each market was covered by one of three teams of researchers, whether from the Alpha Center in Washington, D.C., the University of California at San Francisco, or the University of Washington. The teams conducted extensive local interviews and reviewed secondary materials. They prepared reports on the nature and sources of change in that market: the experiences, reactions, and strategies of major actors in that market, including providers, purchasers, insurers and health plans, public policy makers, and consumers; and the potential trajectory of the market.¹On the basis of these snapshots, the Center and members of the three research teams also were able to develop cross-cutting analyses that identified and explored similarities and differences in the patterns observed across communities^.2

In addition, the Foundation commissioned Louis Harris and Associates to undertake a broad survey of consumers, including a nationally representative sample of 605 respondents and separate representative samples of approximately 300 respondents in each of the fifteen markets studied. Consumers in both the national and market-specific surveys were asked three broad sets of questions: about their perceptions of trends in access to health care and its cost and quality; about their reactions to the growing influx and influence of managed care, and about their expectations and concerns for the future.³

Here, then, was a wealth of material that could help journalists refine their understanding of the changes taking place in their communities' health care markets, the interplay among sets of actors and interests, and the perceptions and reactions of consumers (their readers). What is more, because fifteen markets had been analyzed concurrently within a common framework, and because surveys had been conducted in those markets and nationally with a common instrument, we were able to draw comparisons across markets and, for the survey results, relate the response patterns in an individual community to those in the national sample.

The fourth predicate for this initiative was that the Center's work potentially had value to journalists over time as well as in the short term. The Center's findings--particularly the results of the market-specific surveys--were news, and we hoped that they would be covered as such. But we also hoped that our briefings about the site visit reports and the surveys would make a more lasting contribution--that they would help journalists place future news stories in context for their readers. Our effort was meant to educate, not only to disseminate. That is why, within The Robert Wood Johnson Foundation, it came to be known as the Local Media Education Project.

In the spring of 1996, under the auspices of the Foundation, the two authors of this chapter visited fourteen markets out of the fifteen studied, in which health care providers, insurers, employers, public officials, and, not least, patients are living through a period of consolidation, competition, and dislocation. In our visits, we met with journalists who cover the transformation of those markets. We briefed newspaper reporters and editors on changes in their specific market, with information from research conducted under the auspices of the Center for Studying Health System Change.

We met with an average of four journalists at each of the newspapers we visited. At fourteen of the fifteen newspapers, our briefings were attended not only by reporters but also by editors. The presence of editors was significant because they decide a newspaper's priorities--what reporters are assigned to cover, what topics and stories find their way into print. At seven of the newspapers, we spoke with editorial writers, too.

Briefings were constructed from five sets of materials: (l) the site visit reports for the fifteen markets studied; (2) the results from the market-specific surveys and the national poll conducted by Louis Harris and Associates; (3) updated reports for each of the markets, typically written by one of the original analysts on the basis of follow-up interviews and a review of secondary materials; (4) newspaper articles, found in NEXIS searches, about health system changes in each market since the site visit reports were completed; and (5) the researchers' analysis of patterns and trends across markets. The meetings we had with editors and reporters were highly interactive and fluid. We invited journalists to jump in at any time with questions or observations, and they did.

We started each session by describing The Robert Wood Johnson Foundation and its work and, in turn, the Center for Studying Health System Change, its Community Snapshots Project, and its research program. Next, we summarized the broad patterns of change, causation, and strategies found across the fifteen communities. Distinctive features of the particular market under discussion were highlighted, framing, with themes and potential story lines, the market-specific details to follow. Journalists at virtually every newspaper we visited wanted to know what was special about their area's health care market--what set it apart from the others studied.

The next (and longest) portion of the briefing was a discussion of the major players, directions and drivers of change, and patterns of competition. We also listed emerging trends and potential developments in the market--trends and developments that might warrant future coverage. The final component of the presentation at each newspaper was an examination of the findings of the Harris survey in the local market and a comparison of them with findings in the national survey.

The participating journalists were knowledgeable and energetic. They asked all sorts of questions, about their markets, other markets, the workings of competition, and managed care. As busy as these journalists were, they stayed put for our briefings, each of which lasted an average of two hours. The Local Media Education Project led to a first wave of thirty articles or editorials in the fourteen markets we visited. Every newspaper ran at least one story about the research conducted by the center and its collaborators. Five newspapers ran front-page stories: the Orange County Register (California); the Gainesville Sun; the Indianapolis Star; the Forum in Fargo, North Dakota; and the Des Moines Register. Two papers put articles about the center's findings on page one of the metro or regional section, and three others on the front page of the business section.

As we had suspected they would, newspapers treated the results of surveys in their markets as news. But most of them did much more than simply report those results. They also put news from the surveys into context by comparing local response patterns to patterns in the national survey and by relating the findings of the survey to the characteristics of the local health care market, as described in the site visit reports and the briefings. Some of the newspapers also focused more directly on the findings of site visit reports about their markets and, drawing on the briefings, put those findings into context as well by comparing local markets to others that had been analyzed by the site visit teams. Four newspapers also published editorials that discussed the results and the implications of the site visits and surveys.

Here are some of the lessons that we took away from our briefings that we hope others who are contemplating similar conversations with print journalists will find helpful.

In Fargo, Joe Dill, the editor of the Forum, asked us the single best question we heard in fifteen briefings: "In all of these materials about the Fargo health care market, what surprised you the most?" The question reminded us that surprise--or freshness, at least--is at the heart of most news. If findings are not new or surprising, maybe they are not, as viewed by journalists, newsworthy. They may, nevertheless, be important in framing news--that is, in providing context.

At almost every session, journalists asked, in these words or a close approximation, "What does this"--a consolidation of hospitals, the proliferation of managed care, efforts to measure outcomes--"mean for our readers?" Journalists see themselves as surrogates and watchdogs for readers, looking out for their interests and asking questions on their behalf.

We offer three corollary observations. First, not all journalists at a newspaper define their readers identically. Thus, some business reporters asked us what particular phenomena might mean for employers, hospitals, or insurers; they were especially interested in overall cost trends and competitive impacts. Reporters for the main news or metro sections of newspapers tended to ask about effects on patients and consumers; they focused on quality of care and out-of-pocket costs. Second, if the answer to that central question, "What does this mean for our readers?" is "not much," chances are that that is a good estimate of how much coverage will be forthcoming. A health systems researcher who is contemplating an approach to journalists would be well advised to be ready with a more substantial and persuasive response; if none is possible regarding a particular research project, then perhaps that project, however worthy it may otherwise be, is just not prime material for journalists. Third, journalists know that the meaning of a development or a trend may be different for different readers. That is why they often ask, as many did in the briefings, "Who are the winners and the losers?"

Researchers, especially those affiliated with academic institutions or independent research organizations, have an advantage over others who seek to speak with journalists about health care: they are accorded a presumption not just of objectivity but of fairness--of freedom from, in particular, pecuniary motivations. Thus, one reporter told us that most of the people he hears from about health care issues "have an ax to grind" and "stand to make or lose a lot of money" in the local health care market; he exempted us from this characterization. Researchers may have a related advantage as well: the perception that they offer a fresh take. Here, for instance, is the opening sentence of a column by Eve Tahmincioglu, in the News Journal, about the site visit report for the Wilmington, Delaware, market: "It's always great to get the perspective of outsiders, especially when it comes to your community's health system."⁴

Many of the journalists we met came to our briefings for news--the results of a survey of local consumers, the findings of a site visit report--but stayed for context. These briefings allowed them to step back from the day-to-day rush of new developments and to take in the big picture: not just the pieces but the dynamics of their local market; not just their local market but that market in comparison to others; not just current events but their causes, potential consequences, and possible trajectories. Many of the questions that journalists asked were about context and went beyond what they needed to know to write a story or two in the short run. Researchers who brief journalists should expect--and perhaps even encourage--questions that help reporters, editors, and editorial writers to refine and test their broader understandings.

It takes time to meet with journalists, but our experience suggests that the extra effort pays dividends. A face-to-face conversation, at a scheduled time and away from the hubbub of a newsroom, allows for a more relaxed exploration of the issues raised by research and of the context of the work and findings. That exploration can contribute to a journalist's understanding and his or her ability over time to explain developments to readers--and it increases the chances of coverage, and better coverage, in the near future. The articles written after our briefing sessions about the findings of the Community Snapshots Project went farther in providing detail, linking survey results and site visit findings, and explaining context than they could or would have on the basis of a press release alone, or a press release supplemented by hurried telephone conversations with busy journalists on deadline.

For several years now, the ratings for national news broadcasts have declined while the number of local television news viewers has grown steadily. An opportunity presented itself to launch a component of the Local Media Education Project targeting local television stations with information about the changing health care system in their communities. In conjunction with the Radio and Television News Directors Foundation, the Education Project held one-day seminars in Indianapolis, Houston, San Diego, and Miami. In each location, broadcast journalists were invited to a two-part program.

The first part consisted of an overview of the Snapshots report and Harris poll data, followed by panel discussions on recent or upcoming local health care developments. For the second part of the program, we went into the field, to health care settings where reporters could witness firsthand the consequences of their health system in flux. What was learned from discussions with seminar participants during the events, in questionnaires returned immediately after the seminars, and in lengthy telephone interviews six weeks later contributed to our understanding of how to present health care information to broadcast journalists, as distinguished from their newspaper counterparts.

Information in a newspaper story generally includes context, analysis, background, and various points of view. The three-dimensional character of this reporting is possible because of the longer lead time a print journalist usually has to research a story and the space allotted for its exposition. The constraints that television news imposes on the time a reporter has to research and report a story, and on the time allotted for it in an actual broadcast, are much different from those faced by print journalists. These constraints dictate not only how to present information to television reporters but also how to shape its substance so as to get it reported. News decisions for both television and newspapers are determined by whether an item directly or indirectly affects large numbers of people, and in what ways. The more salient (and, usually, the more disruptive), the more newsworthy. Ordinarily, television reporters can be approached only on the basis of news. For example, while the Snapshots report contained valuable information on the shifting dynamics of health care delivery in the markets of the television reporters, they regarded only the opinion polls as being able to cross the news threshold and make it onto a broadcast. In one market, which managed care had barely penetrated, it was not even possible to interest television reporters to attend a news briefing on the poll. The phenomenon of managed care simply hadn't reached a level where reporters considered it news.

But perhaps the most significant factor in how information gets treated on television news is time. Television reporters typically have at most three minutes to tell a story, and as a result nuance, complexity, and subtlety are sacrificed for generalization and oversimplification. This brief window allows comfortably for only two points of view on a single issue, contributing to the "he said/she said" phenomenon of television news. When panel discussions ventured into territory that is necessarily complex, such as a county moving its entire Medicaid population into managed care, evaluation forms came back complaining that the sessions were too technical, too detailed, too complicated.

A recurring criticism of the seminars was that the panel discussions did not sufficiently set the dynamics of the changing marketplace in dramatic relief. Television news, we were told, is about conflict. The diversity of opinions expressed in the panel discussions frustrated many broadcast reporters who wanted to be able to analyze developments in the health care system in terms of simple, clear-cut terms of winners and losers. Furthermore, we found that a single expert able to present two sides of an issue was of less interest to broadcast reporters than two individuals who were able to take opposite ends of the same issue. For example, journalists gave high marks to a panel discussion that contrasted one physician in favor of managed care with another highly critical of it.

Another great divide between print and television journalism lies in their respective abilities to use numbers to tell a story. Clearly, television is a medium driven by images to tell a story. Numbers in the form of charts and tables impede the narrative flow. When the Harris Poll results were reported on the news, for example, they took the form of a graph that was on and off the screen before viewers could absorb it. If numbers are to be depicted pictorially on television, they need to be presented with the same dramatic treatment as the images in which they are embedded.

What all this means, we think, is that it is difficult for local television news--given its tight time constraints and focus on conflict--to cover and explain complicated and interconnected changes in local health care systems. The nature of the medium leads producers and journalists to present imprecise metaphors for these changes: stories of medical mishaps and fraud, for example, that are anecdotal rather than analytical. The challenge is not to change this medium but to devise ways, within the constraints of local broadcasts, to help viewers understand their health care systems better.

The pace of change in health care shows no sign of slowing. Readers and viewers look to journalists, in print and on the air, for more than late-breaking news. They look to journalists for reliable and clear guidance about what the latest developments may mean for their health, their finances, and, in some cases, their professional lives and strategies. Researchers can perform a significant public service by helping journalists understand and explain those implications.