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How to report on the rising problem of out-of-pocket health care costs

How to report on the rising problem of out-of-pocket health care costs

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While the Affordable Care Act and its expansion of insurance coverage have been the focus of the national health care conversation, more and more Americans are concerned with something more personal: their own rising out-of-pocket medical costs.

“Increasingly, it appears that Americans are singularly focused on this issue above almost all issues in health care,” said Los Angeles Times national health care reporter Noam Levey, a panelist in this week’s Health Matters webinar hosted by Reporting on Health. 

The webinar, which focused on rising health spending and surprise medical bills, also featured Larry Levitt, senior vice president at the Kaiser Family Foundation and Blair Hickman, audience editor for The Marshall Project. The trio helped reporters understand out-of-pocket costs and highlighted strategies for bringing these stories to life.

Levitt explained various types of out-of-pocket expenses, such as deductibles, copayments, coinsurance and balance billing, which occurs when a provider charges patients more than what their insurance plan pays.

When reporters compare Affordable Care Act exchange plans, Levitt advised them to carefully analyze the out-of-pocket costs. Even though premiums for various plans may be similar, deductibles can be vastly different, which can dramatically affect one’s out-of-pocket costs. Sometimes, the deductible applies to prescription drug costs, but other times it may not. Another nuance that often gets lost in the discussion is that the lowest-income enrollees can receive government cost-sharing subsidies in addition to premium subsidies, he said.

Understanding cost sharing is important because it affects both the cost of health care and how much patients use these services. “When patients face higher cost sharing, they use care less,” Levitt said.

Levitt also explored surprise medical bills, which typically fall into two scenarios. The first happens when someone goes outside of their plan’s network for emergency care and is billed for the services not covered by insurance. These surprise costs can also occur when a patient schedules an in-network procedure, but unexpectedly receives some services – such as anesthesia or lab work – from out-of-network providers. While there’s been some activity at the state level to combat these surprise bills, the key challenge is determining whether the insurance company or health provider should eat the costs. “If you’re going to protect the patient, who ends up being responsible?” Levitt asked. New York has attempted to tackle that issue by establishing an independent dispute resolution process.

Noam Levey, who covers national health care for the Los Angeles Times, helped reporters translate these cost-sharing trends into a series of compelling story ideas:

  • Variations of Cost Sharing: “The cost-sharing story … is having a greater impact in some places than others,” he said. Levey suggested not only examining how your local market’s cost sharing compares to national figures, but also contrasting that amount to the median income there. Even though health costs might appear higher in say, the Northeast, the absolute costs might be higher in states where incomes are lower such as the South – making the financial impact on consumers even more acute there. Data from The Commonwealth Fund is an excellent source for such cost comparisons. Also, take a look at your state and examine what employees are bearing in terms of both deductibles and premiums – another figure that can vary widely by geography.
  • Impact of Rising Deductibles: Reporters can look into the impact of rising deductibles. More and more patients are delaying seeing a provider until they’re sicker because they are reluctant to pay their out-of-pocket costs. Another interesting angle to consider is the impact of this on the finances of medical practices. Levey said he recently spoke to a medical group that has been struggling to balance their books, something they attribute in part to people coming to see the doctor less as their deductibles rise. Check with your local provider groups or hospitals and see what impacts high deductible plans are having on their financial outlook.
  • Surprise Billing Resolutions: Even though there’s a widespread sense that consumer protections against surprise billings are inadequate, the system for arbitrating disputes is complex. For example, California tried to pass legislature on this topic that stalled, in part, because medical groups lobbied against it and the lack of a clear resolution process for billing disputes. Consumers Union is a great resource on this topic since they’ve taken the lead on the issue, Levey said.
  • Different Insurance Plans: Another trend to keep an eye on is the development of insurance plans with a value-based design. Having a high deductible can keep people from going to the doctor, Levey said. To combat this, there are some experiments in insurance design that encourage patients to get the care they need. For example, people with diabetes might find some types of visits exempt from copays. Also, some employers are looking to reduce cost sharing in ways that increase overall health, such as incentivizing people to schedule procedures at “centers of excellence,” where outcomes may be better.

The Marshall Project’s Blair Hickman offered ideas on how to find real people who could personalize these topics in news stories. Hickman discussed use of the “callout,” an online questionnaire that you can use to find sources online. (Here’s an example from Pro Publica.) When designing questions for these forms, make them as structured as possible, she said.

“The reason is, one of the goal’s in doing an online questionnaire is volume,” she said. “As people start to fill out the answers, you’re going to get a big picture view of the landscape of the issue.”

That can be difficult, though, if all the questions are open-ended. That’s why she suggests multiple choice questions that use check boxes rather than providing open fields for the patient to fill in their own thoughts in essay form. Google forms are a convenient, free way to design these surveys, and they also allow the reporter to share the data.

To find people to complete your survey, check for established online groups such as “Paying Till it Hurts,” a popular Facebook group that stemmed from a New York Times series. Facebook groups tend to be preferable for general populations queries, while LinkedIn is best for locating specific professional groups, she said.

When crafting your callout strategy, make sure to consider all the invested parties, Hickman said. For example, if you want to know what’s happening on the consumer side, you might also design a separate questionnaire for doctors. Frame it so that they’re invited to share their expertise.

Hickman also advised reporters to invest the time to get to know their online communities and establish rapport. You can do so by hitting “like” on community posts, commenting and asking questions. “It’s important not to just parachute in,” she said. If you’re on a tighter deadline, consider sending a message to the online group’s moderator; be upfront and transparent about your aims.

When you’re working on a longer investigation that might not publish for some time, consider offering the community tidbits of information along the way, such as a Q&A with an expert on one the issue’s you are covering. Creating that content will provide value and pull people to you, she said.

Hickman concluded by discussing crowd-sourcing projects, which involve posting documents online and having readers help sort it. That can help organize what’s in a massive data set, and bring the most relevant issues to the forefront.

In the Q&A, panelists discussed how to capture both sides of a story involving “surprise billing”: While it’s tempting to make insurers the villain, it’s rarely that simple. Levey suggested reporters consider whether some physician groups are even basing their business practice on such a billing strategy, and the role those higher charges might have in keeping them in business.

Levey also proposed that reporters take a look at provider directories and see what specialties might be missing from plans with narrow networks. Resources such as Consumers Union and Clear Health Costs are also useful for navigating these complex cost-sharing stories.

When using crowd sourcing for article ideas, Levitt offered the following caveat: “It’s really important to be careful how they’re presented and reported since they’re not randomly-drawn samples and you can’t necessarily generalize from them.” 

Finally, Hickman emphasized the potential of community members to amplify one’s reporting: “They serve as little ambassadors. That’s one of the most powerful ways to get your work out there.”


Watch the archived event here: 


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Thanks for mentioning Consumers Union (CU) as a resource on health care costs. Yesterday we released a new Advocates Guide that focuses on surprise bills from out-of-network providers and is intended to help advocates and policymakers interested in practical steps to address surprise medical bills. You can view it here:

CU also collects consumer stories on surprise medical bills to identify problems and share with media and policy makers addressing this issue. You can learn more and share your story at

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Thanks for this interesting webinar!

Here at, we've been partnering with public media -- KQED in San Francisco, KPCC in Los Angeles, WHYY in Philadelphia -- and others (MedPage Today) to use shoe-leather journalism combined with database reporting and crowdsourcing to form a full picture of pricing and engage with our communities.

Here's some of the coverage: Let us know if you want to join in!

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