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"," a new documentary about nonprofit hospitals, follows the lives of three patients and their families as they get caught between two feuding healthcare giants in Pittsburgh -- the University of Pittsburgh Medical Center (UPMC) and Highmark Health -- when UPMC announced it would stop accepting Highmark Health's insurance in a business move.

Very sick patients were at risk of losing their doctors completely once an agreement between the two systems expired. With the help of journalists, activist organizers, and allies in government, they petitioned local lawmakers and even disrupted a UPMC board meeting.

This situation is a microcosm of the larger problem with the U.S. healthcare system: most hospitals are nonprofit, but still operate like big businesses. They generate enormous revenues. Instead of those profits going to stockholders, like a for-profit company, or to significant charities, money is poured back into the hospitals themselves, allowing them to expand rapidly and inflate executive pay without paying taxes locally. These nonprofit giants, "InHospitable" argues, can make whole communities dependent on them, but without accountability to taxpayers, employees, or their patients.

Sandra Alvarez, the director of "InHospitable," spoke with MedPage Today about what went into the making of the film.

Congratulations, first of all. Just to start off with, if you could tell me just a little about your own background, but also what led you to want to focus on hospitals?

Alvarez: I'm a documentary filmmaker, and I've worked on a lot of different projects and a lot of different types of worlds. I did a series for Netflix about pornography in society, I've done projects about martial arts masters and, you know, makeover mavens, so I've been all over the place. I'm always really interested in asking questions, and during all the presidential debates, right in advance of the election, you just heard people talking about insurance and Big Pharma, medical devices, and you know, "our healthcare system is broken," but you just never hear anyone talking about hospitals. ... What was their role?

I just started doing some research and started to find some pretty alarming and disturbing information about hospital consolidation, and some of the bad behaviors that nonprofit hospitals were doing, and just got really interested in that. I realized, okay, well, there hasn't been a documentary about this. Regular folks don't know about what's going on with hospitals and it affects every single one of us, so I should probably do a documentary about it.

Normally people aren't thrilled to dive into healthcare. Was it really just listening to Congress, [and] public conversations and just thinking, "I wonder what's going on with hospitals?"

Alvarez: Yeah, I just was so shocked when I started to find out these points about nonprofit hospitals and the way that they're not being really held accountable and this idea that they have all these tax breaks. It really affects the community. You still think of hospitals ... as you know, "that's the place that my dad had a heart attack and they saved his life." That's where people have their babies, and people love their doctors.

Not that there was anything nefarious -- but it just seemed like the hospitals are just being run like businesses and it bothered me because the product is a human life. And I felt like as I started working on this, I was like, well, this is kind of the ultimate test of that -- what is more complex, besides like, the tax code, than our healthcare system?

Healthcare is hard to visualize. How did you make decisions about visual cues and video? What were some unique considerations when talking about something like healthcare?

Alvarez: When we first started diving in, I think that the biggest challenge was figuring out how much of the personal story are we going to tell about the individuals and how it was personally affecting them. Because that's the thing that people really connect with, always. And how much of the bigger-picture story about hospital consolidation and accountability? What's the balance of those two things? When I say we, I'm talking about Stacy Goldate, who is our editor and one of our producers, and my collaborator.

To me, that situation in Pittsburgh was just so complicated because you had the consent decrees, and you had something that happened back in 2015, and the consent decrees had expired, and who's the consent decree with? And why?

We thought the animation would be a really great way to tell this story. But the challenge is, we didn't want the animation to feel frivolous or feel cartoonish, or that we were almost ridiculing the situation, because it was so serious. So we asked the animator to use Pink Floyd's "The Wall" as a template and just go kind of pretty dark with the animation, so people could walk away with the information they needed about the complexities of the situation in Pittsburgh, but also come away with an emotional response as well.

It's something that Natasha Lindstrom, the reporter in Pittsburgh, and I talked about all the time. She said, "This is my challenge with writing about this situation and about healthcare. How do you keep people engaged when you actually have to explain a really complex situation? How do they just not turn their computer off or just say, 'forget it'?" She collaborated on those animations, and she voiced them, to make sure that we had all the factual accuracy and the journalistic checks.

Was there anything that stood out to you, or what was the most surprising for you that you found out along the way?

Alvarez: It wasn't necessarily surprising to me that hospitals were being run like businesses. The extent [to which they were] was kind of disturbing, but it wasn't surprising. We all know we've decided as a country that we are going to have private businesses run our healthcare. But to me what was the most surprising was this question of nonprofit hospitals, and how the majority of hospitals in this country are nonprofit, and they're just, according to the communities in them, not benefiting the community in a way that justifies their large tax breaks.

Also this idea that it's a self-perpetuating system, because as the hospitals make more money, they can't claim it as profit. So they have to reinvest it in themselves. So they keep building and building and building, and they're taking all this property and these communities off the tax rolls that otherwise [would be] businesses that would be paying taxes. So now, you have less money going to schools and roads and transportation and affordable housing and all the things that we pay for with taxes, and these hospitals are making so much money. That all felt really -- it still doesn't feel right.

There's really no incentive for the hospitals to put that money back in and pass it along -- as was talked about in the film -- to patients, or for services that will be preventive. They want more patients, they want to do more services.

Alvarez: Right, right. The other thing is, so many of the people that run these hospitals are business people. They have business degrees, and they come maybe from running some other large business. And so it's difficult because they're just doing their actual job and running a business, and they're trying to figure out, "okay, what's our bottom line? How can we be most efficient? How do we lower our costs and make more money?" But the problem is when the products are human beings, and you make more money when people are sick, it gets really tricky.

You talked about incentives -- a lot of our interviewees talked a lot about value-based care, but we didn't have time to get into it in the film. But that was something that was really interesting to me, because that was the thing: these are business people. How do you incentivize them to make it so that people are healthier, instead of making more money when people are sick?

Who is the most responsible for tackling this? You mentioned value-based care -- what are some things that can actually be done?

Alvarez: The FTC [Federal Trade Commission] has recently gotten a lot more serious about it. But the problem is, you can't unscramble the egg. And so once these hospitals have these large monopolies in [an] area, it's a lot harder to break them up. You know, Amy Klobuchar and the antitrust subcommittee in the Senate and the House both watched the film, and they used the film for meetings on hospital consolidation, so committee meetings. So that was really great ... but the main concern of a lot of the experts we interviewed was, is it just too late to use that to really make an impact? Because they've [the hospitals] gotten so big.

The other question is, using the nonprofit status as an accountability lever -- every hospital is so different, so it's hard to generalize, but just being able to look at each community and say, "okay, what's not being done?" Or "how is the community being harmed and what can this specific hospital do to actually truly benefit the community?" And if [nonprofit hospitals] don't want to do it, then they can just pay taxes. One of the economists, Zack Cooper, talks about price regulation, and he makes this joke that says, "as an economist, we hate talking about price regulation. We want the market to figure itself out. We don't want to step in and have to regulate things, but I think we're at that point that that's what needs to happen."

Do you feel optimistic after making this film?

Alvarez: Yeah, I mean, this film just feels like the first step. Because really, the goal of the film was a baseline education to the general public about what's going on with hospitals. Hopefully, it generates interest in people doing their own research, reaching out to their public officials. We're hoping to screen this with a lot of politicians and public officials, so that they're educated on them.

That's the other thing I learned. A lot of people in politics, and public officials, just really had no idea, because hospitals benefit the community in these ways that seem really great, right? They're donating money to all kinds of organizations. They donate money to politicians, campaigns. They employ so many people in the community. And that seems like a great thing. They're not an easy villain in the way that insurance companies and pharmaceutical companies are. It's just harder to take them on.

Our audience is a lot of healthcare professionals and doctors. What should they be thinking about?

Alvarez: We did an interview with Dr. Dale Owen and he was from this organization called Tryon Medical Partners, and we had a whole section that we had to pull out for time, but they were the first physician's office that actually pulled out of the hospital and went independent. He talked a lot about the benefits and the freedoms they have now to actually treat the patient instead of just feeling like they're just these cogs. It's difficult, but there's definitely a path to finding their own independence.

One of the big problems is that hospitals are just buying up all these physician offices, and they're all under this one umbrella, and then they just don't have the freedom and independence to do what they would like to do, which is treat the patient, and not treat [patients] like a number on paper.

Is there anything else that you wanted to mention?

Alvarez: I think it was tricky because a lot of [people who work for healthcare systems] felt like they were all individually on their own islands if they were fighting back, if they spoke out about these problems. I always got that impression that all the doctors and the nurses and people working in these hospitals were the people that were really actually doing this wonderful, wonderful work. And so, it's not about the people that are working there. A lot of times, people conflate the two things. So when you hear like, "the hospital is doing all these bad things," it's like, well, how could they? These doctors are incredible.

Five months into making this documentary, my dad had a massive heart attack and went into cardiac arrest. And he was at Jackson Memorial Hospital in Miami for 3 months. And they saved his life. So, even for me working on this documentary about hospitals, I also had this other side, of this incredible care that he got there. And Jackson's a public hospital, so it's a little different. That was a big thing for me, really being able to separate those two things: looking at the administrators and the executives and the MBAs and people running these hospitals, and understanding that the doctors and nurses and the hospital workers are actually really caught in the middle. A lot of times when I was talking to people about this project, [they'd] say, "oh, yeah, doctors just rip you off, doctors are so greedy." I think there's a stereotype, and working on this project made me really realize that most doctors, at this point, are working as employees for these hospital systems and they're kind of at the mercy of their employers.

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