Medical Debt Research Articles

How Infectious Disease Experts Impacted the Coronavirus Disease 2019 Response: Lessons From the Front Lines.

In this article, we summarize findings from research conducted by the Johns Hopkins Center for Health Security and the Infectious Diseases Society of America to understand infectious disease (ID) workforce contributions to the coronavirus disease 2019 (COVID-19) response and their impacts. ID experts were found to have made diverse and unique contributions that went well beyond their usual responsibilities, with many spending several hours a week on these activities without additional compensation. These efforts were thought to not only build community resilience but also augment the ongoing public health response. Respondents also reported several hospital and clinical leadership roles taken on during the pandemic, such as developing protocols and leading clinical trials. We also make several policy recommendations, such as medical student debt relief and improved compensation, that will be needed to help fortify the ID workforce for future pandemics.

PC42. The Epidemiology of Postoperative Catastrophic Health Expenditure in The United States

PURPOSE: Approximately 23 million people struggle with medical debt in the U.S. This amounts to over $195 billion debt in collection. The burden of healthcare costs on patients is defined quantitatively as catastrophic health expenditures (CHE). The burden of CHE among surgical patients remains unknown. The goal of this study was to define the burden of CHE on surgical patients in the U.S. METHODS: Survey data from a nationally-representative sample of hospitalized adults undergoing surgery between 2016 and 2019 were analyzed using the Medical Expenditure Panel Survey. CHE was defined as out-of-pocket and premium costs greater than 10% of household income. Federal income subgroups included: lowest-income (138% or less of federal poverty level [FPL]), low-income (139%-250%FPL), middle-income (251%-400%FPL), and high-income (>400%FPL). Logistic regression models were used to estimate odds of CHE. RESULTS: Incidence of CHE was 24.9% in all surgical patients. Incidence was 49.2% for the lowest-income category, 28.3% for low-income, 22.1% for middle income, and 12.4% for high-income. Each descent in poverty category was associated with 52% increased odds of CHE (OR 0.657, 95% CI [0.627 - 0.690], p < 0.001). Incidence of CHE was 39.9% in the publicly insured, and 18.6% in privately insured. Patients with Medicare or Medicaid were four times more likely to experience CHE than the privately insured (OR 4.06, 95% CI [3.50 - 4.71], p < 0.001). CONCLUSION: Incidence of CHE after surgery is higher than previously modelled, with lowest-income and underinsured patients at highest risk. Identifying vulnerable populations facilitates implementation of targeted interventions.

Embracing our responsibility to ensure trainee competency.

Embracing our responsibility to ensure trainee competency.

Satan Shoes or Satan Speech? Balancing Trademark and First Amendment Rights in the Altered Authentic Goods Context

Satan Shoes or Satan Speech? Balancing Trademark and First Amendment Rights in the Altered Authentic Goods Context

Overcoming Burnout and Promoting Wellness in Radiation Oncology: A Report From the ACR Commission on Radiation Oncology

Burnout, defined by the presence of emotional exhaustion, depersonalization, and decreased sense of personal accomplishment, impacts a significant portion of radiation oncologists. This has been exacerbated by the COVID-19 pandemic, is notably worse for women, and has been identified as an international concern. Key contributors to burnout within radiation oncology include inadequate clinical and administrative support, imbalanced personal and professional lives including time with family and for self-care, decreased job satisfaction secondary to increased electronic medical record and decreased patient time, unsupportive organizational culture, lack of transparency from leadership and inclusion in administrative decisions, emotionally intensive patient interactions, challenges within the radiation oncology workforce, financial security related to productivity-based compensation and increasing medical training-related debt, limited education on wellness, and fear of seeking mental health services due to stigma and potential negative impacts on the trajectory of one’s career. Limited data exist to quantify the impacts of these factors on the overall levels of burnout within radiation oncology specifically, and additional efforts are needed to understand and address root causes of burnout within the field. Strategies should focus on improving the systems in which physicians work and providing the necessary skills and resources to thrive in high-stress, high-stakes work environments.

"It was kind of a nightmare, it really was:" financial toxicity among rural women cancer survivors.

The purpose of this study was to examine how rural women cancer survivors experience and manage financial toxicity. A qualitative descriptive design was used to explore experiences of financial toxicity among rural women who received cancer treatment. We conducted qualitative interviews with 36 socioeconomically diverse rural women cancer survivors. Participants were categorized into three groups: (1) survivors who struggled to afford basic living expenses but did not take on medical debt; (2) survivors who took on medical debt but were able to meet their basic needs; and (3) survivors who reported no financial toxicity. The groups differed by financial and job security and insurance type. We describe each group and, for the first two groups, the strategies they used to manage financial toxicity. Financial toxicity related to cancer treatment is experienced differently by rural women cancer survivors depending on financial and job security and insurance type. Financial assistance and navigation programs should be tailored to support rural patients experiencing different forms of financial toxicity. Rural cancer survivors with financial security and private insurance may benefit from policies aimed at limiting patient cost-sharing and financial navigation to help patients understand and maximize their insurance benefits. Rural cancer survivors who are financially and/or job insecure and have public insurance may benefit from financial navigation services tailored to rural patients that can assist with living expenses and social needs.

The Things We Give

How much is a year of your life worth? How much would you sell a year at the end of your life for? In this work of philosophical short story fiction, Martha finds herself in need of money. She heard from a friend that LifeCorp will pay $500,000 for a year of the end of your life. She heads in, fills out the forms, and finds out, because of her drinking, smoking, and rudderless lifestyle, her life is only worth $20,000 per year. She sells 18 years of her life, pays off her parent’s medical debt, and goes to get drunk. A few months later, she finds out she is pregnant with Benito’s child. It’s a casual relationship, but he agrees they should both go in to sell a year of their life to help support their new child. Benito’s sale is successful, however, when they run tests on Martha, they determine she doesn’t have a year left to sell.

Radiology as a Screening Encounter for Medical Financial Hardship.

Medical financial hardship is a well-documented issue in the United States, with 56% of adult Americans reporting financial hardship between 2015 and 2017 [1]. Financial hardship consists of three domains—material conditions from increased out-of-pocket costs (OOPC) (eg, medical debt), psychological responses (eg, financial worry), and coping behaviors (eg, forgoing care because of cost)—and is associated with decreased quality of life and survival [2].

The Impact of Hospital Closures on Medical Debt in Collections: Analysis Using Consumer Credit Bureau Data

The Impact of Hospital Closures on Medical Debt in Collections: Analysis Using Consumer Credit Bureau Data

Abigail Geisinger Primary Care Scholars: An Innovative Educational Program Addressing Critical Workforce Needs.

The number of primary care physicians in the United States is inadequate to meet current or projected needs. This is likely exacerbated by continuing increases in the cost of medical education and student debt. The Geisinger Commonwealth School of Medicine is part of an integrated care delivery system in which primary care is central to managing health, improving access, and advancing value-based care. The need for primary care providers and psychiatrists is difficult to meet despite generous recruiting incentives. To address this, the Abigail Geisinger Scholars Program (AGSP) represents a novel curricular approach linked with the provision of full tuition and fees and a living stipend to students who commit to work at Geisinger in primary care or psychiatry following residency. The support is provided as a forgivable loan. The program features preferential clinical placements, curricular enhancements, and celebration of the dedicated cohort. Fair and nonpunitive provisions allow students to opt-out. The AGSP supports 45 students in each class of 115. Outcomes monitored include withdrawals from the AGSP; academic performance of participants and their satisfaction with the program; the number who choose to repay the loan rather than fulfill the service obligation; the percentage who remain at Geisinger and in primary care following the period of obligation; and other measures. This model offers an attractive opportunity for students to experience a curriculum enhanced in primary care while receiving generous financing for their medical education. It bolsters the primary care physician workforce and aligns care delivery with new financing models.

Hospitals Suing Patients: How Hospitals Use North Carolina Courts to Collect Medical Debt

Hospitals Suing Patients: How Hospitals Use North Carolina Courts to Collect Medical Debt

Financial Toxicity: A Barrier to Achieving Health Equity in Cancer Care

Financial Toxicity: A Barrier to Achieving Health Equity in Cancer Care

256: FAMILY FINANCIAL HARDSHIP BEFORE AND AFTER PEDIATRIC CRITICAL ILLNESS

Introduction: Little is known about caregiver financial hardship before versus after a child’s Pediatric Intensive Care Unit (PICU) hospitalization. Methods: We used a novel dataset linking statewide commercial insurance claims to cross-sectional commercial credit data. Using validated revenue codes, we identified PICU hospitalizations (age ≤18 years) in January-June 2020 and January-June 2021. Caregivers of these children were identified as adults listed as the primary plan holder or spouse of the primary plan holder. Financial measures in January 2021 assessed pre-PICU status in the January-June 2021 cohort and post-PICU status in the January-June 2020 cohort. Financial measures included delinquent debt, debt in collections by type (medical and non-medical), low credit score(< 660), and financial hardship(composite of any outcome). Logistic and generalized linear regression models were used to compare caregiver financial status in the 2021 vs 2020 cohorts (pre- vs post-PICU). Models were adjusted for child’s age and comorbidity status, hospital length of stay, and household status (primary plan holder with a spouse on the plan; spouse; and primary plan holder with no spouse on the plan). Results: We identified 1038 caregivers for 608 children pre-PICU and 1092 caregivers for 631 children post-PICU. 99.8% (n=2,126) of caregivers were linked to their credit report data; 1035 pre-PICU and 1091 post-PICU caregivers. Post-PICU caregivers had higher adjusted odds of any delinquent debt [adjusted Odds Ratio 1.22; 95%CI 1.00-1.48; p=0.04]. Post-PICU caregivers had higher frequencies of medical and non-medical debt in collections, and low credit score, though not statistically significant. For those with delinquent debt, post-PICU caregivers had higher adjusted mean debt than pre-PICU caregivers ($3692 vs $2536, p< 0.01). Amounts of medical and non-medical debt in collections were similar. 45.7% and 49.8% of pre- and post-PICU families had any measure of financial hardship. Conclusions: Financial hardship is common in caregivers of critically ill children—present in nearly half before and after PICU hospitalization. While delinquent debt was higher after PICU hospitalization, medical debt in collections was similar pre- vs post-PICU, suggesting non-medical costs may be a key driver of financial hardship post-PICU.

Health Insurance and Young Adult Financial Distress

AbstractWe study how health insurance eligibility affects financial distress for young adults using the Affordable Care Act's (ACA) dependent coverage mandate─the part of the ACA that requires private health insurance plans to cover individuals up to their 26th birthday. We examine the effects of both gaining and losing eligibility by exploiting the mandate's implementation in 2010 and its automatic disenrollment mechanism at age 26. Our estimates show that increasing access to health insurance lowers young adults’ out‐of‐pocket medical expenditures and debt in third‐party collections. However, reductions in financial distress are transitory, as they diminish after an individual loses access to parental insurance when they age out of the mandate at age 26.

Falling Short: Examining Medical Debt and Cost Avoidance in American Indian and Alaska Native Households.

The Affordable Care Act (ACA) expanded access and assistance to many Americans, but health care remains prohibitively expensive for some, including people with insurance. The COVID-19 pandemic brought to the forefront the precarious conditions of those facing financial and health crises, including American Indians and Alaska Natives (AI/ANs). Theoretically, AI/ANs should have some insulation because of their health care access through Indian Health Service (IHS) and ACA Tribal health insurance options. We use 2018 National Financial Capability Study's survey data to examine household medical debt and cost avoidance behaviors. Findings show AI/ANs are more likely to have medical debt and skip filling prescriptions due to costs than non-Hispanic Whites. Implications are AI/ANs may face financial and health burdens due to insufficient health coverage, possibly exacerbated by the shortcomings of IHS or other underlying factors. Future research should use a qualitative approach to elucidate factors influencing health care finances and behaviors of AI/AN communities.

Medical Student Debt and the US Infectious Diseases Workforce.

Student debt in the United States is at historically high levels and poses an excessive burden on medical graduates. Studies suggest that financial limitations dissuade some medical trainees from pursuing careers in infectious diseases (ID) and other cognitive specialties, despite their interest in the subject matter. Addressing student debt may have a transformative impact on ID recruitment, diversification of the ID workforce, and contributions of ID physicians to underserved public health needs. Relief of student debt also has the potential to narrow the racial wealth gap because nonwhite students are more likely to finance their postsecondary education, including medical school, with student loans, yet they have a lower earning potential following graduation. An executive order from the Biden-Harris administration announced in August 2022 presents a first step toward student debt relief, but the policy would need to be expanded in volume and scope to effectively achieve these goals.

Exploring US internal medicine resident career preferences: a Q-methodology study.

Career selection in medicine is a complex and underexplored process. Most medical career studies performed in the U.S. focused on the effect of demographic variables and medical education debt on career choice. Considering ongoing U.S. physician workforce shortages and the trilateral adaptive model of career decision making, a robust assessment of professional attitudes and work-life preferences is necessary. The objective of this study was to explore and define the dominant viewpoints related to career choice selection in a cohort of U.S. IM residents. We administered an electronic Q-sort in which 218 IM residents sorted 50 statements reflecting the spectrum of opinions that influence postgraduate career choice decisions. Participants provided comments that explained the reasoning behind their individual responses. In the final year of residency training, we ascertained participating residents' chosen career. Factor analysis grouped similar sorts and revealed four distinct viewpoints. We characterized the viewpoints as "Fellowship-Bound-Academic," "Altruistic-Longitudinal-Generalist," "Inpatient-Burnout-Aware," and "Lifestyle-Focused-Consultant." There is concordance between residents who loaded significantly onto a viewpoint and their ultimate career choice. Four dominant career choice viewpoints were found among contemporary U.S. IM residents. These viewpoints reflect the intersection of competing priorities, personal interests, professional identity, socio-economic factors, and work/life satisfaction. Better appreciation of determinants of IM residents' career choices may help address workforce shortages and enhance professional satisfaction.

CareCredit: Profiting off Medical Debt.

CareCredit: Profiting off Medical Debt.

Medical debt during epidemics: A case for resolving the situation in low- and middle-income countries such as Kenya

This paper evaluates the problem of medical debt in Kenya during the COVID-19 pandemic. The medical debt problem is compounded during pandemics such as COVID-19 when patients seek treatment and end up in insurmountable debt because illnesses related to the pandemic are not covered by the Kenyan National Health Insurance Fund (NHIF), the public health coverage body under government control. As a result, discharged patients may be detained in hospitals and dead bodies are locked away in mortuaries, until relatives and friends fundraise and clear the bills. Apart from causing vulnerability, fear, and emotional stress among the poor, this practice leads to a growing lack of trust in the healthcare system, with patients deliberately avoiding hospitals whenever they suspect they have COVID-19. The resulting vicious cycle makes healthcare more inaccessible by limiting the choices that people may have. User fees, which were introduced in all public health facilities by the Kenyan government as part of a World Bank prescription for cost-sharing, normally affect more women than men. Although Kenya has implemented a general waiver system in public hospitals for those who cannot pay their medical bills, the process of obtaining this waiver can be burdensome, demeaning, and dangerous for the health of the patients. This undermines the government’s commitment to the provision of equitable and affordable health care for the citizens. In this article, the problem of medical debt in Kenya is addressed as a multi-faceted problem drawing on issues of justice and fairness, human dignity, good governance, the interplay between global and local policies, as well as politics and law. It argues that it is in the best interest of Kenya and other African countries to ensure that public health coverage covers pandemics so that the majority poor can afford and access healthcare.

Insurance Subsidies, the Affordable Care Act, and Financial Stability

AbstractThis paper measures the effects of subsidies in the Affordable Care Act on adverse financial outcomes using administrative tax data and credit data on financial outcomes. Using a difference‐in‐differences design with propensity score reweighting, I find that at $100 per capita, ACA premium tax credits and cost‐sharing reduction subsidies reduced consumer bankruptcies and severe auto delinquency by 8 percent and 7 percent, respectively, and substantially reduced right‐tail delinquent debt and third‐party collections. The value of recipients’ risk protection against medical debt payments amounts to approximately 16 to 21 percent of the cash costs of the subsidies, while the subsidies provided substantial indirect transfers to external parties.