Unpaid Medical Bills Research Articles

The effects of price transparency and debt collection policies on intentions to consume recommended health care: A randomized vignette experiment

AbstractNew laws promote price transparency in health care, though effects on patient decision‐making are not known. Price disclosure may increase the salience of cost and cause lower‐income patients to decline recommended care, worsening inequities in health outcomes. Whether patients perceive a disclosed cost as higher or lower than their expectations may also affect care decisions, but has not been studied. Scholars and policymakers have paid much less attention to the question of whether patients will have to pay the prices charged (whether disclosed or not), and how expectations regarding collections may also affect healthcare consumption. Some hospitals aggressively collect on unpaid medical bills. Others hospitals do not. Actively disclosing collection policies (whether aggressive or protective) could magnify or counteract effects of price disclosures, especially for low‐income patients. To test the effect of price disclosure and debt‐collection disclosures on willingness to obtain recommended care, we recruited a nationally representative sample (N = 2997) and deployed a full factorial, controlled experiment in a standardized clinical vignette model. We find that disclosing a higher‐than‐anticipated price increases the probability of declining recommended care (odds ratio = 1.900), with larger effects for low‐income individuals. Even more, disclosing aggressive collections increases the risk of declining care (odds ratio = 4.493), at higher rates for low‐income patients. Where patients fear collections, but do not know prices, they are most likely to decline care. Disclosure of an aggressive collections policy makes patients feel less informed, harms patient trust in providers, makes them feel that they were not treated fairly, and undermines their confidence in the value of their care. Mediation analysis shows that about half of the effect of collections risk is via these attitudinal variables.

The Relationship Between Coronavirus Disease 2019 (COVID-19) Pandemic-linked Job Losses and Health Care Access and Household Financial Health in Medicaid Expansion and Nonexpansion States.

Unemployment associated with the coronavirus disease 2019 (COVID-19) pandemic was linked to financial insecurity and disruptions in access to health care. To explore whether expanded access to Medicaid mitigated the likelihood of health and non-health financial hardship associated with pandemic-linked job loss. We estimate linear regression models comparing differences in the levels of outcomes attributable to pandemic-linked joblessness in Medicaid expansion and nonexpansion states. A total of 20,281 adults aged 19-64 were in the 2021 National Financial Capability Study. Our key exposure was job loss, layoffs, and furloughs, attributable to the COVID-19 pandemic. Outcomes under evaluation include indicators of health care access and household financial health. Relative to persons reporting pandemic-linked unemployment in nonexpansion states, adults experiencing pandemic-linked job loss in expansion states were less likely to report as uninsured [-6.2 percentage points (PPs); 95% CI: -10.8, -1.6; P < 0.01], having unpaid medical bills (-4.3 PP; 95% CI: -8, -0.6; P < 0.05), having unmet medical needs due to cost (-5.3 PP; 95% CI: -10.1, -0.5; P < 0.05), and having calls from debt collection agencies (-6.9 PP; 95% CI: -10.6, -3.1; P < 0.01). Patterns consistent with Medicaid acting as a safety net for the adverse financial effects of job loss were more pronounced for middle-income households. In economic downturns, such as the COVID-19 crisis, Medicaid can help insulate households from diminished health care access and financial distress associated with job loss.

Functional impairment is associated with medical debt in male cancer survivors and credit card debt in female cancer survivors.

To examine the associations of functional limitations with medical and credit card debt among cancer survivor families and explore sex differences in these associations. This cross-sectional study used data from the 2019 wave of the Panel Study of Income Dynamics, a nationally representative, population-based survey of individuals and households in the US administered in both English and Spanish and includes all households where either the head of household or spouse/partner reported having been diagnosed with cancer. Participants reported on functional limitations in six instrumental activities of daily living (IADL) and seven activities of daily living (ADL). Functional impairment was categorized as 0, 1-2 and ≥ 3 limitations. Medical debt was defined as self-reported unpaid medical bills. Credit card debt was defined as revolving credit card debt. Multivariable logistic regression analyses were performed. Credit card debt was more common than medical debt (39.8% vs. 7.6% of cancer survivor families). Families of male cancer survivors were 7.3 percentage points more likely to have medical debt and 16.0 percentage points less likely to have credit card debt compared to families of female cancer survivors. Whereas male cancer survivors with increasing levels of impairment were 24.7 percentage point (p-value = 0.006) more likely to have medical debt, female survivors with more functional impairment were 13.6 percentage points (p-value = 0.010) more likely to have credit card debt. More research on medical and credit card debt burden among cancer survivors with functional limitations is needed.

Access to Healthcare Services among Thai Immigrants in Japan: A Study of the Areas Surrounding Tokyo.

Numerous undocumented and uninsured foreigners living in Japan have faced barriers when trying to obtain appropriate healthcare services, which have occasionally led to issues with unpaid medical bills to medical institutions. Although information on health and socioeconomic status is essential to tackle such issues, relevant data has been unavailable due to difficulties in contacting this population. This study involved a cross-sectional survey using questionnaires concerning the general demographic characteristics, socioeconomic status, health profiles, information access, and knowledge/attitude/practice of health insurance of Thai nationals living in Japan. The study participants included Thai nationals who lived in Tokyo and the surrounding prefectures. The survey was conducted mainly at public religious events from September 2022 to December 2022. Overall, the questionnaires were obtained from 84 participants, though 67 participants were included in the final analysis after excluding missing variables. There were participants with unspecified visa status (32.8%) and uninsured status (40.3%). Among them, 86.4% expressed positive attitudes towards health insurance. However, multivariate multivariable regression analyses revealed the low insurance practice status among the unspecified visa group (aOR, 0.02; 95% CI, 0.00-0.13). Overall, the results reveal limited access to healthcare services in subgroups of Thai immigrants in Japan.

Hospital Detention for the Inability to Pay: A Qualitative Study of Patient Experiences in Cameroon

IntroductionEquitable access to quality surgical care and low-cost healthcare services for all segments of the population remains a big problem in many African health systems. In Cameroon, it is very common to find medically discharged patients who have received surgical treatment and are unable to pay the resulting bills. These patients can be held in detention in hospitals until payments are complete. Even the corpses of patients who die with unpaid medical bills can be withheld until their family members pay off the debt. While this practice has been ongoing for many y, there remains very little scholarship on the issue reported in the literature. The main objective of this study was to uncover the lived experiences of discharged patients residing in hospital detention for being unable to pay their medical bills. MethodsIn-depth interviews, focus group discussions, and observations were conducted with purposefully selected patients living in detention in 2 rural private hospitals in the Fundong Health District in Cameroon. A thematic framework technique was used to analyze the transcribed data. The study was ethically approved by the Cameroon Bioethics Initiative, and informed consent was obtained from all participants. ResultsLiving in hospital detention after receiving treatment constitutes an economic, social, and psychological burden for patients. Economically, it exacerbated poverty for the patients unable to purchase food, medications, and clothing due to lack of jobs and financial support. Socially, many of these individuals suffered from isolation, loneliness, shame, stigma, risk of contracting other diseases, and precarious sleeping conditions. The psychological burden was comprised of stress, depression, trauma, nightmares, and suicidal thoughts. ConclusionsThe experiences of discharged patients in hospital detention suggest that they live in very deplorable conditions. There is a need for a functional healthcare protection mechanism, such as universal health coverage, to reduce the cost of healthcare services and surgical operations. Alternative payment mechanisms should also be considered.

Student Loan Debt and Financial Hardships in Health Care Utilization

This study examines the association between student loan debt and financial hardships in health care utilization among young adults, with a focus on differences by race. This study analyzes data from the 2018 National Financial Capability Study, a publicly available data set, and includes 4,535 young adults in the age groups of 24–35 years. The study results show that student loan debt was related to financial hardships in health care utilization, measured with unpaid medical bills and missed health care services because of costs, after controlling for a range of socioeconomic factors as well as measures of financial knowledge and behaviors. In addition, student loan debt had additional negative influence on missed health care services for minority young adults. Further analyses indicate that among young adults who had outstanding student loans, those with late loan payments were more likely to have unpaid medical bills and missed health care services, compared to those without late loan payments. These findings inform helpful policy and practice implications for improving financial status of young adults with student loans, especially those with late loan payment and minority young adults.

Characteristics of US hospitals using extraordinary collections actions against patients for unpaid medical bills: a cross-sectional study

ObjectiveThis study aims to characterise and evaluate the largest 100 hospitals in the USA that have adopted aggressive collection tactics to pursue patients with unpaid medical bills, such as lawsuits,...

Payment of Medical Invoices by Inpatients at the Mangobo General Referral Hospital in Kisangani (DR Congo) from 2016 to 2020

Introduction: The study looked at the problem of payment of healthcare bills by hospital patients. It was conducted at the Mangobo General Referral Hospital in Kisangani (DR Congo) during the period from 2016 to 2020. It aimed to identify the proportion of medical bills paid and not paid by inpatients. &#x0D; Methodology: This study was carried out using an inductive method based on documentary analysis. We used the general trend technique, which concerned all the medical bills paid and not paid by patients hospitalised at the Mangobo General Referral Hospital.&#x0D; Results: The total amounts of paid and unpaid medical care bills were respectively US$15, 250,500.92 and US$17,200.00 with a proportion of 99.89% for the former, against 0.11% for the latter. All the amounts of the paid and unpaid health care bills had an upward trend. The study provides hospital managers with an overview of the inpatient bill recovery mechanism. It also constitutes a plea to the political and health authorities to make health care accessible to the population.

Hospital Lawsuits Over Unpaid Bills Increased By 37Percent In Wisconsin From 2001 To 2018.

We analyzed Wisconsin court records from the period 2001-18 to document trends in hospital lawsuits to recover patients' unpaid medical bills. These lawsuits increased 37percent during this period, from 1.12 per 1,000 residents in 2001 to 1.53 per 1,000 residents in 2018, with lawsuits being disproportionately directed at Black patients and patients living in poorer and less densely populated counties.

Trends in Hospital Lawsuits Filed Against Patients for Unpaid Bills Following Published Research About This Activity

Suing patients and garnishing their wages for unpaid medical bills can be a predatory form of financial activity that may be inconsistent with the mission of a hospital. Many hospitals in the state of Virginia were discovered to be suing patients for unpaid medical bills, as first presented in a 2019 research article that launched 2.5 months of media attention on hospital billing practices and a grassroots public demand for hospitals to stop the practice. To evaluate the association of a research publication and subsequent media coverage with the number of hospital lawsuits filed against patients for unpaid medical bills. This cross-sectional study of Virginia hospitals that sued patients for unpaid medical bills used an interrupted time series analysis. Data on hospitals suing patients for unpaid medical bills were collected during a preintervention period (June 25, 2018, to June 24, 2019), an intervention period (June 25, 2019, to September 10, 2019), and a postintervention period (September 11, 2019, to September 10, 2020). Publication of a research article and subsequent media coverage. The total number of warrant in debt and wage garnishment lawsuits filed by Virginia hospitals and the frequency of those lawsuits filed before, during, and after the intervention period on a weekly basis. A total of 50 387 lawsuits, filed by 67 Virginia hospitals, were included; 33 204 (65.9%) were warrant in debt lawsuits, and 17 183 (34.1%) were wage garnishment lawsuits. From the preintervention period to the postintervention period, there was a 59% decrease in the number of lawsuits filed (from 30 760 lawsuits to 12 510 lawsuits), a 55% decrease in the number of warrant in debt cases filed (from 19 329 to 8651), a 66% decrease in the number of wage garnishments filed (from 11 431 to 3859), and a 64% decrease in the dollar amount pursued in court (from $38 700 209 to $13 960 300). During the study period, 11 hospitals banned the practice of suing patients for unpaid medical bills. The interrupted time series analysis showed a significant decrease of 5% (incidence rate ratio, 0.95; 95% CI, 0.94-0.96) in the total weekly number of lawsuits in the postintervention period. The findings of this study suggest that research leading to public awareness can shift hospital billing practices.

Student Loans and Health-related Financial Hardship

Research has shown that student loan borrowers in repayment exhibit physical and mental health problems. These can be exacerbated by and contribute to health-related financial hardship. We use the 2015 U.S. National Financial Capability Study to examine the likelihood of having past due medical bills and of avoiding health care services by not purchasing prescribed medication, skipping tests or follow-up with a doctor or not seeking care for a medical problem. Borrowers on income-driven repayment plans and those who made late payments are found to be more likely to have unpaid medical bills and to have avoided required medical attention. In addition, those who completed their funded education program but had made a late payment were more likely to avoid seeking medical attention when needed. Practical implications for loan administrators and those working with students are discussed.

When Hospitals Sue Patients

Grimly demonstrated by the COVID-19 pandemic, hospitals serve as the central hub of American health care. Increasingly exercising market power, setting clinical standards, and fostering innovation, hospitals’ influence over health care delivery and access is unmatched. They are the behemoth in the delivery chain, exerting unrivaled control.As such, hospitals have naturally become the locus of the worst of the collision between consumerism and universality, between cost and access—a gloomy setting for citizens who simply cannot afford the health care they need to flourish, or to survive. Indeed, the price of American health care—a cost that is increasingly borne by American patients—is unsustainable. Those costs continue to rise thanks to a pernicious mix of increasingly brittle and ineffective insurance plans, a squeeze on public funding, and a lack of price sensitivity among the providers of American health care. Patients are suffering. And hospitals aren’t getting paid.In a predictable but catastrophic turn, hospitals are suing their former patients for unpaid medical bills. Litigation has replaced systematic financing. The operating room has been swapped for the courtroom. And adversarial proceedings now follow the Hippocratic Oath. Tracking the phenomenon of these lawsuits, this article lays out the harms that result to the American health care system. When hospitals sue patients, they harm public health and destroy patient trust. And they shatter widely-held beliefs, highlighting the inadequacy of policy goals and the inequity of health finance rules. Further, once and for all, they expose the failure of the consumer-based paradigm of American health care, spotlighting the inapplicability of moral hazard, and demonstrating the means by which individuals with private insurance and high deductibles—a rapidly growing population in the United States—are inadequately protected against the very actors that undertake to protect their health and wellbeing. This article makes the moral, legal, and policy-based argument that hospital lawsuits against former patients must be brought to an end. American patients simply cannot afford it.

Contact by Collection Agencies for Medical Debt: Rural-Urban Differences Among Older and Younger Medicare Beneficiaries.

Geographic disparities in health and health care are increasingly well-documented, as are financial barriers to accessing care. Still, less is known about whether Medicare beneficiaries differ in their ability to pay for care by rurality. Using data from the 2016 Medicare Current Beneficiary Survey (n = 12,688 U.S. community-dwelling beneficiaries), we analyzed rural-urban differences in rates of collection agency contact for unpaid medical bills using chi-square tests and multivariable logistic regression for the full sample and by age (65+ and <65). Nearly 10% of Medicare beneficiaries had been contacted by a collection agency for medical debt in the previous year, with higher percentages among rural beneficiaries (8% for urban vs 10% for rural micropolitan and 11% for rural noncore, p < .05). This difference attenuated after adjusting for educational attainment and income, suggesting that attention to socio-economic status among rural Medicare beneficiaries would help to address financial barriers to care and decrease medical debt.

Impact of Severity of Chronic Liver Disease on Health-Related Economics

Background: Chronic liver disease (CLD) is one of the leading causes of morbidity and mortality worldwide. It is accountable for a multifaceted disease encumbrance upsetting the psychological, physical, and economic health of not only the patients but also their caregivers. Objectives: The study purposes to cover the economic aspect of CLD to comprehend the financial burden imposed on the patients. Methods: This cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan. The CLD patients presenting in gastroenterology clinics were recruited, and their socio-demographic, financial, and disease-related information including Model for End-stage Liver Disease (MELD) score and Child Turcotte Pugh (CTP) scores were collected. Out of 190 CLD patients enrolled, 127 (67.2%) were males. The mean age was 50.09 years. Variables assessed include self-perceived social/economic status, self-perception of disease responsibility for worsening of social/economic situation, the impact of the disease on economic status due to medical expense, the impact of economic status on treatment compliance due to medical expenses, impact of severity of disease on socioeconomic status and treatment compliance, and impact of gender on disease status and treatment compliance. Results: Regardless of the disease duration, CLD significantly impacted a patient’s life, as 81% and 69% of the patients blamed their disease responsible for the worsening of social and economic conditions, respectively. In our study, 85% of patients had consumed all savings during their course of illness, and 67% had to borrow money for medical expenses. Nearly half of the patients had to leave or cut short their medicines, skip the physician's appointment, or defer their children's education. One-third of patients had unpaid medical and utility bills or even skipped their meals. The severity of disease affected the socioeconomic status significantly (89% in CTP class C vs. 40% in CTP class A). Patients with worsening socioeconomic status had significantly higher MELD scores as compared to those with stable socioeconomic status. Conclusions: Chronic liver disease imposes incredible socioeconomic encumbrance on patients and the family unit, and CLD associated expenditures influence the family unit’s everyday working and therapeutic compliance, which is directly linked to the severity of disease expressed in terms of CTP and MELD scores.

The credit consequences of unpaid medical bills

This paper quantifies the costs of leaving medical bills unpaid and what these costs imply for the value of health insurance to beneficiaries. We argue that a large fraction of unpaid medical bills is sent to third-party collections and reported to credit bureaus, with detrimental effects on patients' credit outcomes. Combining a large panel of credit records with data on credit offers, we find that the ACA Medicaid expansion reduced newly-reported medical collections by $5.89 billion and led to better terms of credit. We find that the financial benefits of Medicaid at least double when including this indirect credit channel.

Understanding Debt in the Older Population

Poor financial capability can erode well-being in later life. To explore debt and debt management among older Americans, age 51-61, we designed and analyzed a new module in the 2018 Health and Retirement Study along with information from the 2018 National Financial Capability Study. Even though this group should be at the peak of their retirement savings, it nevertheless carries debt due to student loans and unpaid medical bills; having children also contributes to carrying debt close to retirement. By contrast, the financially literate have more positive financial perceptions and behaviors. Specifically, being able to answer one additional financial literacy question correctly is associated with a higher probability of reporting an above average credit record and planning for retirement. Higher financial literacy is also linked to being less likely to carry excessive debt, being contacted by debt collectors, and carrying medical debt or student loans, even after accounting for a large range of demographics and other characteristics. Evidently, financial knowledge can help limit debt exposure at older ages. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Household Debt and Children’s Risk of Food Insecurity

AbstractIn the United States, almost one in six households with children cannot access adequate food for a healthy and active lifestyle. Although food insecurity disproportionately affects lower-income households, it remains unclear why some lower-income families are more vulnerable to food insecurity than others. Household unsecured debt, such as debt incurred from credit cards and medical bills, may be an unexplored financial constraint associated with food insecurity. Using data from the 2014 Child Development Supplement (CDS) of the Panel Study of Income Dynamics (PSID), I assess whether unsecured debt, by amount and type of debt, is associated with food insecurity among lower-income households with children (N=1,319). Results indicate that medical debt increases odds of household food insecurity even after accounting for key sociodemographic and economic risk factors, while no relationship exists between other forms of unsecured debt and food insecurity. Moreover, although liquid assets decrease the risk of household food insecurity and attenuate the harmful effects associated with unpaid medical bills, few households have enough liquid assets to mitigate the risks associated with medical debt. Efforts to prevent medical debt may be essential for eliminating food insecurity among lower-income households with children.

Prevalence and Characteristics of Virginia Hospitals Suing Patients and Garnishing Wages for Unpaid Medical Bills

This study uses 2017 court records to characterize how frequently Virginia hospitals take legal action to garnish patients’ wages to recover unpaid medical expenses, and the characteristics of hospitals and patient employers associated with the actions.

Impact of Severity of Chronic Liver Disease on Health Related Economics

Background: Chronic liver disease (CLD) is one of the leading causes of morbidity and mortality worldwide. It is accountable for a multifaceted disease encumbrance upsetting the psychological, physical, and economic health of not only the patients but also their caregivers. Objectives: The study purposes to cover the economic aspect of CLD to comprehend the financial burden imposed on the patients. Methods: This cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan. The CLD patients presenting in gastroenterology clinics were recruited, and their socio-demographic, financial, and disease-related information including Model for End-stage Liver Disease (MELD) score and Child Turcotte Pugh (CTP) scores were collected. Out of 190 CLD patients enrolled, 127 (67.2%) were males. The mean age was 50.09 years. Variables assessed include self-perceived social/economic status, self-perception of disease responsibility for worsening of social/economic situation, the impact of the disease on economic status due to medical expense, the impact of economic status on treatment compliance due to medical expenses, impact of severity of disease on socioeconomic status and treatment compliance, and impact of gender on disease status and treatment compliance. Results: Regardless of the disease duration, CLD significantly impacted a patient’s life, as 81% and 69% of the patients blamed their disease responsible for the worsening of social and economic conditions, respectively. In our study, 85% of patients had consumed all savings during their course of illness, and 67% had to borrow money for medical expenses. Nearly half of the patients had to leave or cut short their medicines, skip the physician's appointment, or defer their children's education. One-third of patients had unpaid medical and utility bills or even skipped their meals. The severity of disease affected the socioeconomic status significantly (89% in CTP class C vs. 40% in CTP class A). Patients with worsening socioeconomic status had significantly higher MELD scores as compared to those with stable socioeconomic status. Conclusions: Chronic liver disease imposes incredible socioeconomic encumbrance on patients and the family unit, and CLD associated expenditures influence the family unit’s everyday working and therapeutic compliance, which is directly linked to the severity of disease expressed in terms of CTP and MELD scores.

Medicaid and Financial Health

This paper investigates the effects of the Medicaid expansion provision of the Affordable Care Act (ACA) on households' financial health. Our findings indicate that, in addition to reducing the incidence of unpaid medical bills, the reform provided substantial indirect financial benefits to households. Using a nationally representative panel of 5 million credit records, we find that the expansion reduced unpaid medical bills sent to collection by $3.4 billion in its first two years, prevented new delinquencies, and improved credit scores. Using data on credit offers and pricing, we document that improvements in households' financial health led to better terms for available credit valued at $250 million per year. We calculated that the financial benefits of Medicaid double when considering these indirect benefits in addition to the direct reduction in out-of-pocket expenditures.