An Assessment of the An Assessment of the Relationship between Relationship between
Consumer Medical Debt and Consumer Medical Debt and Access to Care, Knowledge of Access to Care, Knowledge of
Financial Assistance, and Financial Assistance, and Hospital Collection Practices Hospital Collection Practices
in Central Massachusettsin Central Massachusetts
ALE Final Presentation in conjunction with Lorianne ALE Final Presentation in conjunction with Lorianne Sainsbury-Wong, Esq., Health Law Advocates, Inc. Sainsbury-Wong, Esq., Health Law Advocates, Inc.
(HLA)(HLA)Christina ChanChristina ChanJD/MPH 2010JD/MPH 2010
August 25, 2009August 25, 2009
Research Goals & Research Goals & ObjectivesObjectives
Goal: To gather information from low-income Goal: To gather information from low-income consumers with medical debt to assess consumers with medical debt to assess whether these individuals are being denied whether these individuals are being denied care to which they are eligiblecare to which they are eligible
3 Objectives:3 Objectives:
1)1) To assess whether consumer medical debt presents To assess whether consumer medical debt presents a barrier to accessing hospital carea barrier to accessing hospital care
2)2) To assess scope of consumer knowledge/awareness To assess scope of consumer knowledge/awareness regarding the availability of hospital financial regarding the availability of hospital financial assistanceassistance
3)3) To assess whether hospitals are complying with To assess whether hospitals are complying with free care and debt collection laws free care and debt collection laws
MA Division of Health Care MA Division of Health Care Finance & Policy (DHCFP) Health Finance & Policy (DHCFP) Health
Safety Net (HSN) Regulations, Safety Net (HSN) Regulations, 114.6 CMR 13.00114.6 CMR 13.00
Eligibility for HSN Eligibility for HSN Low-income status (income below 400% FPL)Low-income status (income below 400% FPL) Hospital is the gatekeeperHospital is the gatekeeper 114.6 CMR 13.00 states: Providers (hospitals) MUST assist 114.6 CMR 13.00 states: Providers (hospitals) MUST assist
the applicant to complete a medical hardship application and the applicant to complete a medical hardship application and submit the application electronically to the HSN officesubmit the application electronically to the HSN office
Payment plansPayment plans Providers must offer payment plans pursuant to 114.6 CMR Providers must offer payment plans pursuant to 114.6 CMR
13.0813.08 An individual with a debt balance of $1000 or less MUST be An individual with a debt balance of $1000 or less MUST be
offered payment plan with a minimum monthly payment of no offered payment plan with a minimum monthly payment of no more than $25more than $25
Collection PracticesCollection Practices Provider may not require pre-admission and/or pre-treatment Provider may not require pre-admission and/or pre-treatment
deposits for emergency servicesdeposits for emergency services Must comply with MA Attorney General’s fair debt collection Must comply with MA Attorney General’s fair debt collection
regulations, 940 CMR 7.00 regulations, 940 CMR 7.00 Prohibits threats of arrest, wage garnishment, placing liens on Prohibits threats of arrest, wage garnishment, placing liens on
cars or homescars or homes
MethodologyMethodology Consumer SurveyConsumer Survey
Survey asked questions about:Survey asked questions about: Impact of medical debt on use of health services Impact of medical debt on use of health services Knowledge of availability of free careKnowledge of availability of free care Experience with hospital collection effortsExperience with hospital collection efforts
Hardcopy distribution through HLA Hardcopy distribution through HLA partners with online optionpartners with online option
Translated survey into Portuguese and Translated survey into Portuguese and SpanishSpanish
Target PopulationTarget Population Low-income, minority residents Low-income, minority residents
(Portuguese and Hispanic) in central (Portuguese and Hispanic) in central MassachusettsMassachusetts
Total Sample size (N=139)Total Sample size (N=139)
ResultsResults1) Access to Care1) Access to Care
Of consumers with medical debt:Of consumers with medical debt: 51% of consumers said they did not go to 51% of consumers said they did not go to
hospital because they were scared of the hospital because they were scared of the costcost
9% of consumers were asked to pay 9% of consumers were asked to pay upfront before receiving careupfront before receiving care
7% of consumers report being denied 7% of consumers report being denied care because of their unpaid medical billscare because of their unpaid medical bills
ResultsResults2)2) Consumer Knowledge of Consumer Knowledge of
Hospital Financial AssistanceHospital Financial Assistance
Of those reporting medical debt:Of those reporting medical debt: 52% of consumers did not know that hospitals 52% of consumers did not know that hospitals
offer financial assistance in paying for medical offer financial assistance in paying for medical billsbills
ResultsResults2)2) Consumer Knowledge of Consumer Knowledge of
Hospital Financial AssistanceHospital Financial Assistance
Of those who received an Of those who received an application for MassHealth application for MassHealth or HSN:or HSN: 65% of consumers said the 65% of consumers said the
hospital did hospital did notnot help them fill help them fill it out (in violation of MA it out (in violation of MA DHCFP regulations, 114.6 DHCFP regulations, 114.6 CMR 13.00)CMR 13.00)
Of those who did learn that the hospital Of those who did learn that the hospital offers financial assistance:offers financial assistance: 47% of consumers learned either after they got 47% of consumers learned either after they got
a hospital bill, after they received medical care, a hospital bill, after they received medical care, or after their bill went to collectionsor after their bill went to collections
ResultsResults3)3) Hospital Collection EffortsHospital Collection Efforts
Payment plans were the most common Payment plans were the most common form of financial assistance, however:form of financial assistance, however: 35% were given this option only when they 35% were given this option only when they
called about their billcalled about their bill 23% were given a plan only right before their 23% were given a plan only right before their
bill went to collections or AFTER their bill bill went to collections or AFTER their bill went to collectionswent to collections
52% were given minimum monthly 52% were given minimum monthly payments of over $25 (in violation of the payments of over $25 (in violation of the MA DHCFP regulations, 114.6 CMR 13.00)MA DHCFP regulations, 114.6 CMR 13.00)
ResultsResults3)3) Hospital Collection EffortsHospital Collection Efforts
When contacted by an outside collection When contacted by an outside collection agency for unpaid hospital bills: agency for unpaid hospital bills: 46% of consumers report being only given the 46% of consumers report being only given the
option for “payment in full” or prompt-pay option for “payment in full” or prompt-pay discountsdiscounts
When consumers could not make payments, When consumers could not make payments, the collection agency used aggressive the collection agency used aggressive tactics:tactics: 52% were repeatedly “harassed or pressured to 52% were repeatedly “harassed or pressured to
make a payment”make a payment” 33% stated the collection agency “reported their 33% stated the collection agency “reported their
bills to a consumer credit/debt bureau”bills to a consumer credit/debt bureau”
Key Problem AreasKey Problem Areas1.1. Consumers forgoing care because they are afraid of Consumers forgoing care because they are afraid of
incurring medical debtincurring medical debt2.2. Consumers asked to pay money upfront before Consumers asked to pay money upfront before
receiving care receiving care 3.3. Consumers denied care because of unpaid hospital billsConsumers denied care because of unpaid hospital bills4.4. Consumers not knowing that hospitals offer financial Consumers not knowing that hospitals offer financial
assistanceassistance5.5. Hospitals are not helping consumers fill out HSN Hospitals are not helping consumers fill out HSN
applications as required by MA DHCFP regulationsapplications as required by MA DHCFP regulations6.6. Payment plans are being offered that do not comply Payment plans are being offered that do not comply
with MA DHCFP regulationswith MA DHCFP regulations
7.7. Patients had to ask to be put on a payment plan Patients had to ask to be put on a payment plan after bills went to collections or after receiving after bills went to collections or after receiving carecare
8.8. Collection agencies offer many individuals the Collection agencies offer many individuals the option to pay in full only or report consumers’ option to pay in full only or report consumers’ medical debt to credit bureausmedical debt to credit bureaus
RecommendationsRecommendations The public health community should focus The public health community should focus
further efforts on: further efforts on: Increasing outreach and awareness of the availability Increasing outreach and awareness of the availability
of hospital financial assistance programs of hospital financial assistance programs Engaging in more rigorous pre-screening practices Engaging in more rigorous pre-screening practices
for free care eligibility during the hospital intake and for free care eligibility during the hospital intake and registration process prior to the provision of any registration process prior to the provision of any health care serviceshealth care services
Before taking any collection action, ensuring Before taking any collection action, ensuring payment plans and/or any free or discounted care payment plans and/or any free or discounted care has been offered to eligible patientshas been offered to eligible patients
Ensuring hospitals are helping assisting patients to Ensuring hospitals are helping assisting patients to complete HSN applications in accordance with complete HSN applications in accordance with DHCFP regulationsDHCFP regulations
Ensuring hospital collection efforts are compliant Ensuring hospital collection efforts are compliant with AG regulations prohibiting overly aggressive with AG regulations prohibiting overly aggressive collection tacticscollection tactics
LimitationsLimitations Generalizability Generalizability
Small sample size (n=44)Small sample size (n=44) Survey attrition (abandoned, partially-filled out Survey attrition (abandoned, partially-filled out
surveys)surveys) # of total responses differed by question# of total responses differed by question Hard-to-reach target populationHard-to-reach target population
Self-reported dataSelf-reported data Self-selection/convenience sample biasSelf-selection/convenience sample bias Translation issuesTranslation issues
Non-English speaking consumers need help Non-English speaking consumers need help filling applications or being told about free filling applications or being told about free care eligibilitycare eligibility
AcknowledgmentsAcknowledgmentsThank you very much for the support Thank you very much for the support
and guidance from:and guidance from:Lorianne Sainsbury-Wong, Health Law Advocates, Lorianne Sainsbury-Wong, Health Law Advocates,
Inc.Inc.
Marcia Boumil, JD/MPH advisorMarcia Boumil, JD/MPH advisor
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