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