Healthcare could be improved if hospitals were measured on billing quality, Marty Makary, MD, and Simon Mathews, MD, both of Johns Hopkins University in Baltimore, .
"Half of Americans have less than $400 cash in their savings account," Makary, who is ľֱ's editor-in-chief, said in an audio interview accompanying the "Viewpoint" article. "Life can be a struggle for many Americans living paycheck to paycheck.... Patients are getting hammered and these bills can be catastrophic."
While many hospitals are forgiving and compassionate, "other hospitals have engaged in what I call price gouging," he said. "This new business model of price gouging and predatory billing threatens the great public trust in the medical profession, and we all as physicians should be concerned about it."
In a recent analysis, 36% (48/135) of hospitals in Virginia garnished wages of patients with unpaid medical bills, and five hospitals accounted for 4,690 garnishment cases in 2017, representing 51% of all cases, the authors noted. In total, hospitals in Virginia filed 20,054 lawsuits against patients for unpaid debt.
Given the wide variation in hospitals' prices and collections practices, "measures of billing practices are needed," Makary and Mathews wrote. They suggest five metrics on which to rate hospital billing:
- Itemized bills. Are patients routinely provided an itemized bill with items explained in plain English?
- Price transparency. Are patients provided real prices for common "shoppable" services when they ask? In the audio interview, Makary called it "super disappointing" that hospitals sued the Trump administration over its proposal that hospitals publish prices for 300 common services. "This is a common sense thing that the American public wants. The idea that they cannot provide the prices for 300 common, shoppable services is really very sad."
- Service quality. Can patients speak with a billing representative promptly about a concern they have about their bill and be informed of a transparent review process?
- Suing patients. For patients who have not entered into a written agreement specifying a price for a medical service, does the institution sue patients to garnish their wages, place a lien on their home, or involuntarily withdraw money from a patient's income tax return?
- Surprise bills. Are out-of-network patients paying out of pocket expected to pay more than the region-specific reference-based price? Are patients billed for complications stemming from National Quality Forum serious reportable events? "Hospitals were designed to be a safe haven, a refuge for people at a time when they're vulnerable," said Makary. "It does not seem right to take care of somebody and then take advantage of them when they're vulnerable." He noted that one large hospital system in Nashville took all the contracts they had with their physicians on staff and told them that their contract would now state that the physicians couldn't charge more than the in-network price. "That hospital has been able to eliminate the problem of price-gouging people on surprise bills."
Makary pointed out that 60% of Americans say they've avoided or delayed care for fear of medical bills. "We can have the cure for cancer, but if half the public is not coming in, those cures are no good for them," he said. "If we can create public accountability to move the ball forward, I think it will go a long way in rebuilding that badly needed public trust."
Although it's hard to tell exactly how valuable it would be to publish such metrics, "I think something along these lines could be useful, especially items 4 and 5," Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy in Washington, said in an email. "If hospitals had to disclose their billing practices and those of physicians who work in their facility (and how each of these groups sue patients), it would at least shine a light on some of these practices."
The American Hospital Association (AHA) did not comment specifically on the article, but an association spokesperson noted in an email that "in 2012, we issued guidelines stating that the billing and collection process should treat patients with dignity and respect, and that should continue from the bedside to the billing office."
However, because more people now have "skinny plans" that require higher copays and deductibles, the spokesperson said the AHA was "re-evaluating the guidelines to ensure they best serve the needs of patients" and added that "we strive to provide access to financial assistance and counseling to all patients who might qualify for it."
"In the event of an unpaid bill, the IRS [Internal Revenue Service] has prescribed an extensive series of steps and wait times that hospitals must adhere to before taking any collection actions, which is a last resort," the spokesperson said. "As a field, we will always continue to look for new and better ways to work with patients who need help paying their bills."