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Medical debt and aggressive debt restitution practices: predatory billing among the urban poor
Thomas P O'Toole1, Jose J Arbelaez, Robert S Lawrence
1Johns Hopkins University Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Balitomore, MD 21205, USA. totoole@jhmi.edu
Insights
Medical debt and collection agency referrals negatively impact health-seeking behaviors, particularly for vulnerable populations. These practices disproportionately affect individuals with lower education and those experiencing homelessness.
Area of Science:
- Health Services Research
- Public Health
- Socioeconomic Determinants of Health
Background:
- Increasing reliance of healthcare providers on collection agencies for medical charges.
- Limited understanding of the prevalence of medical debt collection in low-income communities.
- Unknown impact of medical debt collection on patient health-seeking behaviors.
Purpose of the Study:
- To investigate the prevalence of medical debt and collection agency referrals among patients at safety-net provider sites.
- To examine the association between medical debt, collection actions, and subsequent health-seeking behaviors.
- To identify demographic and clinical factors influencing changes in health-seeking behavior due to medical debt.
Main Methods:
- Cross-sectional survey conducted at 10 safety-net provider sites in Baltimore, Maryland.
- Data collected on underlying comorbidities, current medical debt, debt collection actions, and impact on health-seeking behavior.
- Statistical analysis, including multiple logistic regression, to identify associated factors.
Main Results:
- Nearly half of the 274 surveyed adults (46.2%) reported current medical debt, with an average of $3,409.
- Over a third (39.4%) had been referred to a collection agency for medical debt.
- A significant majority (67.4%) reported that medical debt or collection referrals affected their subsequent care-seeking, leading to avoidance, delays, or reliance on emergency departments.
Conclusions:
- Aggressive medical debt retrieval practices appear to be applied broadly.
- These practices have a detrimental effect on the health-seeking behaviors of vulnerable populations.
- Individuals with less education and those experiencing homelessness were more likely to alter their health-seeking behavior.
Background:
Health care providers are increasingly relying on collection agencies to recoup charges associated with medical care. Little is known about the prevalence of this practice in low-income communities and what effect it has on health-seeking behavior.
Methods:
Cross-sectional survey at 10 "safety net" provider sites in Baltimore, Md. Specific queries were made to underlying comorbidities, whether they had a current medical debt, actions taken against that debt, and any effect this has had on health-seeking behavior.
Results:
Overall, 274 adults were interviewed. The average age was 43.9 years, 77.3% were African American, 54.6% were male, 47.2% were homeless, and 34.4% had less than a 12th grade education. Of these, 46.2% reported they currently had a medical debt (average, 3,409 dollars) and 39.4% reported ever having been referred to a collection agency for a medical debt. Overall, 67.4% of individuals reported that either having a current medical debt or having been referred to a collection agency for a medical debt affected their seeking subsequent care: 24.5% no longer went to that site for care; 18.6% delayed seeking care when needed; and 10.4% reported only going to emergency departments now. In the multiple logistic regression model, having less than a 12th grade education (odds ration [OR], 2.5; 95% confidence interval [CI], 1.0 to 6.0) and being homeless (OR, 4.1; 95% CI, 1.4 to 12.3) were associated with a change in health-seeking behavior while having a chronic medical condition (OR, 0.2; 95% CI, 0.1 to 0.5) and going to a community clinic for usual care (OR, 0.2; 95% CI, 0.1 to 1.0) were protective.
Conclusions:
Aggressive debt retrieval for medical care appears to be indiscriminately applied with a negative effect on subsequent health-seeking behavior among those least capable of navigating the health system.
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