1. An Assessment of the Relationship between Consumer Medical Debt and Access to Care, Knowledge of Financial Assistance, and Hospital Collection Practices in Central Massachusetts ALE Final Presentation in conjunction with Lorianne Sainsbury-Wong, Esq., Health Law Advocates, Inc. (HLA) Christina Chan JD/MPH 2010 August 25, 2009

2. Research Goals & Objectives Goal: To gather information from low-income consumers with medical debt to assess whether these individuals are being denied care to which they are eligible 3 Objectives: 3 Objectives: 1) To assess whether consumer medical debt presents a barrier to accessing hospital care 2) To assess scope of consumer knowledge/awareness regarding the availability of hospital financial assistance 3) To assess whether hospitals are complying with free care and debt collection laws

3. MA Division of Health Care Finance & Policy (DHCFP) Health Safety Net (HSN) Regulations, 114.6 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 gatekeeper Hospital is the gatekeeper 114.6 CMR 13.00 states: Providers (hospitals) MUST assist the applicant to complete a medical hardship application and submit the application electronically to the HSN office 114.6 CMR 13.00 states: Providers (hospitals) MUST assist the applicant to complete a medical hardship application and submit the application electronically to the HSN office Payment plans Payment plans Providers must offer payment plans pursuant to 114.6 CMR 13.08 Providers must offer payment plans pursuant to 114.6 CMR 13.08 An individual with a debt balance of $1000 or less MUST be offered payment plan with a minimum monthly payment of no more than $25 An individual with a debt balance of $1000 or less MUST be offered payment plan with a minimum monthly payment of no more than $25 Collection Practices Collection Practices Provider may not require pre-admission and/or pre-treatment deposits for emergency services Provider may not require pre-admission and/or pre-treatment deposits for emergency services Must comply with MA Attorney General’s fair debt collection regulations, 940 CMR 7.00 Must comply with MA Attorney General’s fair debt collection regulations, 940 CMR 7.00 Prohibits threats of arrest, wage garnishment, placing liens on cars or homes Prohibits threats of arrest, wage garnishment, placing liens on cars or homes

4. Methodology Consumer Survey Consumer 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 care Knowledge of availability of free care Experience with hospital collection efforts Experience with hospital collection efforts Hardcopy distribution through HLA partners with online option Hardcopy distribution through HLA partners with online option Translated survey into Portuguese and Spanish Translated survey into Portuguese and Spanish Target Population Target Population Low-income, minority residents (Portuguese and Hispanic) in central Massachusetts Low-income, minority residents (Portuguese and Hispanic) in central Massachusetts Total Sample size (N=139) Total Sample size (N=139)

5. Results 1) Access to Care Of consumers with medical debt: 51% of consumers said they did not go to hospital because they were scared of the cost 51% of consumers said they did not go to hospital because they were scared of the cost 9% of consumers were asked to pay upfront before receiving care 9% of consumers were asked to pay upfront before receiving care 7% of consumers report being denied care because of their unpaid medical bills 7% of consumers report being denied care because of their unpaid medical bills

6. Results 2) Consumer Knowledge of Hospital Financial Assistance Of those reporting medical debt: 52% of consumers did not know that hospitals offer financial assistance in paying for medical bills

7. Results 2) Consumer Knowledge of Hospital Financial Assistance Of those who received an application for MassHealth or HSN: Of those who received an application for MassHealth or HSN: 65% of consumers said the hospital did not help them fill it out (in violation of MA DHCFP regulations, 114.6 CMR 13.00) 65% of consumers said the hospital did not help them fill it out (in violation of MA DHCFP regulations, 114.6 CMR 13.00) Of those who did learn that the hospital offers financial assistance: 47% of consumers learned either after they got a hospital bill, after they received medical care, or after their bill went to collections

8. Results 3) Hospital Collection Efforts Payment plans were the most common form of financial assistance, however: 35% were given this option only when they called about their bill 23% were given a plan only right before their bill went to collections or AFTER their bill went to collections 52% were given minimum monthly payments of over $25 (in violation of the MA DHCFP regulations, 114.6 CMR 13.00)

9. Results 3) Hospital Collection Efforts When contacted by an outside collection agency for unpaid hospital bills: When contacted by an outside collection agency for unpaid hospital bills: 46% of consumers report being only given the option for “payment in full” or prompt-pay discounts 46% of consumers report being only given the option for “payment in full” or prompt-pay discounts When consumers could not make payments, the collection agency used aggressive tactics: When consumers could not make payments, the collection agency used aggressive tactics: 52% were repeatedly “harassed or pressured to make a payment” 52% were repeatedly “harassed or pressured to make a payment” 33% stated the collection agency “reported their bills to a consumer credit/debt bureau” 33% stated the collection agency “reported their bills to a consumer credit/debt bureau”

10. Key Problem Areas 1. Consumers forgoing care because they are afraid of incurring medical debt 2. Consumers asked to pay money upfront before receiving care 3. Consumers denied care because of unpaid hospital bills 4. Consumers not knowing that hospitals offer financial assistance 5. Hospitals are not helping consumers fill out HSN applications as required by MA DHCFP regulations 6. Payment plans are being offered that do not comply with MA DHCFP regulations 7. Patients had to ask to be put on a payment plan after bills went to collections or after receiving care 8. Collection agencies offer many individuals the option to pay in full only or report consumers’ medical debt to credit bureaus

11. Recommendations The public health community should focus further efforts on: The public health community should focus further efforts on: Increasing outreach and awareness of the availability of hospital financial assistance programs Increasing outreach and awareness of the availability of hospital financial assistance programs Engaging in more rigorous pre-screening practices for free care eligibility during the hospital intake and registration process prior to the provision of any health care services Engaging in more rigorous pre-screening practices for free care eligibility during the hospital intake and registration process prior to the provision of any health care services Before taking any collection action, ensuring payment plans and/or any free or discounted care has been offered to eligible patients Before taking any collection action, ensuring payment plans and/or any free or discounted care has been offered to eligible patients Ensuring hospitals are helping assisting patients to complete HSN applications in accordance with DHCFP regulations Ensuring hospitals are helping assisting patients to complete HSN applications in accordance with DHCFP regulations Ensuring hospital collection efforts are compliant with AG regulations prohibiting overly aggressive collection tactics Ensuring hospital collection efforts are compliant with AG regulations prohibiting overly aggressive collection tactics

12. Limitations Generalizability Generalizability Small sample size (n=44) Small sample size (n=44) Survey attrition (abandoned, partially-filled out surveys) Survey attrition (abandoned, partially-filled out surveys) # of total responses differed by question # of total responses differed by question Hard-to-reach target population Hard-to-reach target population Self-reported data Self-reported data Self-selection/convenience sample bias Self-selection/convenience sample bias Translation issues Translation issues Non-English speaking consumers need help filling applications or being told about free care eligibility Non-English speaking consumers need help filling applications or being told about free care eligibility

13. Acknowledgments Thank you very much for the support and guidance from: Lorianne Sainsbury-Wong, Health Law Advocates, Inc. Marcia Boumil, JD/MPH advisor