Update: Debt Collectors in the ER?

A few weeks ago, we wrote about medical debt collection going on in hospitals, and whether it was interfering with treatment or intimidating patients out of seeking needed care. Now Kaiser Health News is reporting on new Treasury Department proposed rules curbing this practice. (See also: straight from the horse’s mouth, here is the press release). Is the Obama administration reading N & L? (I kid, I kid). These rules are called for in the Affordable Care Act, and, as expected, are controversial– the American Hospital Association, for instance, thinks hospitals are being held too responsible for the actions of 3rd parties when required to provide this new protection– which is just too much to ask, apparently? Come on now, let’s not forget that health care is supposed to be about patients!

You need stitches, is this going on your VISA today?

. . . and while you’re here, you owe us five thousand dollars. The NYT reported twice recently on medical debts and collections issue: here and here.

 Nurse: For me, this is just one more symptom of the overall huge problem of the way our health insurance and healthcare systems (fail to) work. I was especially surprised that FICO said it doesn’t consider medical debt any differently from other debts– so debt you incur for being irresponsible is the same as debt you incur for being genuinely unlucky. You got sick and couldn’t pay? Your credit score takes the same bump it does if you overspent your credit card at Saks.

Lawyer: I don’t know much about how FICO operates, but there are lots of shades, too. I mean, student loan debt is different from credit card debt is different from your cell phone plan is different from healthcare. 

 I suppose one could argue that their job isn’t to measure how “responsible” you are, so much as how responsive you are in paying debts that you do have, no matter why you have them. 

But one of the real problems seems to be that people get caught in this crazy maze of not knowing who’s actually responsible for what, or wanting to dispute certain things, and having that process damage their credit (rather than straight up unpaid bills — which is also a problem, but a different one.)

 Nurse: It sounds like the bill under discussion here is reasonable– removing these medical credit black marks more quickly– but I don’t know, do you think there would be unintended consequences? I don’t buy the “quality of data” decline that the credit agency advocates are pushing.

 Lawyer: I agree that it seems like a reasonable bill. And the “quality of data” thing sounds like a crock to me, too, especially given the high rates these stories are reporting of things being either straight up errors or being matters of genuine dispute. I think other possible solutions involve including that info in the reports, but separating it out and clearly identifying it as a specific type of problem, so that users of the score (e.g. lenders) can evaluate whether they find it relevant or not. Or doing what they do with credit cards — forbidding them to report it to credit agencies in certain types of dispute situations, pending some reasonable resolution of the dispute. 

 Nurse: Of course, this doesn’t even get into the fact that, as the article points out, billing errors are rampant. That goes back to my original point that the system is so far broken, what can we do? You can’t get a doctor or hospital to quote your a price for treatment, so how are you supposed to really evaluate if you’ve been billed correctly? Have you ever tried to use an insurance company phone tree? Have you ever tried to do any of this while you or a family member was ill?

Lawyer: A classmate in the business school here was recently overbilled for a procedure, and it took her (a Stanford MBA student) a huge amount of time and effort to get it sorted out — she also says she just barely caught the error. I hate to imagine how difficult it would be for someone who doesn’t have any background or training in dealing with such things. Where do we lay the blame? Maybe the problem is with hospitals sending things into collection too quickly, without addressing/resolving disputes with patients first. (See above proposal about not reporting to credit agencies during a dispute resolution process.)

Nurse: On the bedside debt collectors: dude, not cool. Hospitals may employ debt collection agencies, and they often do, which is ok, but allowing them into patient care areas? This is slimy, having debt collectors posing as hospital employees, or having them demand payment before treatment in the ER. Isn’t that illegal, lawyer? EMTALA?

 Lawyer: I don’t know much about EMTALA (that’s the Emergency Medical Treatment and Active Labor Act) — I think it forbids refusing care based on inability to pay, but I’m not sure it forbids demanding payment in advance where possible. I could see a problem arising if the hospital didn’t make it clear to the patient that they would receive emergency treatment even if they couldn’t pay. (In other words, if they mislead the patient, and the patient leaves without care, that could be trouble.)

It certainly sounds like some of these practices are some kind of possible fraud or misrepresentation. And it probably violates state law in a lot of places that have good consumer protection laws.

Nurse: Yes, my concern is that it may seem to patients that they are or will be refused care if they can’t pay, even if that’s not really the case– it’s essentially intimidation on the threat of not receiving care. Patients, you are entitled to evaluation and stabilization in and ER, whether or not you can pay, and whether or not you owe anyone money. They can ask you for payment, but they must evaluate and treat you, payment or not.  Also not cool: You should not need to fear that seeking treatment in an ER will lead to your harassment for current or previous bills.

Lawyer: Very good point. 

Nurse: Yes, hospitals provide uncompensated care. No, they can’t fix it this way. Unless they care more about money than about care– in which case, they should go work for Goldman Sachs, am I right?

Lawyer: Maybe it’s kind of a desperation play? Because heaven forbid we should work to reduce the cost of care. That would probably do more to keep the doors open.

Nurse: Yeah, I mean, they try that, but it’s a big, messy problem. True, you can’t provide any care at all if you are entirely broke– but there is a line, and this practice crosses it.

Lawyer: Where do you think that line is? Is it okay to just talk about payment before providing care (assuming the person isn’t actively dying at the moment?)

What about people who actually legitimately incur costs that they can’t pay — when can the hospital start pursuing them for payment? 

Nurse: I think if they could tell you what it will cost, and make it clear that your will receive treatment no matter what, it might be ok. But it’s pretty near impossible to find out what a medical treatment is going to cost you before you get it. Just try sometime. You’ll be told, “well, it depends. . . .” There have been lots of studies comparing costs of treatments lately and it’s just wild. 

I would not want to work as a nurse in this environment– and I think my duty as a patient advocate would be to treat and protect these patients upfront. After they are treated, on their way out, fine, but not on my watch.

 Lawyer: Luckily, a lot of times when debt is sold, it’s done sloppily, so collection agencies sometimes sue for collection and it turns out they don’t have clear enough records to actually state any kind of legal claim to the debt. (Though this happens more with consumer debt than with medical debt, which is, perhaps obviously, more closely tied to the person who incurred it.) 

I don’t know how that interacts with the credit agencies.

 For now, I’m gonna put my money on state law for eliminating these abuses. But fingers crossed on the federal laws about credit scores, too!

On Nurse’s bookshelf. . .

Nurse is a sucker for comics (you read my other blog, nursosaurus, right?). Nurse is also a sucker for health reform (it’s a BFD).

Nurse knows: it's a BFD.

So it should come as no surprise that I picked up Health Care Reform, by economist and long-time health reform expert/advocate Jonathan Gruber, when it came out a few months ago.

It gives a walk-through of the imperiled health law, the PP-ACA, in basic terms– a “what does it mean to ME?” approach.  I think most of the arguing that goes on around this thing doesn’t look at what it means to individuals– so bravo, Gruber, bravo.  Not only is it readable, person-focused, and clear, it’s also very smart (Gruber’s an economist at MIT, has a PhD from Harvard, and worked on MA’s healthcare with Romney back in the day).

My only gripe? Well, it’s not really a gripe– he’s passionate. He wants it to succeed, and he believes it’s right, and he tells us why– but he pretty much ignores the problems with it, which even the loudest booster must know are there. So this comic-book-style explanation of the law is great, if you want to understand the basics– but it won’t prepare you to debate a republican– except maybe Mitt Romney ;)

let’s talk about death!

Not to preach to the choir, but let’s talk about this ridiculous coinage, “death panels.” almost brilliant– who’s in favor of death panels? the problem is, whatever a death panel is, it was never part of the Obama health proposal.

the proposal was to allow doctors to be compensated for time that they spend counseling patients on end-of-life options. there is not, and never was, any type of “panel” involved. so we can dismiss that part. and the death? well, yes, there is death. and there always will be. but discussing options for how to manage it is NOT the same thing as denying care to old people, or allowing people who might get well to die instead.
indulge me a minute– i am not a critically ill person, and i haven’t had a very close family member deteriorate and die in front of me. but i have seen, very much up close and personal, a lot of patients and families go through this. sometimes, patients or their families have made their wishes very clear all along– do everything, including ventilators, IV nutrition, and shot-in-the-dark risky surgeries, for a glimmer of home. that is a choice, and there is no proposal on the table that will eliminate it. I have also seen families whose clearly stated wishes were to withhold aggressive treatment  in the care of terminal illness. This is also a choice, and a difficult one, but often a good one. What’s really at stake here, though, are the people who have not ever stated clear wishes, or perhaps even considered them. These are people who would benefit from a thorough, honest conversation with a medical professional. They need to know that sometimes people put on ventilators never get off, that they may be sedated but still in pain, that they can get pressure sores despite excellent care, that they may have tubes in their rectum and bladder and nose and throat, keeping them alive. Not to talk them out of it, but to make sure that they know what could happen. I have seen a 90 year old person elect to have aggressive surgery only to die in the ICU after 30 minutes of CPR. I have seen an end-stage cancer patient die in a messy, chaotic hospital room in a flurry of strangers while his loved ones waited outside.
we need to create a culture that doesn’t judge people one way or the other for the decisions they make– and we need a culture that encoruages them to make decisions.

What do docs know about policy?

The New York Times is running an interesting article about members of congress who are doctors. One of the first things they point out is that they don’t all agree, so I’ll be the first to confess to having sort of lumped doctors together in the past, saying things like “Doctors like this measure.” Sorry, guys. Um, law students like diet coke. Right? All of us?

Of course, this spring, republican docs in the house actually formed a “doctors caucus.” Which suggests that they might be banding together a little more firmly than the Times’s individual interviews suggest. Why are there 11 republicans and only 5 dems? Tough to say. Anyone?

The upshot seems to be that they pretty much all agree (and have seen with their own eyes) that we need a new plan — but just like the rest of us, they can’t agree on what it should be. My first instinct, given that info, would be to say that it’s simply not a medical question. But thinking about it more, I’m wondering if this isn’t a reflection of the almost intractable complexity of this problem. Every one of these doctors has had different experiences, and the solution that would help the patients one of them has seen might leave another’s in the lurch.

I believe that one of the reasons this issue is so difficult to find common ground on is that everyone has personal experience with it. Even gun control or abortion affects only some portion of the population, but we all have health care experiences, and we all know we will need health care in the future, and it’s difficult for most people to completely put aside their personal experiences in trying to design a big-picture system. If you have a wealth of personal experiences (say, because you are a physician and have been seeing patients get screwed by this system every day for thirty years), how can you see it all in the clearest way possible?

Don’t get me wrong. These “in the trenches” stories are essential. If no one is paying attention to the actual things that befall actual people when the system breaks down, we don’t stand a chance. But it’s awfully tempting to believe that what we’ve seen with our own eyes is somehow more important than other problems out there.

By the way: to my knowledge, there are no nurses in congress. Hey, nurse! Wanna run for congress?