Why Hospitals Want Patients to Pay Upfront

By John Tozzi
September 25, 2014 - Businessweek

Melody Rempe spends much of her day telling people who are about to go into the hospital how much they’ll have to pay. As a patient financial counselor at Nebraska Methodist Health System, she calls patients about a week before they go in for procedures with estimates of their bills and what portion insurance will cover. Although many are grateful, some cry or yell. “Sometimes you’re talking to them about the biggest thing in their life,” she says. Rempe says most calls end well when she walks patients through the hospital’s payment-plan options or other financial assistance.

Hospitals have good reason to be concerned about their patients’ finances: Even people with insurance are increasingly responsible for a big portion of their medical bills. Among Americans who get health coverage at work, 41 percent have deductibles of at least $1,000 they must meet before insurance starts paying. That’s up from 10 percent in 2006, according to the Kaiser Family Foundation. Those with employer coverage are joined by 7 million new enrollees in Obamacare plans, which typically make patients share a large chunk of costs. The average deductible in the most popular “silver” tier of coverage is $2,267, according to an analysis by the Robert Wood Johnson Foundation.

Raising deductibles helps employers and insurers limit premium hikes. It also shifts more of the risk onto individuals. That in turn boosts the chances that doctors and hospitals won’t get paid. If a patient has a $2,900 deductible, “it’s far more difficult to get that $2,900 from an individual patient than it is from the Medicare program or from Blue Cross Blue Shield,” says Richard Gundling, vice president of the Healthcare Financial Management Association, a trade group. A March report on hospitals from Moody’s (MCO), the credit-rating firm, was blunt: “Today’s high deductibles are tomorrow’s bad debt.”

“Tell me what 28-year-old is going to be able to provide, especially in this economy, $6,000 of their own money?”—Jan Grigsby, CFO, Springhill Medical Center

Hospitals’ total cost of uncompensated care reached $46 billion in 2012, equal to about 6 percent of their expenses, the American Hospital Association says. Large for-profit chains such as LifePoint Hospitals (LPNT), which operates more than 60 medical centers in 20 states, have felt the impact of rising deductibles. LifePoint’s bad debt related to copays and deductibles is running at $25 million per quarter this year, up from $15 million per quarter in 2013, Leif Murphy, the company’s chief financial officer, said on an earnings call in July. He blamed the increase in part on the growing prevalence of high-deductible plans.

As the mechanics of insurance policies become more complicated, Americans are having a harder time understanding how their plan choices will affect their finances. Only 14 percent of insured adults correctly understand insurance jargon such as deductibles, coinsurance, copays, and out-of-pocket maximums, according to a 2013 study published in the Journal of Health Economics.

Many Americans aren’t prepared for a medical emergency. Dr. Marilyn Peitso, a pediatrician in St. Cloud, Minn., says parents often can’t afford $300 to $400 for antibiotics to treat an ear infection. “For young working families, this can get to be a real financial burden, and it can make them less likely to seek needed care,” she says. About 44 percent of households have less than three months of savings, according to an analysis by the Corporation for Enterprise Development, an antipoverty group. “Tell me what 28-year-old is going to be able to provide, especially in this economy, $6,000 of their own money?” says Jan Grigsby, chief financial officer at Springhill Medical Center in Mobile, Ala.

Like Nebraska Methodist, Springhill reaches out to patients before scheduled procedures with an estimate of what they’ll owe, Grigsby says. For those who can’t pay immediately, the hospital works with lenders to arrange no-interest payment plans of as long as two years. Staff members also check whether patients are eligible for charity care from the hospital or if they qualify for Medicaid.

Many hospitals try to get patients to pay upfront 30 percent to 50 percent of what they’ll owe and some offer discounts for paying early, says Yaro Voloshin of health-care consultant MedAssets (MDAS). One reason is that they want to avoid the damage to their reputations that accompanies aggressive debt collection practices. “Over the years there’s been some stigma about collecting from patients,” says Zac Stillerman, an executive with the Advisory Board, which sells software and consulting services to hospitals. “It’s a bit of a third rail.”

Managers at Nebraska Methodist noticed payment problems getting worse about seven years ago, when a large employer in the Omaha area introduced a plan with a $5,000 deductible. “We would bill a procedure for a patient; the entire amount would be applied to the deductible,” says Bob Wagner, the hospital’s director for revenue cycle. “We actually got no money.”

Now any patient scheduling a procedure expected to cost more than $500 out of pocket gets a call from Rempe or another of Nebraska Methodist’s five financial counselors. The hospital tries to get some payment in advance, but it doesn’t turn away those who can’t pay.

Even simply identifying the indigent can help, says Gundling of the Healthcare Financial Management Association. “For both the patient and the facility,” he says, “trying to collect a debt that can’t be paid just wastes everybody’s time.”