Medical Debt, and Improper Medical Billing

Medical debt and billing is complex. At times, intentional complexity messages that administrations and finances prefer the public as an underdog. There’s no reason to maintain this status quo, the issue is not insurmountable, and there’s no reason treat the financial fracture anything more than what it is: beatable.

Teamwork continues to respond to medical billing and medical debt, and the players are getting a lot of things right.

• Military families spend time and worry on medical debt and improper medical billing. The consequences of poor financial administration directly affect their wellbeing and futures, including credit scores. Consequences have been highlighted through great reporting. Watchdogs continue to share concerns using data and personal stories [1,2,3,4,5]. Tying healthcare reimbursement to new quality metrics in billing processes, as well as system accountability with an individual’s debt management, are just two of the ways the future remains exciting.
• Military families are supported by continued legislative agenda toward improved debt collection and improved proper billing. The teamwork itself is an opportunity toward financial integrity. For example, if 7% of a recent $716 million in improperly processed payments resulted in improper veteran bills [6], and likely contributed to credit score issues and other debt considerations. Improvement expectations could be set. Conversations with credit and debt players could also enhance security for these families, given the assumptions of human error, as well as civilian families. Reports indirectly suggest that opportunities to alter methodology for total debt estimates could be created, including risk-adjustment for the improper billing that adds to the total debt.
• National medical debt and improper medical billing reports are increasingly on point. The percentage of Americans with medical debt by report. Kaiser’s use of the 2019 Census Bureau data states 1 in 10 Americans, or 23 million people [7], are indebted. Kaiser’s use of 2,375 in-depth interviews included dental debt [8] and stated that 41% of Americans have medical debt. In another study. 17.8% of people with a credit report had medical debt [9, 10]. Polled through debt.com, 50% of Americans have medical debt [11]. Given the spotlight, clarity and quality to the data will likely improve. Improvement will also help sharpen statements, like the report that indicated a more than 10% increase in debt for those living in the south and those in states that denied Medicaid expansion. Health outcome comparisons could also support [12]. Reports could ensure dental inclusion and account for personal loans, particularly loans from loved ones.
• National medical debt and billing practices should be a national conversation between hospital associations, physician associations, the Department of Health and Human Services, the VA and the DoD. There is no reason for some of the discrepancies detailed in these reports. Additionally, there is no reason to continue status quo with charitable contributions with unknown effects on the hospital an healthcare system. If a hospital decides to cover an unpaid bill, and a military hospital doesn’t, the indirect advantages and disadvantages for these moves can be part of the national improvement conversation. Accountability to match is an exciting future for us all.
• National reports demonstrate an opportunity to include active duty and veteran status for clarity. For example, authors with the Uniformed Services University of the Health Sciences and the Henry M.  Jackson Foundation for the Advancement of Military Medicine (affiliated with the Department of Defense) used Panel Study of Income Dynamics (PSID ) [13]. The PSID collects data on employment, it is unknown if military employment is stratified, yet the study did not take the opportunity to include data covering employment or income. Asking about one’s veteran or active duty status is an opportunity that creates a compelling future for improved analytics and for research on health. In fact, medical debt has been debated as a social determinant of health [14].
• National reports on improper billing are conducted by experts, and these experts are wholly capable of delving into operational details. Rules and regulations for healthcare billing are readily found. Common billing mistakes and poor practices are also easy to find online, though there is no public accountability where private authors have commented. The training, education and management of medical billing, claims specialists and coders would be important to understand. How common the errors are, and the reasons for the errors, are also important. If practices have altered billing for perceived fairness to the practice or to the patient who cannot afford care, we should better understand. If healthcare is assuming claims were denied just because they were rejected, or if practices are duplicate billing by mistake, trends should be known. The underlying reasons for common behaviors are important, and better transparency on the issue is welcomed.
• Personal loans have seen new attention in reports [15]. Borrowing money is rarely included in medical debt data, particularly informal loans between loved ones. There is no clear literature on financial stress, nor financial assistance between these groups. Given intimate pressures of deployment and physical distance, the lack of priority to obtain this data is intriguing. If approximately 8% of the US population are active duty or veteran status [16, 17], it would be critical to understand this population’s involvement with US medical debt. This is especially true given recent headlines, concerns and legislation on the issue [18,19, 20]. And, this is especially true given the reported link between medical debt and poorer mental health[14]. Watchdogs, data analysts and reports could also begin to include non-dependent, non-household love ones’ medical debt and medical billing anxiety shouldered by the military serviceperson. The data could include socioeconomics as well as deployment status.
• Racial and ethnic differences in medical debt reports are critical, helpful and should continue to be spotlighted [21,22]. Analyses for solutions to racial gaps in medical debt should be utilized for consensus on forward movement [23,24]. Teamwork has excelled here, and will continue to excel.
• Legislation that helps protect the public from surprise medical billing is crucial [25]. Ongoing analysis and actions for known gaps in surprise billing oversight will help. Summarizing ongoing bill issues or addressing ambulance payment gaps could be advanced without delay, for example. When legislation steps in to support, poor performing players who sparked the need for oversight can be assigned accountability for improvement.
• Analysis of major differences in Medicare and Medicaid payments are important, and we are fortunate for analyses initiatives. Differences by state and by insurer could assist [26]. Concern for the Medicare program’s financial stability have been noted in continued analyses[28]. Experts continue to examine best paths forward, thankfully. These assessments could include VA leadership at the tables [29].
• Crowd-sourcing cash assistance is a significant component to health finances. It is important to note the $3 million granted, as well as the $10 million requested, on Go Fund me from 2010-2018 [27]. Reports that cash assistance supports a patient’s health decision making, and that it increases positive health outcomes, should be backed by scientific research. These are true opportunities offered by initial inclusion of crowd-sourcing reports.
• Global health has worked very hard to organize the frameworks for health-related financial risk protection, access to quality essential health services and access to safe, effective, quality and affordable essential medicines and vaccines for all. Reports on individual out of pocket (OOP) spending by OECD country are extremely helpful, especially spotlight that 2/3 of OOP spending goes to outpatient, dental and pharmaceuticals [30]. Resources used as indicators for comparison are helpful[31]. Incorporating these indicators into standing reports is feasible, as is reporting on data source quality[32]. Indicators could also include dental components, given the outstanding work that has already accomplished insight. Additionally, this work offers opportunities for policy. Policies and legislation that tackle reasons for outpatient, dental and pharmaceutical financial differences (staffing, education, supply, markets) are possible and offer hope. Global health could also define and shape fraud, from legal frameworks to justice routes.
• OCED reports are specific. Opportunities to include surprise billing and medical debt [33] have potential. Other global universal health coverage efforts could also be included[34]. Assessment of OOP expenditures, using various methods, has been notable. A 2007 assessment on OOP for the continent of Africa [35] is noteworthy, and updates would be welcomed. Updates to comparisons of health systems could be assess for potential metrics adoption [36].
• WHO and partners have worked tirelessly to initiate and carry the conversation of affordable and accessible universal healthcare [37,38,39,40]. Efforts to categorize payer models and coverage paradigms would also be welcomed. Misunderstanding over universal health coverage terminology can also be confronted. When countries are facing major medical finance concerns, it becomes increasingly difficult to advocate for tax-paid international aid. The potential for political winds to censure international aid rather than fix what’s domestically broken increases without transparency around healthcare finances. In the context of aid, universal healthcare could be better clarified.
• World health has been observant and involved in healthcare financing. Conversations with high-income countries on comparative metrics should continue, and conversations that support best implementation for low and middle income (LMIC) financing designs should include honesty and transparency over the limitations of the design. The honesty should come from those managing these designs, and from those with implementation. A conversation between LMIC Asia and the United States on efficiency, outcomes and access to hospitals[41], for example, could commit to healthcare financing planning through metrics and comparisons.

1. https://www.consumerfinance.gov/about-us/newsroom/cfpb-report-highlights-experiences-of-

military-families-with-medical-billing-credit-reporting-and-debt-collection/

2. https://files.consumerfinance.gov/f/documents/cfpb_osa-annual-report-2021.pdf

3. https://www.consumerfinance.gov/about-us/blog/new-va-rule-relieves-financial-distress-for-

thousands-of-veterans-with-medical-bills/

4. https://reservenationalguard.com/money/new-report-highlights-top-military-concerns-on-

medical-billing-errors-credit-reporting-issues/

5. https://www.moaa.org/content/publications-and-media/news-articles/2022-news-

articles/medical-debt,-credit-report-errors-drive-rise-in-military-consumer-complaints/

6. https://www.militarytimes.com/news/pentagon-congress/2019/08/14/investigators-find-53-

million-in-improper-medical-bills-for-veterans/

7. https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-

states/#Share%20of%20aggregate%20total%20medical%20debt%20in%20the%20U.S.,%20by%20th

e%20amount%20of%20debt%20individuals%20owe,%202019

8. https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/

9. https://siepr.stanford.edu/news/americas-medical-debt-much-worse-we-think

10. https://jamanetwork.com/journals/jama/article-abstract/2782187

11. https://www.forbes.com/sites/debgordon/2021/10/13/50-of-americans-now-carry-medical-

debt-a-new-chronic-condition-for-millions/?sh=448a7b245e5d

12. https://www.consumerreports.org/medical-billing/could-your-medical-bills-make-you-sick/

13. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199598

14. https://jamanetwork.com/journals/jama/article-abstract/2782205

15. https://www.kff.org/report-section/the-burden-of-medical-debt-section-3-consequences-of-

medical-bill-problems/

16. https://www.cfr.org/backgrounder/demographics-us-military

17. https://www.census.gov/topics/population/veterans.html#:~:text=This%20report%20looks%20

at%20the,U.S.%20Armed%20Forces%20in%202018.&text=This%20report%20examines%20the%

20demographic,years%20compared%20with%20nonveteran%20women

18. https://www.nclc.org/media-center/president-bidens-announcement-on-veterans-medical-

debt-will-lift-a-burden-from-veteran-families.html

19. https://www.businessinsider.com/va-veterans-medical-debt-unreported-credit-bureau-cfpb-

financial-distress-2022-2

20. https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-

supporting-veterans-experiencing-financial-hardship-and-addressing-the-harmful-effects-of-

military-environmental-exposures/

21. https://www.urban.org/research/publication/medical-debt-fell-during-pandemic-how-can-

decline-be-sustained

22. https://www.brookings.edu/research/the-racial-implications-of-medical-debt-how-moving-

toward-universal-health-care-and-other-reforms-can-address-them/

23. https://www.commonwealthfund.org/blog/2022/how-health-care-coverage-expansions-can-

address-racial-equity

24. https://www.commonwealthfund.org/publications/scorecard/2021/nov/achieving-racial-ethnic-

equity-us-health-care-state-performance

25. https://www.commonwealthfund.org/blog/2020/surprise-billing-protections-cusp-becoming-

law

26. https://www.commonwealthfund.org/blog/2022/how-differences-medicaid-medicare-and-

commercial-health-insurance-payment-rates-impact

27. https://www.commonwealthfund.org/blog/2022/cash-assistance-eases-financial-burden-

associated-medical-emergencies

28. https://www.commonwealthfund.org/blog/2021/addressing-medicare-solvency-will-require-

both-revenue-and-spending-changes

29. https://www.medicareinteractive.org/get-answers/coordinating-medicare-with-other-types-of-

insurance/veterans-affairs-va-benefits-and-medicare/making-part-b-enrollment-decisions-with-

va-benefits

30. https://www.oecd.org/health/health-systems/OECD-Focus-on-Out-of-Pocket-Spending-April-

2019.pdf

31. https://data.oecd.org/healthres/pharmaceutical-spending.htm

32. https://read.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-

2021_919b5f62-en#page2

33. https://www.oecd.org/els/health-systems/health-data.htm

34. https://www.worldbank.org/en/topic/universalhealthcoverage

35. https://apps.who.int/iris/bitstream/handle/10665/85677/HSS_HSF_DP.07.7_eng.pdf?sequence

=1&isAllowed=y

36. https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-

reflecting-poorly

37. https://www.uhc2030.org/what-we-do/improving-collaboration/health-systems-strengthening/

38. https://www.uhc2030.org/what-we-do/improving-collaboration/country-compacts/

39. https://www.uhc2030.org/what-we-do/improving-collaboration/health-systems-

strengthening/financial-management-assessment/

40. https://www.uhc2030.org/fileadmin/uploads/uhc2030/Documents/Key_Issues/Advocacy/UHC2

030_Health_systems_narrative__actions_paper.pdf

41. https://www.who.int/publications/i/item/9789290617327