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The pandemic is shaking up health care delivery and markets. And it's an election year.

Health policy is often designed to help protect patients' financial security. However, there is limited understanding of the role medical debt plays in household finances. We used credit report data on more than four million Americans to study the age profile of people whose medical bills were sent to a US collections agency in 2016. We found that, unlike health care use and spending, medical collections decreased substantially with age. The average size of medical debt decreased nearly 40 percent from patients age twenty-seven to sixty-four, with increases in health insurance coverage and incomes likely playing important mediating roles. However, the frequency of medical collections-that is, the proportion of people with a collection by age-was less closely tied to insurance coverage rates. A potential explanation is that most medical collections were relatively modest in size, with more than half of them less than $600 annually. As a result, medical collections could still occur under typical insurance plans. We discuss how these results could inform policies targeting medical debt and insurance regulation, such as restrictions on age rating.

On the island Nation of Guam, the United States Department of Defense has stationed military personnel from every service branch. Guam is utilized as a strategic waypoint for the U.S. military in the Pacific theater. As the largest service branch in the region, the Navy has placed a few Diving Medical Officers in Guam to collectively manage and treat patients with recompression therapy. Guam is also a popular tourist destination, with multiple recreational diving companies certifying individuals who are looking to take advantage of the beautiful warm water and exotic marine life. Unfortunately, with an increase in training and certifying inexperienced divers, came an increase in the operational tempo of the U.S. Navy’s recompression chamber on Guam. The recompression chamber on Naval Base Guam (NBG) has been treating patients since 1971. With the only multiplace chamber in the Mariana Islands, Diving Medical Officers, with the accompanying chamber staff, treat military personnel, active-duty sponsored patients and civilian patients. Treating civilian patients by military providers through military treat- ment facilities presents multiple issues that must be addres- sed in an effort to provide efficient quality medical care. This article reviews the records, documents, and activity of the NBG chamber over the last four decades. Through the obtained data the information provides projected financial reimbursement from civilian patients. The article also sheds light on areas of needed improvement with regard to data collection, third-party financial collection efforts and the necessity of an inclusive electronic health record (EHR) for military and civilian patients.

Background Consumer credit may reflect financial hardship that patients face due to cancer treatment, which in turn may impact ability to manage health after cancer; however, credit’s relationship to economic burden and health after cancer has not been evaluated. Methods From May to September 2015, 123 women with a history of breast cancer residing in Pennsylvania or New Jersey completed a cross-sectional survey of demographics, socioeconomic position, comorbidities, SF-12 self-rated health, economic burden since cancer diagnosis, psychosocial stress, and self-reported (poor to excellent) credit quality. Ordinal logistic regression evaluated credit’s contribution to economic burden and self-rated health. Results Mean respondent age was 64 years. Mean year from diagnosis was 11.5. Forty percent of respondents were Black or Other and 60% were White. Twenty-four percent self-reported poor credit, and 76% reported good to excellent credit quality. In adjusted models, changing income, using savings, borrowing money, and being unable to purchase a health need since cancer were associated with poorer credit. Better credit was associated with 7.72 ([1.22, 14.20], p = 0.02) higher physical health t-score, and a − 2.00 ([− 3.92, − 0.09], p = 0.04) point change in psychosocial stress. Conclusions This exploratory analysis establishes the premise for consumer credit as a marker of economic burden and health for breast cancer survivors. Future work should validate these findings in larger samples and for other health conditions. Implications for Cancer Survivors Stabilizing and monitoring consumer credit may be a potential intervention point for mitigating economic burden after breast cancer.

The Centers for MedicareMedicaid Services requires hospitals to give patients an array of documents to explain their rights, their status, and any financial obligations they may incur — and it’s usually up to case managers to see that the hospital complies. •The Medicare Outpatient Observation Notice (MOON) is the latest requirement, but the Important Message (IM) from Medicare also is required under the Medicare Conditions of Participation. In order to bill patients for services that are incurred but not covered, hospitals also must give patients a Hospital Issued Notice of Noncoverage (HINN). •If the documents are delivered at the proper time, they could affect the hospital’s reimbursement, increase the risk of audit, and affect patients’ understanding of their rights and responsibilities. •The entire treatment team should be aware of the documents and intentions. Education on delivering these documents should be part of case management orientation and regular education. •Hospitals should develop a process for delivering HINNs if the need arises. Before that happens, case managers should communicate frequently with the patient and family about the next level of care. •Patients may demand that their status be changed from observation to inpatient, but they can’t be admitted unless they meet inpatient criteria.

Now that Geisinger is confident in the payment process for providers, it will continue to innovate new ways to improve the member experience. The goal is to be not just one of the top companies for members and not just one of the top health care organizations, but one of top organizations among all the companies in the United States.

Novant Health’s zero-interest loan program allows patients to add new healthcare service fees to existing balances.

Data evolution is forcing revenue cycle silos to crumble. And that's a good thing.

Messages specific to balance due amounts allow hospitals to tailor wording and payment options based on high or low balances.

Preparation is key to limiting revenue dips.

New Internal Revenue Service rules that ostensibly limit harsh hospital billing practices provide inadequate protection for many patients by excluding for-profit hospitals and allowing hospitals to determine eligibility for financial assistance.

Although regional variations in Medicare spending are known, it is not clear whether regional variations exist in hospital charges for total joint arthroplasty. Data from Centers for Medicare and Medicaid Services (CMS) on Diagnosis Related Groups 469 and 470 (Major Joint with and without Major Complicating or Comorbid Condition) from 2011 were analyzed for variation by region. Drastic variations in charges between institutions were apparent with significant differences between regions for hospital charges and payments. The median hospital charge nationwide was $71,601 and $46,219 for Diagnosis Related Groups 469 and 470, respectively, with corresponding median payments of $21,231 and $13,743. Weak to no correlation was found between hospital charges and payments despite adjustments for wage index, cost of living, low-income care and teaching institution status.

The American Cancer Society's Health Insurance Assistance Service provides callers to its National Cancer Information Center with detailed knowledge to help them access or maintain health insurance coverage for which they might be eligible. Demographic data from April 2009 to June 2011 show that 76 % were uninsured and between the ages of 40-60; 65 % were Caucasian, 17 % African American, and 12% Hispanic; and monthly incomes were $1,999 or less. Current trends indicate that callers are similar to those identified in various health care reform publications: callers are unable to afford co-pays; facilities are requesting cash upfront; callers report loss of coverage, less adequate or less affordable coverage from employers; large out-of-pocket expense or high deductibles are needed; and modification of the CDC's Breast and Cervical Screening Program's eligibility guidelines create challenges. Six lessons that have been learned while initiating and managing this program are presented.

This article describes findings from ongoing research and analysis of current literature in addition to discussions with leaders in the field, communications with lawyers and administrators of advocacy and government agencies pertaining to integrated primary care (IPC). Standards of care are established based on a myriad of factors, including professional codes of ethics, case law, state and federal laws, professional standards, existing best practices, current professional guidelines, administrative rules and regulations, and licensing board regulations. Regulations may differ for behavioral health and medical providers, posing challenges in IPC settings. This article provides a review of these regulations, particularly 42CFR Part 2, a federal law governing confidentiality for substance abuse programs, Health Insurance Portability and Accountability Act (HIPAA), and state laws relevant to patient care in IPC settings. On the basis of findings from the study, the authors make recommendations related to patient care practices concerning informed consent and release of information procedures, treatment and warm hand-off protocols, documentation and electronic record keeping, agreements with other providers, and billing.

Objectives. To evaluate African American–White differences in medical debt among older adults and the extent to which economic and health factors explained these. Methods. We used nationally representative data from the 2007 and 2010 US Health Tracking Household Survey (n = 5838) and computed population-based estimates of medical debt attributable to economic and health factors with adjustment for age, gender, marital status, and education. Results. African Americans had 2.6 times higher odds of medical debt (odds ratio = 2.62; 95% confidence interval = 1.85, 3.72) than did Whites. Health status explained 22.8% of the observed disparity, and income and insurance explained 19.4%. These factors combined explained 42.4% of the observed disparity. In addition, African Americans were more likely to be contacted by a collection agency and to borrow money because of medical debt, whereas Whites were more likely to use savings. Conclusions. African Americans incur substantial medical debt compared with Whites, and more than 40% of this is mediated by health status, income, and insurance disparities. Public health implications. In Medicare, low-income beneficiaries, especially low-income African Americans with poor health status, should be protected from the unintended financial consequences of cost-reduction strategies.

Drawing from the medical sociology literature on the patient–doctor relationship and microeconomic sociological scholarship about the role of money in personal relationships, I examined patient–physician interactions within a clinic that offered eye health and cosmetic facial services in the United States. Relying on ethnographic observations conducted in 2008, I evaluated how financial pressures shape the patient–physician relationship during the clinical encounter. To gain a financial advantage, patients attempted to reshape the relationship toward a socially intimate one, where favor and gift exchanges are more common. To ensure the rendering of services, the physician in turn allied herself with the patient, demonstrating how external parties are the barriers to affordable care. This allied relationship was tested when conflicts emerged, primarily because of the role of financial intermediaries in the clinical encounter. These conflicts resulted in the disintegration of the personal relationship, with patient and physician pitted against one another.

Forensic practice fees, billing, and collection procedures are quite different from those in general psychiatry. Most forensic practices have far fewer "clients," and individual bills are usually larger. Collections are usually better (and less frequently discounted) in forensic practice, and resolving billing disputes is far more straightforward. Medicare, Medicaid, other insurance coverage, provider networks and agreements, procedure codes, and diagnosis-related groups (DRGs) are all largely irrelevant in forensic work (although sometimes important to direct clinical services in correctional psychiatry or forensic treatment clinics). An understanding of the practicalities and ethics of charging and billing for forensic services greatly simplifies practice management.

When developing strategies for collecting on patient debt, hospitals can benefit from following the example of the banking industry: Banks take a "do-it-yourself" approach, working delinquent accounts in-house for as long as practical. They embrace technology to give in-house debt collectors optimal opportunity to connect with customers to work out terms for resolving debt. They strategically leverage outside collections agencies based on the makeup of their debt portfolio.

Development of a self-pay plan is key to improving collections. The five opportunities for providers to do this include: Pre-registration/scheduling. Admissions, time of service, discharge, post-billing.

U.S. nonprofit hospitals must now have written policies regarding charity care, charge reasonable amounts for it, refrain from extraordinary bill-collection practices, and assess community health needs every 3 years. The effects on charity care are likely to be mixed.