title: Medical debt and aggressive debt restitution practices: predatory billing among the urban poor.
abstract: BACKGROUND
  Health care providers are increasingly relying on collection agencies to recoup charges associated with medical care. Little is known about the prevalence of this practice in low-income communities and what effect it has on health-seeking behavior.
  
  
  METHODS
  Cross-sectional survey at 10 "safety net" provider sites in Baltimore, Md. Specific queries were made to underlying comorbidities, whether they had a current medical debt, actions taken against that debt, and any effect this has had on health-seeking behavior.
  
  
  RESULTS
  Overall, 274 adults were interviewed. The average age was 43.9 years, 77.3% were African American, 54.6% were male, 47.2% were homeless, and 34.4% had less than a 12th grade education. Of these, 46.2% reported they currently had a medical debt (average, 3,409 dollars) and 39.4% reported ever having been referred to a collection agency for a medical debt. Overall, 67.4% of individuals reported that either having a current medical debt or having been referred to a collection agency for a medical debt affected their seeking subsequent care: 24.5% no longer went to that site for care; 18.6% delayed seeking care when needed; and 10.4% reported only going to emergency departments now. In the multiple logistic regression model, having less than a 12th grade education (odds ration [OR], 2.5; 95% confidence interval [CI], 1.0 to 6.0) and being homeless (OR, 4.1; 95% CI, 1.4 to 12.3) were associated with a change in health-seeking behavior while having a chronic medical condition (OR, 0.2; 95% CI, 0.1 to 0.5) and going to a community clinic for usual care (OR, 0.2; 95% CI, 0.1 to 1.0) were protective.
  
  
  CONCLUSIONS
  Aggressive debt retrieval for medical care appears to be indiscriminately applied with a negative effect on subsequent health-seeking behavior among those least capable of navigating the health system.
authors.affiliation: Johns Hopkins University Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Balitomore, MD 21205, USA. totoole@jhmi.edu
authors.forename: Thomas P
authors.initials: TP
authors.lastname: O'Toole
authors.forename: Jose J
authors.initials: JJ
authors.lastname: Arbelaez
authors.forename: Robert S
authors.initials: RS
authors.lastname: Lawrence
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000374:Aggression; D015142:Baltimore; D015897:Comorbidity; D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility / Q000191:economics*; D006786:Hospitals, Urban / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D017057:Medically Uninsured; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000208:ethnology; D010350:Patient Credit and Collection / Q000379:methods*; D011203:Poverty / Q000191:economics*; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D019037:Urban Health Services / Q000191:economics* / Q000706:statistics & numerical data