Medical debt and aggressive debt restitution practices: predatory billing among the urban poor.
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.
O'Toole
Thomas P
TP
Johns Hopkins University Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Balitomore, MD 21205, USA. totoole@jhmi.edu
Arbelaez
Jose J
JJ
Lawrence
Robert S
RS
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