ARI SHAPIRO, HOST:
When patients don't pay their hospital bills, some hospitals respond with lawsuits. A study published today in the Journal of the American Medical Association finds about a third of hospitals in Virginia take that route.
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One of them, Mary Washington Hospital in Fredericksburg, files so many lawsuits against patients that the second Friday of every month is reserved for them at the local courthouse. And this month, 300 cases were on the docket.
SHAPIRO: Mary Washington and other hospitals around the country defend the practice as a legitimate way to collect on unpaid bills. Patient advocates say it's immoral and can ruin patients' lives. NPR's Selena Simmons-Duffin reports.
SELENA SIMMONS-DUFFIN, BYLINE: The Fredericksburg General District Court is a red brick courthouse with Greek columns in a quaint colonial town. An actual horse and carriage is usually parked outside the visitor's center down the street. On this sunny morning, the second Friday in June, the first defendant at court is a young woman with glasses and a plaid purple shirt.
DAISHA SMITH: My name is Daisha Smith. I am 24 years old.
SIMMONS-DUFFIN: She arrived early, having just worked an overnight shift.
SMITH: I work with older people, so I take care of them. I feed them. I bathe them. I do everything for them.
SIMMONS-DUFFIN: Inside the courthouse, it's not hard to figure out where to go. The hospital sues so many patients, it's got a system down. Right through court security, there are signs on colored paper - Mary Washington cases this way. The elevator doors open - another Mary Washington sign. Mary Washington billing staff walk through the halls and set up a kind of field office and a witness room right at the back of the courtroom. On this day in June, only a handful of the 300 people summoned to court show up. Daisha Smith is the first called to the bench.
SMITH: So when I went in there today, that's why the lawyer came up there...
SIMMONS-DUFFIN: Back in 2017, Smith was admitted to Mary Washington Hospital for two weeks. She doesn't want to give the details.
SMITH: I was not myself. So I walked myself into Mary Washington to get help, to get myself on track.
SIMMONS-DUFFIN: Smith says she never saw a bill and no one talked to her or called to explain the hospital's financial assistance policy. At the time, she was working part time at Walmart for $11 an hour. She had no insurance. According to Mary Washington Healthcare's financial assistance policy, someone making less than $25,000 without health insurance should qualify for free care. But Smith was sued for over $12,000. Last year, the hospital began taking money out of her paycheck.
SMITH: When I looked in my pay stub, I'm like, why do I only have 600-some dollars in my account? And it says garnish. And I'm like, who's garnishing my check? So I call my company and ask them and they say Mary Washington. Mary Washington never called me and told me it was garnishing my check. I didn't get nothing from them. They just take it out of my account.
SIMMONS-DUFFIN: Smith knows Mary Washington Hospital sues a lot. She says one of her relatives is on a payment plan. Her co-worker was sued over an unpaid bill, too, from Mary Washington Hospital.
SMITH: And that's crazy. Like, people need help. Y'all just money hungry.
SIMMONS-DUFFIN: There are no good national data, but reporters have identified hospitals suing thousands of patients all over the country, in North Carolina, Ohio, Nebraska. In 2014, NPR and ProPublica published stories about a hospital suing patients in Missouri. Many of the hospitals that do this are nonprofits.
JENIFER BOSCO: Under federal law, nonprofit hospitals that have tax-exempt status need to follow certain IRS rules and regulations.
SIMMONS-DUFFIN: That's Jenifer Bosco of the National Consumer Law Center.
BOSCO: And there is a rule put in place as part of the Affordable Care Act that requires nonprofit hospitals to have financial assistance policies and also limit certain harsher debt collection practices for lower income people.
SIMMONS-DUFFIN: Mary Washington Healthcare stands by its practice of suing patients. It says the practice is legal and that lawsuits are a last resort. Lisa Henry is director of communications for the health system.
LISA HENRY: We have a process that we are going to try to reach our patients by phone, by mail, by email, any access point we're given from them when they register.
SIMMONS-DUFFIN: She says they try to reach patients for around seven months.
HENRY: Unfortunately, if we don't hear back from folks or they don't make a payment, we're assuming that they're not prepared to pay their bill. So we do issue papers to the court.
SIMMONS-DUFFIN: Even though thousands of cases a year may seem like a lot, Henry says it's actually a small percentage of their patients.
HENRY: The vast majority of our patients fill out the paperwork or call us. A small percentage then goes onto collection and then an even smaller goes to litigation. We see thousands of patients a year, and less than 1% go to litigation.
SIMMONS-DUFFIN: Henry says Mary Washington is getting unfairly singled out for an issue all hospitals are grappling with - how to collect on their unpaid bills. She says other hospitals use private debt collection agencies. Mary Washington chose the legal system instead in part because it's more transparent.
HENRY: We selected to do this because we think it is a fair and appropriate way to help our patients reach out to us.
SIMMONS-DUFFIN: Without national data, it's hard to know how many nonprofit hospitals sue patients who haven't paid their bills versus using debt collectors versus writing it off, says Erin Fuse Brown. She's a law professor at Georgia State University.
ERIN FUSE BROWN: I haven't seen data estimating the number of hospitals that are taking these actions and how common or frequent this is.
SIMMONS-DUFFIN: Whether it's common or not, she says, there are bigger philosophical questions here about a hospital's role.
BROWN: There has to be a balance between getting their bills paid but also being a reasonable community member.
SIMMONS-DUFFIN: Garnishment generally doesn't bring in very much for hospitals filing lawsuits. In the JAMA study of Virginia hospitals, the average of total revenue from garnishment was 0.1%. For Mary Washington last year, garnishing accounted for 0.2% of their total revenue, which was $624 million.
BROWN: It doesn't seem to be worth the effort, and it's so ruinous to the patient, not just the financial obligation but the effect on your credit, on your record, you know, the emotional effect of being sued.
SIMMONS-DUFFIN: Mary Washington Hospital's lawsuits have gotten the attention of Martin Makary, a surgeon at Johns Hopkins in Baltimore.
MARTIN MAKARY: This is a disgrace. It's a disgrace every place where it happens. Hospitals are supposed to be a refuge for the sick and injured. So to see these aggressive and even predatory collection strategies affect everyday teachers, farmers, even nurses, it's heartbreaking. And it's wrong, and it needs to stop.
SIMMONS-DUFFIN: Makary first found out about this hospital's lawsuits last fall while working on "The Price We Pay," his forthcoming book on the health care system. That led to formal research and the study published today in JAMA.
MAKARY: We looked at all Virginia hospitals and found that most have never sued a patient, about 30-some percent have sued a patient and a small fraction of them, about 10%, sue very aggressively and oftentimes very quickly.
SIMMONS-DUFFIN: He's now part of a full-fledged advocacy effort to get Mary Washington Hospital to stop suing. He's written to the hospital board and CEO. He's been coming to Fredericksburg every month for hospital docket day, bringing students and other doctors with him. They've even brought in a local attorney.
JOSEPH KIRCHGESSNER: My real name is Joseph Kirchgessner, but I go by Joey K. or Joey Kirchgessner.
SIMMONS-DUFFIN: So far, he's represented about 15 patients in contesting their Mary Washington Hospital bills. This month when he came to court, he took Daisha Smith on as a new client.
KIRCHGESSNER: I need to meet with her one on one, and we're going to try to either get the payment lowered, removed altogether, which is a little bit less likely.
SIMMONS-DUFFIN: Just lowering the amount the hospital garnishes each month would help. Right now, Smith says she's only left with about $1,400 a month and her rent is over a thousand.
SMITH: If they wasn't garnishing my check, I'd be fine. I would have everything that I needed, saving money, everything would be paid, food would be in the house. I literally have no food in my house because of them garnishing my check. So I'm, like, asking people and borrowing money from people.
SIMMONS-DUFFIN: And she took on a second job. She says now if she had a medical issue, she would go to urgent care. She says she stays away from Mary Washington. Selena Simmons-Duffin, NPR News, Fredericksburg, Va.
(SOUNDBITE OF WILLIAM ORBIT'S "PAVANE POUR UNE INFANTE DEFUNTE")
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