Understanding the Aggressive Practices of Nonprofit Hospitals in Pursuit of Patient Debt

Health Soc Work. 2022 Jan 31;47(1):36-44. doi: 10.1093/hsw/hlab034.


Nonprofit hospitals have attracted scrutiny for aggressive collection activities against patients, which persist despite the Patient Protection and Affordable Care Act's attempt to limit particularly egregious practices, called "extraordinary collection actions" (ECAs). This study examines the prevalence of ECAs and characteristics of nonprofit hospitals that reported this behavior as of 2016. Using Community Benefit Insight data, characteristics of hospitals that reported ECAs are compared with hospitals that did not report these practices. ECAs include reporting patient debt to credit agencies, filing lawsuits, placing liens on residences, and issuing civil arrest. Predictors of ECAs among nonprofit hospitals are identified using logistic regression analysis. The prevalence of ECAs is examined for the 2010-2016 time period, and nonprofit hospitals that reported ECAs are mapped to show the geographic distribution. Hospitals reporting ECAs significantly differed in total revenue, system membership, bed size, urban location, financial assistance policy use, and use of poverty guidelines for discounted care. In full logistic regression models, lower total hospital revenue was a significant predictor of ECAs. As social workers, it is vital to understand the landscape of nonprofit hospital collection actions to advocate for policy that protects patients from predatory practices while holding nonprofit hospitals accountable.

Keywords: healthcare; hospitals; medical debt; policy.

MeSH terms

  • Hospitals
  • Humans
  • Organizations, Nonprofit*
  • Patient Protection and Affordable Care Act*
  • Poverty
  • United States