UVA doctors decry aggressive billing practices by their own hospital

Reviewed by Kate Anderton, B.Sc. (Editor)Nov 23 2019

Prominent doctors at UVA Health System are expressing public outrage at their employer’s practices to collect unpaid medical debt from its patients.

A Kaiser Health News report in September that showed UVA sued 36,000 patients over six years for more than $100 million, seizing wages and savings and even pushing families into bankruptcy.

Like many physicians who work at U.S. medical centers, the UVA doctors said they had little idea how aggressively the hospital where they practice was billing and pursuing their patients for payment.

Although the health system has announced some interim measures to scale back collections practices, some of the system's most senior physicians are now calling for UVA to stop suing its patients altogether. And they are urging the pursuit of an “immediate solution" to address the national epidemic of health care debt.

"We were appalled by the revelations of the aggressive, pitiless billing and collections practices" at UVA, Dr. Scott Heysell and two other senior staff members wrote in a letter to KHN published Saturday. "We felt betrayed," they wrote, "and we had, by extension, betrayed those who had relied on us."

Heysell, an infectious-disease specialist and associate professor at UVA School of Medicine, and his co-authors echoed other UVA researchers and clinicians contacted by a reporter who said they were surprised and dismayed by the health system's practices.

UVA initially defended its practices, pointing to the Virginia Debt Collection Act of 1988, which requires state agencies to "aggressively collect" money owed. But within days of the KHN report, UVA said it would reduce its use of the courts and make it easier for patients to qualify for financial assistance.

That's not enough, said the letter's authors, who include Dr. Rebecca Dillingham, director of UVA's Center for Global Health, and Dr. Michael Williams, director of the UVA Center for Health Policy.

They ask "why UVA cannot join other public hospitals that have effectively stopped suing patients altogether?"

Other University of Virginia faculty said the system's practices undermined their efforts to improve care for middle- and lower-income families and was not in keeping with an ethos of putting patients first.

KHN's findings "made me feel utterly hypocritical about my work and efforts to promote health equity," Rajesh Balkrishnan, a UVA public health professor who researches cancer treatment in Appalachia, said in an interview.

"This is a public university with one of the richest endowments in the country," he said. At least take care of the immediate community you serve."

In September, UVA Health said it would "reduce our reliance on the legal system," suing patients only if their household income is more than 400% of the federal poverty level, or $103,000 for a family of four. It also pledged to increase discounts for the uninsured and upgrade its financial assistance for patients.

Those measures are "a first step," it said. On Oct. 28, it named an advisory council of community leaders, patient advocates and UVA students and staff to consider further changes.

"We are continuing to thoughtfully review our billing and collection practices to find additional ways to better serve our patient as well as improve fairness and transparency," said UVA Health spokesman Eric Swensen. "We are looking at all options to achieve these goals."

Virginia Gov. Ralph Northam, who oversees the state's university system and public hospitals, is a pediatric neurologist.

"As a doctor himself, Gov. Northam agrees with the doctors who have taken a stand against unfair and aggressive medical billing practices," his spokeswoman said. "Much more can and should be done to address this issue."

KHN's report prompted discussions across the campus in Charlottesville about how to treat uninsured patients or those with coverage who still struggle with thousands of dollars in out-of-pocket expenses, doctors and faculty said.

"No physician wants to be responsible for bankrupting a patient — not one physician, not one patient," said Dr. Mohan Nadkarni, UVA's chief of general internal medicine. He is the only physician on the advisory council.

"UVA physicians were completely taken aback by the scale and magnitude of the collections practices,” Nadkarni said. Discussion at the council's first meeting reflected "lots of pent-up dissatisfaction from community leaders" about UVA's practices, he said.

But many knew the health system was suing patients, they said. Some had firsthand experience with aggressive tactics from the billing office.

At one "town meeting" of health system employees, held at UVA's Leonard Sandridge Auditorium in response to KHN's report, somebody took the mic and asked, "Who in this room has been taken to collections by UVA?" said Matthew Gillikin, a speech therapist who was there. A third to half the people raised their hands, he said.

Court data analyzed by KHN showed that UVA Health was suing about 100 of its employees every year.

Also at the town meetings, "we heard many agonizing stories of patients and employees having been sued or having wages garnished," Nadkarni said. "We heard loud and clear from many physicians that they heavily supported significant liberalization" of UVA Health's financial assistance policies.

Family physician Dr. Alex Salomon, who worked at UVA for seven years and now is with Augusta Health in Fishersville, Va., had "a lot of patients" with UVA bill and lawsuit problems, many who had insurance but could not make out-of-pocket payments, he said. Still, he added, "I didn't realize UVA was so much worse" than other hospitals.

As part of the University of Virginia, UVA Health is a state institution that is not subject to taxation. UVA Medical Center, the system's flagship hospital, made a $91 million operating profit on revenue of $1.8 billion in the fiscal year ending in June and held stocks, bonds and other investments worth about $1 billion.

Doctors are realizing that financial barriers to treatment and budget squeezes from bills can be as harmful to patients as disease, said Dr. Marty Makary, a surgeon and researcher at Johns Hopkins Medicine who studies hospital debt collection and is urging UVA alumni to press for further change.

"I have not talked to a single patient or student of UVA or faculty member or alumni who thinks it is reasonable for the hospital to sue patients who cannot afford their bill," he said.

News of UVA collections practices served as a teaching moment for at least one class.

"Many of the students in my class work for the UVA Health System, so the recent media coverage about UVA's billing practices has been painful for them as nurses who care deeply about the patients and families they serve," Kimberly Acquaviva, a professor who teaches health policy at UVA's nursing school, tweeted in September. "As a class, we talked about the power that nurses have to shape the lives of the patients and families" by advocating for system change, she said.

She declined a request for an interview, as did five other doctors or professors. Several referred a reporter to UVA spokesman Swensen. About 20 others did not respond to interview requests.

Dr. Chris Ghaemmaghami, an emergency and internal medicine doctor, became UVA Health's acting CEO after Pamela Sutton-Wallace announced her resignation in September. Her departure was unrelated to KHN's revelations, UVA said at the time.

"I understand the disappointment some fellow physicians felt when our historic billing and collection practices came to light," he said in an email responding to questions from KHN.

Heysell, Williams and Dillingham, the doctors who wrote the letter, go further.

"To be clear, we are outraged," they write. "We stand with those that have been financially injured, whose bank accounts have been looted, whose homes have been swallowed as if they were built on quicksand, whose credit scores were ruined, and whose mental health and energy were spent in a courtroom or in anxious conversations with lawyers — all as a result of having sought our care."