TeleSANE services are expanding across the country in rural, sparsely populated areas.

This story was published on Monday, January 3, 2023 in Kaiser Health News.

By Arielle Zionts

Amanda Shelley was sitting in her dentist's waiting room when she received a call from the police. A local teenage girl had been sexually assaulted and needed an exam.

Shelley, a nurse in rural Eagle County, Colorado, went to her car and called a telehealth company to arrange an appointment with a sexual assault nurse examiner, or SANE. The nurse examiners have extensive training in how to care for assault survivors and collect evidence for possible criminal prosecution.

About an hour later, Shelley met the patient at the Colorado Mountain Medical urgent care clinic in the small town of Avon. She used a tablet to connect by video with a SANE about 2,000 miles away, in New Hampshire.

The remote nurse used the video technology to speak with the patient and guide Shelley through each step of a two-hour exam. One of those steps was a colposcopy, in which Shelley used a magnifying device to closely examine the vagina and cervix. The remote nurse saw, in real time, what Shelley could see, with the help of a video camera attached to the machine.

The service, known as "teleSANE," is new at Shelley's hospital. Before, sexual assault patients faced mountains of obstacles — literally — when they had to travel to a hospital in another county for care.

"We're asking them to drive maybe over snowy passes and then [be there] three to four hours for this exam and then drive back home — it's disheartening for them," Shelley said. "They want to start the healing process and go home and shower."

To avoid this scenario, teleSANE services are expanding across the country in rural, sparsely populated areas. Research shows SANE programs encourage psychological healing, provide comprehensive healthcare, allow for professional evidence collection, and improve the chance of a successful prosecution.  

Jennifer Pierce-Weeks is CEO of the International Association of Forensic Nurses, which created the national standards and certification programs for sexual assault nurse examiners. She said every sexual assault survivor faces health consequences. Assaults can cause physical injuries, sexually transmitted infections, unwanted pregnancies, and mental health conditions that can lead to suicide attempts and drug and alcohol misuse.

"If they are cared for on the front end, all of the risks of those things can be reduced dramatically with the right intervention," Pierce-Weeks said.

Pierce-Weeks said there's no comprehensive national data on the number and location of healthcare professionals with SANE training. But she said studies show there's a nationwide shortage, especially in rural areas.

Some rural hospitals struggle to create or maintain in-person SANE programs because of staffing and funding shortfalls, Pierce-Weeks said.

Training costs money and takes time. If rural hospitals train nurses, they still might not have enough to provide round-the-clock coverage. And nurses in rural areas can't practice their skills as often as those who work in busy urban hospitals.

Some hospitals without SANE programs refer sexual assault survivors elsewhere because they don't feel qualified to help and aren't always legally required to provide comprehensive treatment and evidence collection.

Avel eCare, based in Sioux Falls, South Dakota, has been providing telehealth services since 1993. It recently added teleSANE to its offerings.

Avel provides this service to 43 mostly rural and small-town hospitals across five states and is expanding to Indian Health Service hospitals in the Great Plains. Native Americans face high rates of sexual assault and might have to travel hours for care if they live in one of the region's large, rural reservations.

Jen Canton, who oversees Avel's teleSANE program, said arriving at a local hospital and being referred elsewhere can be devastating for sexual assault survivors. "You just went through what is potentially the worst moment of your life, and then you have to travel two, three hours away to another facility," Canton said. "It takes a lot of courage to even come into the first hospital and say what happened to you and ask for help."

Patients who receive care at hospitals without SANE programs might not receive trauma-informed care, which focuses on identifying sources of trauma, determining how those experiences may affect people's health, and preventing the retraumatizing of patients. Emergency department staffers may not have experience with internal exams or evidence collection. They also might not know about patients' options for involving police.

Patients who travel to a second hospital might struggle to arrange for and afford transportation or child care. Other patients don't have the emotional bandwidth to make the trip and retell their stories.

That's why some survivors, like Ada Sapp, don't have an exam.

Sapp, a healthcare executive at Colorado Mountain Medical, was assaulted before the hospital system began its SANE program. She was shocked to learn she would need to drive 45 minutes to another county for an exam. "I didn't feel comfortable doing that by myself," Sapp said. "So, my husband would have had to come with me, or a friend. The logistics made it feel insurmountable."

Sapp's experience inspired her to help bring SANE services to Colorado Mountain Medical.

Shelley and several other of the hospital system's nurses have SANE training but appreciate having telehealth support from the remote nurses with more experience. "We are a rural community and we're not doing these every single day," Shelley said. "A lot of my nurses would get really anxious before an exam because maybe they haven't done one in a couple months."

A remote "second set of eyes" increases the confidence of the in-person nurse and is reassuring to patients, she said.

Avera St. Mary's Hospital in Pierre, South Dakota, recently began using teleSANE. Rural towns, farms, and ranches surround this capital city, home to about 14,000 people. The nearest metropolitan area is about a three-hour drive.

Taking a break from a recent busy morning in the emergency department, nurse Lindee Miller rolled out the mobile teleSANE cart and colposcope device from Avel eCare. She pulled out a thick binder of instructions and forms and opened drawers filled with swabs, evidence tags, measuring devices, and other forensic materials.

"You're never doing the same exam twice," Miller said. "It's all driven by what the patient wants to do."

She said some patients might want only medicine to prevent pregnancy and sexually transmitted infections. Other patients opt for a head-to-toe physical exam. And some might want her to collect forensic evidence.

Federal and state laws provide funding to pay for these sexual assault exams, but some survivors are billed because of legal gaps and a lack of awareness of the rules. A proposed federal law, the No Surprises for Survivors Act, would close some of those gaps.

SANE programs, including telehealth versions aimed at rural communities, are expected to continue expanding across the country.

President Joe Biden signed a bill last year that provides $30 million to expand SANE services, especially those that use telehealth and serve rural, tribal, and other underserved communities. The law also requires the Justice Department to create a website listing the locations of the programs and grant opportunities for starting them.

Arielle Zionts: azionts@kff.org, @Ajzionts

An increasing number of hospital systems have created in-house staffing teams to beat private temp staffing agencies at their own game.

This story was publishedl on Thursday, December 15 in Kaiser Health News.

By Andy Miller, Georgia Health News

Like many nurses these days, Alex Scala got a big pay hike when she switched jobs recently.

Scala also received a welcome mix of assignments when she joined Pittsburgh-based Allegheny Health Network. She signed on with a newly created team that works shifts in various units within the system's 14 hospitals.

After working as a registered nurse on staff at a facility elsewhere, Scala, 31, now commutes from her home in Butler, Pennsylvania, to the system's hospitals across western Pennsylvania. "I can meet new people, learn new procedures, how hospitals do different things," Scala said.

An increasing number of hospital systems like Allegheny Health Network have created in-house staffing teams to cope with the pandemic-fueled nursing shortage — and try to beat private temp staffing agencies at their own game. Depending on the system, the nurses could work a weeklong stint or a multiple-week assignment at a hospital and then do a similar schedule at another facility. Some even work self-scheduled shifts in various locations, unlike regular staff nurses, who typically work in a single medical unit within one hospital. These workers differ from traditional "float" nurses, who shift from unit to unit on an as-needed basis within a single hospital.

The goal of the in-house teams is to offer enough pay and flexibility to attract nurses to the jobs — and thus reduce the systems' heavy dependence on more expensive RNs from outside agencies.

Nationally, such contract labor expenses are nearly 500% higher than they were before the pandemic, according to a consulting firm report commissioned by the American Hospital Association. That spending is pushing many hospitals into the red for 2022, the same firm, Kaufman Hall, estimated recently, although some systems have earned profits during the pandemic.

The members of the new staffing units are typically just a small fraction of a hospital system's workforce. And such teams probably wouldn't be feasible for many small or rural facilities. But hospital officials said the internal staffing agencies will grow as nurses and other workers, such as respiratory therapists and surgical techs, seek flexible work arrangements.

"There's a huge shift in the evolution of healthcare in creating more staff who can move around," said Daniel Hudson, vice president of nursing administration and operations at Philadelphia-based Jefferson Health, which recently created a staffing unit that now has 35 full-time workers.

Although nursing shortages have existed for years, the staffing crunch deepened as the demands of COVID care pushed many hospital nurses to exhaustion. Some quit, retired, or sought jobs at home care agencies, ambulatory surgery centers, and medical offices.

A lot of nurses left the workforce, including newly trained ones, said Beth Ann Swan, associate dean of Emory University's Nell Hodgson Woodruff School of Nursing in Atlanta.

Turnover for hospital staff RNs rose to 27.1% last year, up from 18.7% in 2020, according to a NSI Nursing Solutions report.

So nurses from temp agencies filled more shifts. Their pay — and the subsequent cost to hospitals — soared as COVID-19 surged. Travel nurses were earning up to $10,000 a week in late 2020, although the average price dipped to about $3,000 this year.

Before the pandemic, Atlanta-based Piedmont Healthcare spent $20 million annually on nurses from such agencies. "For the past fiscal year, we spent $400 million," Piedmont CEO Kevin Brown said. About a third of that total went directly to the agencies, not the nurses, he added.

To cut out the middleman, Piedmont formed a hospital staffing unit to provide what officials called the best of both worlds — the flexibility of a staffing agency and the stability and support of a local health system.

Such work flexibility is a key draw for nurses, said Akin Demehin, senior director of quality and patient safety policy at the American Hospital Association. Relevant factors include work location and the frequency and structure of shifts.

Internal hospital staffing agencies aren't a new concept. The five-hospital Henry Ford Health System, based in Detroit, started its internal staffing unit in 2013. Besides nurses, the pool includes medical assistants, as well as surgical and emergency room techs. Members of the team get higher hourly pay than regular staffers do and can choose their shifts.

The overall cost is significantly less than using an outside agency's personnel, said Kim Sauro, director of what the Henry Ford system calls the BestChoice program.

But for many nurses, the in-house hospital programs won't overcome the allure of temp agency pay and travel opportunities, at least during some periods of their lives.

Ryan Bannan and his wife, Bharvi Desai Bannan, both Atlanta nurses, went on the road for nearly two years, working in Florida, Arizona, and Utah, among other locations. "The advantages first and foremost were compensation," he said. Now that the couple is expecting a baby, they're back in Atlanta. Ryan works as a staff nurse in an intensive care unit, while Bharvi is an "internal travel nurse," with 13-week stints, for a second local hospital system.

Allegheny Health Network's Scala said she, too, had considered being a travel nurse. "But I have a toddler," she said.

The medical temp agency industry remains a profitable business even though revenues have dropped since the height of the pandemic. The president of one such firm — Chris Eales of Premier Healthcare Professionals, based in Cumming, Georgia — said the new hospital staffing units don't pose an immediate threat to the temp agency field. "Their success would very much depend on their ability to attract, recruit, and retain nurses," Eales said. "They have to build up some credibility."

His firm, he said, is still placing temp nurses in hospitals that have set up mobile staffing units.

Allegheny Health Network is indeed continuing to use some temp agency help. But an exodus of nurses during the pandemic — many to higher-paying agency jobs — helped prompt the creation of its internal staffing team, said Claire Zangerle, the system's chief nurse executive.

The system increased pay and benefits for staff nurses who stayed. Meanwhile, the new mobile unit offered even higher hourly pay than regular staff RNs get to draw agency nurses back. Those mobile employees move among hospitals yet have access to full benefits and "can sleep in their own bed," Zangerle said.

"I don't think we'll ever be temp agency-free," Zangerle said. But flexible hospital work teams, she added, "are going to change the labor market."

Andy Miller: amiller@kff.org, @gahealthnews

Employers are using a new strategy to deal with the high cost of drugs prescribed to treat conditions such as arthritis, psoriasis, cancer, and hemophilia.

This article was published on December 6, 2022 in Kaiser Health News.

By Julie Appleby, Kaiser Health News

Anna Sutton was shocked when she received a letter from her husband's job-based health plan stating that Humira, an expensive drug used to treat her daughter's juvenile arthritis, was now on a long list of medications considered "nonessential benefits."

The July 2021 letter said the family could either participate in a new effort overseen by a company called SaveOnSP and get the drug free of charge or be saddled with a monthly copayment that could top $1,000.

"It really gave us no choice," said Sutton, of Woodinville, Washington. She added that "every single FDA-approved medication for juvenile arthritis" was on the list of nonessential benefits.

Sutton had unwittingly become part of a strategy that employers are using to deal with the high cost of drugs prescribed to treat conditions such as arthritis, psoriasis, cancer, and hemophilia.

Those employers are tapping into dollars provided through programs they have previously criticized: patient financial assistance initiatives set up by drugmakers, which some benefit managers have complained encourage patients to stay on expensive brand-name drugs when less expensive options might be available.

Now, though, employers, or the vendors and insurers they hire specifically to oversee such efforts, are seeking that money to offset their own costs. Drugmakers object, saying the money was intended primarily for patients. But some benefit brokers and companies like SaveOnSP say they can help trim employers' spending on insurance — which, they say, could be the difference between an employer offering coverage to workers or not.

It's the latest twist in a long-running dispute between the drug industry and insurers over which group is more to blame for rising costs to patients. And patients are, again, caught in the middle.

Patient advocates say the term "nonessential" stresses patients out even though it doesn't mean the drugs — often called "specialty" drugs because of their high prices or the way they are made — are unnecessary.

Some advocates fear the new strategies could be "a way to weed out those with costly healthcare needs," said Rachel Klein, deputy executive director of the AIDS Institute, a nonprofit advocacy group. Workers who rely on the drugs may feel pressured to change insurers or jobs, Klein said.

Two versions of the new strategy are in play. Both are used mainly by self-insured employers that hire vendors, like SaveOnSP, which then work with the employers' pharmacy benefit managers, such as Express Scripts/Cigna, to implement the strategy. There are also smaller vendors, like SHARx and Payer Matrix, some of which work directly with employers.

In one approach, insurers or employers continue to cover the drugs but designate them as "nonessential," which allows the health plans to bypass annual limits set by the Affordable Care Act on how much patients can pay in out-of-pocket costs for drugs. The employer or hired vendor then raises the copay required of the worker, often sharply, but offers to substantially cut or eliminate that copay if the patient participates in the new effort. Workers who agree enroll in drugmaker financial assistance programs meant to cover the drug copays, and the vendor monitoring the effort aims to capture the maximum amount the drugmaker provides annually, according to a lawsuit filed in May by drugmaker Johnson & Johnson against SaveOnSP, which is based in Elma, New York.

The employer must still cover part of the cost of the drug, but the amount is reduced by the amount of copay assistance that is accessed. That assistance can vary widely and be as much as $20,000 a year for some drugs.

In the other approach, employers don't bother naming drugs nonessential; they simply drop coverage for specific drugs or classes of drugs. Then, the outside vendor helps patients provide the financial and other information needed to apply for free medication from drugmakers through charity programs intended for uninsured patients.

"We're seeing it in every state at this point," said Becky Burns, chief operating officer and chief financial officer at the Bleeding and Clotting Disorders Institute in Peoria, Illinois, a federally funded hemophilia treatment center.

The strategies are mostly being used in self-insured employer health plans, which are governed by federal laws that give broad flexibility to employers in designing health benefits.

Still, some patient advocates say these programs can lead to delays for patients in accessing medications while applications are processed — and sometimes unexpected bills for consumers.

"We have patients get billed after they max out their assistance," said Kollet Koulianos, vice president of payer relations at the National Hemophilia Foundation. Once she gets involved, vendors often claim the bills were sent in error, she said.

Even though only about 2% of the workforce needs the drugs, which can cost thousands of dollars a dose, they can lead to a hefty financial liability for self-insured employers, said Drew Mann, a benefits consultant in Knoxville, Tennessee, whose clientele includes employers that use variations of these programs.

Before employer health plans took advantage of such assistance, patients often signed up for these programs on their own, receiving coupons that covered their share of the drug's cost. In that circumstance, drugmakers often paid less than they do under the new employer schemes because a patient's out-of-pocket costs were capped at lower amounts.

Brokers and the CEOs of firms offering the new programs say that in most cases patients continue to get their drugs, often with little or no out-of-pocket costs.

If workers do not qualify for charity because their income is too high, or for another reason, the employer might make an exception and pay the claim or look for an alternative solution, Mann said. Patient groups noted that some specialty drugs may not have any alternatives.

How this practice will play out in the long run remains uncertain. Drugmakers offer both copay assistance and charity care in part because they know many patients, even those with insurance, cannot afford their products. The programs are also good public relations and a tax write-off. But the new emphasis by some employers on maximizing the amount they or their insurers can collect from the programs could cause some drugmakers to take issue with the new strategies or even reconsider their programs.

"Even though our client, like most manufacturers, provides billions in discounts and rebates to health insurers as part of their negotiations, the insurers also want this additional pool of funds, which is meant to help people who can't meet the copay," said Harry Sandick, a lawyer representing J&J.

J&J's lawsuit, filed in U.S. District Court in New Jersey, alleges that patients are "coerced" into participating in copay assistance programs after their drugs are deemed "nonessential" and therefore are "no longer subject to the ACA's annual out-of-pocket maximum."

Once patients enroll, the money from the drugmaker goes to the insurer or employer plan, with SaveOnSP retaining 25%, according to the lawsuit. It claims J&J has lost $100 million to these efforts.

None of that money counts toward patients' deductibles or out-of-pocket maximums for the year.

In addition to the lawsuit over the copay assistance program efforts, there has been other reaction to the new employer strategies. In an October letter to physicians, the Johnson & Johnson Patient Assistance Foundation, a separate entity, said it will no longer offer free medications to patients with insurance starting in January, citing the rise of such "alternative funding programs."

Still, J&J spokesperson L.D. Platt said the drugmaker has plans, also in January, to roll out other assistance to patients who may be "underinsured" so they won't be affected by the foundation's decision.

In a statement, SaveOnSP said that employers object to drug companies' "using their employees' ongoing need for these drugs as an excuse to keep hiking the drugs' prices" and that the firm simply "advises these employers on how to fight back against rising prices while getting employees the drugs they need at no cost to the employees."

In a court filing, SaveOnSP said drugmakers have another option if they don't like efforts by insurers and employers to max out what they can get from the programs: reduce the amount of assistance available. J&J, the filing said, did just that when it recently cut its allotted amount of copay assistance for psoriasis drugs Stelara and Tremfya from $20,000 to $6,000 per participant annually. The filing noted that SaveOnSP participants would still have no copay for those drugs.

For Sutton's part, her family did participate in the program offered through her husband's work-based insurance plan, agreeing to have SaveOnSP monitor their enrollment and payments from the drugmaker.

So far, her 15-year-old daughter has continued to get Humira, and she has not been billed a copay.

Even so, "the whole process seems kind of slimy to me," she said. "The patients are caught in the middle between the drug industry and the insurance industry, each trying to get as much money as possible out of the other."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

As Americans are overwhelmed with medical bills, patient financing is now a multibillion-dollar business.

This article was published on Thursday, November 17, 2022 in Kaiser Health News.

By Noam N. Levey and Aneri Pattani 

Patients at North Carolina-based Atrium Health get what looks like an enticing pitch when they go to the nonprofit hospital system's website: a payment plan from lender AccessOne. The plans offer "easy ways to make monthly payments" on medical bills, the website says. You don't need good credit to get a loan. Everyone is approved. Nothing is reported to credit agencies.

In Minnesota, Allina Health encourages its patients to sign up for an account with MedCredit Financial Services to "consolidate your health expenses." In Southern California, Chino Valley Medical Center, part of the Prime Healthcare chain, touts "promotional financing options with the CareCredit credit card to help you get the care you need, when you need it."

As Americans are overwhelmed with medical bills, patient financing is now a multibillion-dollar business, with private equity and big banks lined up to cash in when patients and their families can't pay for care. By one estimate from research firm IBISWorld, profit margins top 29% in the patient financing industry, seven times what is considered a solid hospital margin.

Hospitals and other providers, which historically put their patients in interest-free payment plans, have welcomed the financing, signing contracts with lenders and enrolling patients in financing plans with rosy promises about convenient bills and easy payments.

For patients, the payment plans often mean something more ominous: yet more debt.

Millions of people are paying interest on these plans, on top of what they owe for medical or dental care, an investigation by KHN and NPR shows. Even with lower rates than a traditional credit card, the interest can add hundreds, even thousands of dollars to medical bills and ratchet up financial strains when patients are most vulnerable.

Robin Milcowitz, a Florida woman who found herself enrolled in an AccessOne loan at a Tampa hospital in 2018 after having a hysterectomy for ovarian cancer, said she was appalled by the financing arrangements.

"Hospitals have found yet another way to monetize our illnesses and our need for medical help," said Milcowitz, a graphic designer. She was charged 11.5% interest — almost three times what she paid for a separate bank loan. "It's immoral," she said.

MedCredit's loans to Allina patients come with 8% interest. Patients enrolled in a CareCredit card from Synchrony, the nation's leading medical lender, face a nearly 27% interest rate if they fail to pay off their loan during a zero-interest promotional period. The high rate hits about 1 in 5 borrowers, according to the company.

For many patients, financing arrangements can be confusing, resulting in missed payments or higher interest rates than they anticipated. The loans can also deepen inequalities. Lower-income patients without the means to make large monthly payments can face higher interest rates, while wealthier patients able to shoulder bigger monthly bills can secure lower rates.

More fundamentally, pushing people into loans that threaten their financial health runs against medical providers' first obligation to not harm their patients, said patient advocate Mark Rukavina, program director at the nonprofit Community Catalyst.

"We're dealing with sick people, scared people, vulnerable people," Rukavina said. "Dangling a financial services product in front of them when they're concerned about their care doesn't seem appropriate."

Debt Upon Debt

Nationwide, about 50 million people — or 1 in 5 adults — are on a financing plan to pay off a medical or dental bill, according to a KFF poll conducted for this project. About a quarter of those borrowers are paying interest, the poll found.

Increasingly, those interest payments are going to financing companies that promise hospitals they will collect more of their medical bills in exchange for a cut.

Hospital officials defend these arrangements, citing the need to offset the cost of offering financing options to patients. Alan Wolf, a spokesperson for the University of North Carolina's hospital system, said that the system, which reported $5.8 billion in patient revenue last year, had a "responsibility to remain financially stable to assure we can provide care to all regardless of ability to pay." UNC Health, as it is known, has contracted since 2019 with AccessOne, a private equity-backed company that finances loans for scores of hospital systems across the country.

This partnership has had a substantial impact on patient debt, according to a KHN analysis of billing and contracting records obtained through public records requests.

UNC Health, which as a public university system touts its commitment "to serve the people of North Carolina," had long offered payment plans without interest. And when AccessOne took over the loans in September 2019, most patients were in no-interest plans.

That has steadily shifted as new patients enrolled in one of AccessOne's plans, several of which have variable interest rates that now charge 13%.

In February 2020, records show, just 9% of UNC patients in an AccessOne plan were in a loan with the highest interest rate. Two years later, 46% were in such a plan. Overall, at any given time more than 100,000 UNC Health patients finance through AccessOne.

The interest can pile on debt. Someone with a $7,000 hospital bill, for example, who enrolls in a five-year financing plan at 13% interest will pay at least $2,500 more to settle that debt.

Rukavina, the patient advocate, said adding this burden on patients makes little sense when medical debt is already creating so much hardship. "It may seem like a short-term solution, but it leads to longer-term problems," he said. Health care debt has forced millions of Americans to cut back on food, give up their homes, and make other sacrifices, KHN found.

UNC Health disavowed responsibility for the additional debt, saying patients signed up for the higher-interest loans. "Any payment plans above zero-interest terms/conditions in place with AccessOne are in place at the request of the patient," Wolf said in an email. UNC Health would only provide answers to written questions.

UNC Health's patients aren't the only ones getting routed into financing plans that require substantial interest payments.

At Atrium Health, a nonprofit system with roots as Charlotte's public hospital that reported more than $7.5 billion in revenues last year, as many as half of patients enrolled in an AccessOne loan were in one of the company's highest-interest plans, according to 2021 billing records analyzed by KHN.

At AU Health, Georgia's main public university hospital system, billing records obtained by KHN show that two-thirds of patients on an AccessOne plan were paying the highest interest rate as of January.

'Empathetic Patient Financing'

AccessOne chief executive Mark Spinner, who in an interview called his firm a "compassionate, empathetic patient financing company," said the range of interest rates gives patients and medical systems valuable options. "By offering AccessOne, you're creating a much safer, more mission-aligned way for consumers to pay and help them stay out of medical debt," he said. "It's an alternative to lawsuits, legal action, and things like that."

AccessOne, which doesn't buy patient debt from hospitals, doesn't run credit checks on patients to qualify them for loans. Nor will the company report patients who default to credit bureaus. The company also frequently markets the availability of zero-interest loans.

Some patients do qualify for no-interest plans, particularly if they have very low incomes. But the loans aren't always as generous as company and hospital officials say.

AccessOne borrowers who miss payments can have their accounts returned to the hospital, which can sue them, report them to credit bureaus, or subject them to other collection actions. UNC Health refers unpaid bills to the state revenue department, which can garnish patients' tax refunds. Atrium's collections policy allows the hospital system to sue patients.

Because AccessOne borrowers can get low interest rates by making larger monthly payments, this financing system can also deepen inequalities. Someone who can pay $292 a month on a $7,000 hospital bill, for example, could qualify for a two-year, interest-free plan. But a patient who can pay only $159 a month would have to take a five-year plan with 13% interest, according to AccessOne. 

"I see wealthier families benefiting," said one former AccessOne employee, who asked not to be identified because she still works in the financing industry. "Lower-income families that have hardship are likely to end up with a higher overall balance due to the interest."

Andy Talford, who oversees patient financial services at Moffitt Cancer Center in Tampa, said the hospital contracted with AccessOne to make it easier for patients to manage their medical bills. "Someone out there is helping them keep track of it," he said.

But patients can get tripped up by the complexities of managing these plans, consumer advocates say. That's what happened to Milcowitz, the graphic designer in Florida.

Milcowitz, 51, had set up a no-interest payment plan with Moffitt to pay off $3,000 she owed for her hysterectomy in 2017. When the medical center switched her account to AccessOne, however, she began receiving late notices, even as she kept making payments.

Only later did she figure out that AccessOne had set up two accounts, one for the cancer surgery and another for medical appointments. Her payments had been applied only to the surgery account, leaving the other past-due. She then got hit with higher interest rates. "It's crazy," she said.

Growing Business Opportunities

While financing plans may mean more headaches and more debt for patients, they're proving profitable for lenders.

That's drawn the interest of private equity firms, which have bought several patient financing companies in recent years. Since 2017, AccessOne's majority owner has been private equity investor Frontier Capital.

Synchrony, which historically marketed its CareCredit cards in patient waiting rooms, is now also inking deals with medical systems to enroll patients in loans when they go online to pay bills.

"They're like pilot fish eating off the back of the shark," said Jonathan Bush, a founder of Athenahealth, a health technology company that has developed electronic medical records and billing systems.

As patient bills skyrocket, hospitals face mounting pressure to collect more, which can make financing arrangements seem appealing, industry experts say. But as health systems go into business with lenders, many are reluctant to share details. Only a handful of hospitals contacted by KHN agreed to be interviewed about their contracts and what they mean for patients.

Several public systems, including Atrium and UNC Health, disclosed information only after KHN submitted public records requests. Even then, the two systems redacted key details, including how much they pay AccessOne.

AU Health, which did not redact its contract, pays AccessOne a 6% "servicing fee" on each patient loan the company administers. But like Atrium and UNC Health, AU Health refused to provide any on-the-record interviews.

Other hospital systems were even less transparent. Mercyhealth, a nonprofit with hospitals and clinics in Illinois and Wisconsin that routes its patients to CareCredit, would not discuss its lending practices. "We do not have anyone available for this," spokesperson Therese Michels said. Allina Health and Prime Healthcare also wouldn't talk about their patient financing deals.

Bush said there's a reason so few hospitals want to discuss their financing deals: They're embarrassed. "It's like they quietly write someone's name on a piece of paper and slide it across the table," he said. "They don't want to be a part of it because they have in their institutional memory that they are supposed to look after patients' best interests."

Some Hospitals Choose Another Path

Not all hospitals expose their patients to extra costs to finance medical bills.

Lake Region Healthcare, a small nonprofit with hospitals and clinics in rural Minnesota that contracts with Missouri-based Commerce Bank, charges no interest or fees on payment plans. That's a decision that spokesperson Katie Johnson said was made "for the benefit of our patients."

Even some AccessOne clients such as the University of Kansas Health System shield patients from interest. But as providers look to boost their bottom lines, it's unclear how long these protections will last. Colette Lasack, who oversees financing for the Kansas system, noted: "There's a cost associated with that."

Meanwhile, large national lenders such as Discover Financial Services are looking at the patient financing business.

"I've had to become more of a health care marketer," said Matt Lattman, vice president for personal loans at Discover, which is pitching the loans to people with unexpected medical bills. "In a world where many people are ill prepared to cover their health care costs, the personal loan can provide an opportunity."

About This Project

"Diagnosis: Debt" is a reporting partnership between KHN and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on the "KFF Health Care Debt Survey," a poll designed and analyzed by public opinion researchers at KFF in collaboration with KHN journalists and editors. The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Additional research was conducted by the Urban Institute, which analyzed credit bureau and other demographic data on poverty, race, and health status to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute analyzed records from a sampling of Chase credit card holders to look at how customers' balances may be affected by major medical expenses.

Reporters from KHN and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

Noam N. Levey: nlevey@kff.org, @NoamLevey

Aneri Pattani: apattani@kff.org, @aneripattani