Physician groups are disproportionately filing lawsuits against people who live in St. Louis ZIP codes with high percentages of poor people and Black residents, according to recently published research in the journal JAMA Network Open.
The research found two physician groups – WashU Medicine Physicians and SLUCare Physicians – brought close to 1,000 lawsuits seeking to collect medical debt from patients between January 2020 and May 2023.
The average judgment was for around $2,000, said lead author Mary Shannon. Some judgments were for even smaller amounts.
“We know that providers need to operate and stay solvent, but suing low-income patients for very modest sums may not make financial or ethical sense, especially when we consider the large financial reserves that these institutions have,” she said. “We know that there were lawsuits filed for sums as small as $104, $218, and I don't see how those cases make business sense.”
Shannon and two other researchers found that though only 22% of the region’s population lives in majority-Black ZIP codes, more than 41% of lawsuits were filed against those who lived in those ZIP codes.
Of the suits filed, around half resulted in judgments. Most were default judgments, which means they were decided without a defendant's participation. Many of the decisions resulted in courts ordering paycheck deductions, according to the data.
“Our analysis raises questions about the alignment of St. Louis University and Washington University in St Louis, the primary plaintiffs, with community health goals,” the authors wrote in the research letter published earlier this month. “Both universities report that the suits do not materially impact their financial stability. The same cannot be said for the patients sued.”
How physician groups work
Physician groups act as a single organization of medical professionals who provide care to patients. WashU Medicine Physicians are the doctors and faculty at Washington University School of Medicine. According to the group’s website, the practice comprises more than 1,900 physicians across dozens of specialties.
The SLUCare Physicians group boasts more than 600 providers who work in hospitals and medical offices throughout the St. Louis region. Members of the group also work as faculty at the St. Louis University medical school.
Patients who receive treatment at hospitals typically receive multiple bills: at least one from the hospital where they are treated and others from the physicians who provide medical care, said Chris Garmon, health administration professor at the University of Missouri-Kansas City.
“The hospital bill is what is paying for the hospital's costs and the nurses’ salaries, whereas the physician bill is paying for the physician services, and then the anesthesiologist bill is paying for the anesthesiologist services, and so on and so forth,” he said.
WashU officials said those affected by the lawsuits represent a small sliver of the patients the medical group has treated. During the time period of the study, WashU Physicians treated nearly 1.5 million patients and provided $752 million in uncompensated care, “underscoring [Wash U’s] role as a critical safety net provider for the uninsured and underinsured,” said spokeswoman Julie Flory.
“In some cases, we are required to pursue collection of amounts owed by patients and only do so with people who have the means to pay, excluding, for example, those who are unemployed, work part-time, or are paying child support,” Flory continued. “We offer assistance to patients with financial needs. Any suggestion that we would target individuals from certain groups for debt collection is false and misguided, and anything that attempts to draw such a conclusion should be closely examined.”
St. Louis University spokesman Clayton Berry explained the university sold SLUCare to SSM Health in July 2022 and no longer operates the physician group. The group operated under the university for approximately two-thirds of the study’s timeframe.
“While SLU has not independently reviewed the study’s data, university policies at the time limited legal action to larger debts and only when patients were employed and ineligible for financial assistance,” Berry said. “Legal action was not authorized for debts under $500 or for patients who were unemployed or earning minimum wage.”
SLU officials appreciate the concerns raised about medical debt and how it affects vulnerable people, he added.
A statement from SSM Health said that the health system does not pursue garnishment, credit reporting or legal action to resolve unpaid medical debts. SLUCare is now part of that system.
“We have dedicated support teams across our facilities who work closely with uninsured and underinsured patients to help them access financial assistance and fully understand their available options,” the statement read, adding employees take great care to treat those dealing with financial hardship with dignity and compassion.
How it was done
Shannon said she got the idea for the research while working as a caseworker at a nonprofit health center. One of her patients arrived with a court summons due to medical debt.
Curious, Shannon began combing through the MO Casenet, a database that tracks state and county-level lawsuits, and began updating a Google spreadsheet she created. She noticed that while hospitals were not filing lawsuits, physician groups were.
She looked for lawsuits from the five largest physician groups in the region and found the WashU and SLU physician groups appeared in court records.
“We are filling a gap in the research by bringing the attention to the physicians who work within them,” she said. “It's great if these hospitals aren't filing lawsuits, but if the doctors inside them are, we still have a problem.”
For years, she added information about defendants’ ZIP codes and wage garnishments to the spreadsheet, all while working independently and without funding.
“These are not individuals who are spending beyond their means on a new iPhone or a luxury vacation or a hot accessory,” she said. “They are seeking health care. These aren't people making bad financial decisions. They're folks that go to the hospital, go to the emergency room, and who knows what bill is going to await them on the other side."
Shannon in time brought her co-authors, lawyer Kathryn Koch and Wash U Brown School Lecturer Molly Metzger, in to help analyze the data.
Who’s responsible?
According to the nonprofit health research organization KFF, around four in 10 adults carry some medical debt, and the share rises for those in households that make less than $40,000 per year.
Another study with a more stringent definition of medical debt found around 9% of Missourians have significant medical bills they can't pay.
Nonprofit hospitals – including Barnes-Jewish Hospital, SSM Health St. Louis University Hospital and others staffed by the groups in the study – are required by federal law to provide some levels of charity care and community benefits to receive tax-exempt status.
It’s unclear whether certain physician groups working at such hospitals are held to the same standard, said Garmon of UMKC. Rules governing community benefit requirements are “pretty fuzzy” and often vary from hospital to hospital and state to state.
He said he could not recall seeing any research about the role of physician groups in medical debt.
"It's hard to do this research, and that's why you don't see much of it,” Garmon said. “You have to scour sources that the health care researchers usually don't use.”
Two doctors, including an oncologist who works at Washington University’s medical school, wrote a supportive response to the newly published research.
Medical debt lawsuits have increased in recent years, according to the letter from oncologists Justin Barnes and S.M. Qasim Hussaini. People who live in poorer neighborhoods are more likely to have fewer resources and less health and legal literacy, they said.
“Medical debt should not be the sole burden of patients and their families,” they wrote. “Responsibility should also rest with hospital systems, as well as state and federal governments to better regulate aggressive medical debt practices and provide additional legal protections for patients.”
The two authors recommended that hospitals adopt standardized financial assistance plans for patients and limits on wage garnishments, liens and other actions until “other means of obtaining financial assistance have been exhausted.”
