Predictors of Payment Behavior Among the Medically Uninsured

A Prospective Cohort Study of Patients Seeking Ambulatory Services

Overwhelming medical expenses discourage uninsured patients from paying any amount of their bills.

When deciding whether to treat an uninsured patient, providers often review the patient’s payment history: providers usually treat patients who have made at least partial payments on previous bills; patients with unpaid bills risk having their health care discontinued. Even so, a recent national study found that after visiting a physician roughly one-quarter of uninsured patients had not paid any amount of their bills.

This article reports on a study that looked for predictors of nonpayment among the uninsured. Prior evidence indicated a correlation between low-income, poor health and medical debt; therefore, the study considered sociodemographic data, health status and prior payment behavior as characteristics that might foretell nonpayment.

The study occurred in the ambulatory clinics and emergency departments (ED) of a for-profit, nonprofit and public medical center in a major metropolitan area. From 2003 to 2004, interviewers conducted surveys with uninsured visitors. Eighteen months after each survey, the health centers provided payment data.

Key Findings:

  • Fifty-seven percent of patients paid something toward their bill when they owed less than $217; when patients owed at least $1,243 only 21 percent paid anything.
  • When uninsured patients received treatment in an emergency department, they were less likely to pay their bills.

This study tracked the payment history of uninsured patients in three settings. The findings suggest that channeling uninsured patients away from EDs and into primary care might encourage bill payment. This study excluded uninsured patients who pre-paid for medical services. The Emergency Medical Treatment and Active Labor Act (EMTALA) forbids pre-payment.