Month: September 2023

The Chief Judge of the Court of Appeals and the State of New York, Hon. Rowan D. Wilson, held a statewide public hearing on September 18, 2023, to evaluate the continuing unmet civil legal services needs in New York and to assess the level of resources necessary to meet those needs. NYHealth submitted the following testimony on protecting New Yorkers from medical debt:

To the Honorable Chief Judge Wilson, Chief Administrative Judge Zayas, Justices of the Appellate Division, and esteemed members of the New York State judicial community, my name is David Sandman, Ph.D., President and CEO of the New York Health Foundation (NYHealth). I appreciate the opportunity to provide testimony on protecting New Yorkers from medical debt, the vital role of civil legal services in doing so, and further necessary reforms.

NYHealth is a private, independent, statewide foundation dedicated to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized. Protecting New Yorkers from medical debt has been a signature area of attention.

NYHealth and our grantees and partners have galvanized policy changes that resulted in hard-won consumer protections. I encourage members of the Courts and judicial community to explore the work of these organizations, including the Volunteer Lawyers Project of Central New York’s (VLPCNY) direct legal assistance and education; the End Medical Debt in New York organizing campaign spearheaded by the Public Policy and Education Fund; the Community Service Society of New York’s (CSS) patient storytelling initiative and medical debt lawsuit research; and the Health Care for All New York Coalition’s advocacy for consumer protections.

Medical Debt is a Crushing Burden for New Yorkers
Medical debt has sometimes been described as a “uniquely American injustice.”^[1] No one should go into medical debt or financial ruin because of illness, injury, or disease. Yet, medical debt is the most common form of consumer debt and the leading cause of personal bankruptcy in the United States.^[2],[3] A 2022 report by the Consumer Financial Protection Bureau (CFPB) found that Americans have $88 billion in medical debt in collections.^[4] This is not just a crisis for those who are uninsured; another CFPB report found that 4 million adults ages 65 and older had unpaid medical bills, even though 98% had health insurance coverage.^[5]

Medical debt threatens financial security and prevents individuals from building credit, securing housing and employment, and affording food and medical care. A recent survey found that more than half of New Yorkers struggle to pay medical bills.^[6] Based on credit reports as of February 2022, an estimated 740,000 New Yorkers were put into collections over medical bills; nearly half of them owed more than $500.^[7] This means that nearly half of New Yorkers with medical debt will still have medical debt appear on their credit reports, following a change in credit reporting practices by the three major credit reporting agencies to exclude medical debts below $500 on credit reports.^[8]

To collect medical debt, more than 53,000 lawsuits were filed against patients by hospitals across New York State between 2015 and 2020, including 4,000 during the height of the COVID-19 pandemic. ^[9],[10] CSS analyses of civil court cases in all counties of New York State found that some judgments resulted in property liens or wage garnishment. Liens were placed on individuals’ homes in nearly 5,000 judgments in just two years, and wages were garnished more than 1,600 times by five hospitals alone.^[11],[12] These extreme collection practices occurred disproportionately in low-income communities.

Medical Debt Disproportionately Harms Marginalized New Yorkers
The Urban Institute, with NYHealth’s support, analyzed a representative sample of credit reports to create a deeper understanding of the impact of medical debt on New Yorkers. The analysis uncovered widespread disparities in medical debt by region, race/ethnicity, income, and other factors throughout New York State.^[13] The shares of consumers with medical debt ranged from 3% on Long Island and 4% in New York City to more than 10% in the Southern Tier, North Country, Mohawk Valley, and Central New York.

The highest rates of medical debt within regions were typically found in communities of color and lower income communities. For instance, in Central New York, 28% of patients in communities of color had medical debt in collections, compared with 12% in predominantly white communities. Communities of color also often owed medical debt in greater amounts. In the Capital District, for example, communities of color had a median medical debt of $899—two times the median amount in predominantly white communities in the region ($448).

New York State Has Advanced Consumer Protections from Medical Debt
New York State has been a national leader with policies that protect consumers from unfair practices related to medical debt. Consumer protections secured in recent years include:

• Reducing the statute of limitations for medical debt lawsuits from six to three years ((N.Y.C.P.L.R. §213-d (2020));
• Lowering maximum interest rates on consumer debt (including medical debt) from nine to two percent ((N.Y.C.P.L.R. §5004 (2021));
• Prohibiting liens and wage garnishment as means of medical debt collection ((N.Y.C.P.L.R. §§ 5201; 5231 (2022));
• Banning hospital facility fees for preventive care and requiring advance notice to consumers for instances in which fees will be charged ((N.Y. Pub. Health L. §2830 (2022));
• Requiring hospitals to use a uniform application to make it easier for patients to apply for financial assistance for medical bills ((N.Y. Pub. Health L. §2807-k(9) (2023)); and
• Closing a loophole in the State’s surprise billing law to cover emergency services (N.Y. Fin. Servs. L §606).

In June 2023, both houses of the New York State legislature passed bills (S4907A/A6275A) to prohibit credit agencies from including medical debt of any amount on credit reports. The bills await Governor Hochul’s signature; New York would be the second state, after Colorado, to enact such a policy.^[14]

Greater Support for Civil Legal Services Will Help New Yorkers Avail Themselves of Newly Secured Consumer Protections
These laudable policies will realize their full potential on the ground. To make the most of this progress, New York should continue and expand support for civil legal services organizations. People burdened by medical debt require help to avail themselves of new consumer protections.

VLPCNY illustrates the importance of such services. As the largest provider of pro bono legal services in Central New York, it has developed a specialization in medical debt and has an attorney with dedicated expertise in medical debt. As examples of its impact, VLPCNY has:

• Assisted clients in disputing medical debt collections of approximately $90,000.
• Provided on-site legal education and assistance at local patient town halls.
• Conducted trainings reaching nearly 150 consumers, legal professionals and students, health and human service professionals, and financial counselors throughout Central New York regarding consumers’ legal rights and recent changes in State law.
• Created plain-language client educational materials on topics including answering a judgment; understanding prohibited collection practices and maximum judgment amounts; understanding medical debt credit reporting practices; and disputing bills and seeking financial assistance.
• Educated State policymakers about the real-life issues New Yorkers face when dealing with medical debt.

Enhanced support will enable civil legal services groups to conduct education and advocacy that supports legal professionals, judges, and policymakers in enforcing new protections and advancing additional protections.

Further Reforms Are Needed
New York has led the way on consumer protections from medical debt, but the work is far from complete. The Courts play a central role in ensuring that the new consumer protections are enforced when presiding over suits brought against patients. The Courts and the State should also consider procedural reforms, including:

• Requiring that the summons or initial filing from a hospital contains a statement that the hospital has screened the patient for eligibility for hospital financial assistance and provided that information to the patient prior to filing suit.
• Ensuring defendants understand the proceedings and their rights. For instance, the Courts could promulgate a plain-language summons (as well as additional notice prior to default) that provides clear and understandable information about the proceedings and lists available resources for legal and other assistance.
• Creating a specialized part to preside over medical debt proceedings in a centralized docket.
• Improving documentation of medical debt cases to monitor trends.

• Restricting legal action from being brought against patients for medical debt, as three other states have done. ^[15]

Thank you for the opportunity to provide testimony on progress and unmet needs in protecting consumers from medical debt and the vital role of civil legal services. If you have additional questions, please reach out to Ali Foti, program officer, at foti@nyhealthfoundation.org or (212) 584-5659.

 

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^[1] RIP Medical Debt, “RIP Medical Debt,” https://ripmedicaldebt.org/about/, accessed September 2023.

^[2] Consumer Financial Protection Bureau. (2022). “Medical Debt Burden in the United States”. https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf.

^[3] Himmelstein, DU.; Lawless, R.D.; Thorne, D.; Foohey, P; Woolhandler, S. (2019). Medical Bankruptcy: Still Common Despite the Affordable Care Act. American Journal of Public Health. 109(3), 431–433. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366487/.

^[4] Consumer Financial Protection Bureau, “Medical Debt Burden in the United States”. https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf.

^[5] Consumer Financial Protection Bureau, “Medical Billing and Collections Among Older Americans,” https://www.consumerfinance.gov/data-research/research-reports/issue-spotlight-medical-billing-and-collections-among-older-americans/full-report/.

^[6] Community Service Society, “Financial Hardship, Avoiding Care: Results from a Statewide Survey,” https://www.cssny.org/news/entry/financial-hardship-avoiding-care-healthcare-affordability-survey, accessed September 2023.

^[7] Urban Institute, “Medical Debt in New York State and Its Unequal Burden across Communities,” https://nyhealthfoundation.org/resource/medical-debt-in-nys-and-unequal-burden-across-communities-report/, accessed September 2023.

^[8] Consumer Financial Protection Bureau, “Consumer Credit and the Removal of Medical Collections from Credit Reports,” https://www.consumerfinance.gov/data-research/research-reports/consumer-credit-and-the-removal-of-medical-collections-from-credit-reports/, accessed September 2023.

^[9] Community Service Society, “Discharged into Debt: New York’s Nonprofit Hospitals are Suring Patients,” https://www.cssny.org/publications/entry/discharged-into-debt, accessed September 2023.

^[10] Community Service Society, “Discharged into Debt: A Pandemic Update.” https://www.cssny.org/publications/entry/discharged-into-debt-a-pandemic-update, accessed September 2023.

^[11] Community Service Society, “Discharged into Debt: Nonprofit Hospitals File Liens on Patients’ Homes,” https://www.cssny.org/publications/entry/discharged-into-debt-nonprofit-hospitals-file-liens-on-patients-homes, accessed September 2023.

^[12] Community Service Society, “Discharged into Debt: New York’s Nonprofit Hospitals Garnish Patients’ Wages,” https://www.cssny.org/publications/entry/discharged-into-debt-new-yorks-nonprofit-hospitals-garnish-patients-wages, accessed September 2023.

^[13] Urban Institute, “Medical Debt in New York State and Its Unequal Burden across Communities,” https://nyhealthfoundation.org/resource/medical-debt-in-nys-and-unequal-burden-across-communities-report/, accessed September 2023.

^[14] Kona M; Raimugia V. “State Protections Against Medical Debt: A Look at Policies Across the U.S.,” Commonwealth Fund, https://www.commonwealthfund.org/publications/fund-reports/2023/sep/state-protections-medical-debt-policies-across-us, accessed September 2023.

^[15] Kona M; Raimugia V. “State Protections Against Medical Debt: A Look at Policies Across the U.S.,” Commonwealth Fund, https://www.commonwealthfund.org/publications/fund-reports/2023/sep/state-protections-medical-debt-policies-across-us, accessed September 2023.

Enhancing the role of community health workers (CHWs) and integrating them into primary care teams is one important way to expand patients’ access to primary care, improve patient health outcomes, reduce strain across the care team, and enhance equity for CHWs themselves through career advancement. NYHealth submitted the following public comments in support of a proposed federal rule to provide Medicare reimbursement for CHWs:

September 11, 2023

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1784-P
P.O. Box 8016
Baltimore, MD 21244-1850

RE: File Code CMS-1784-P; Medicare Program; CY 2024 Payment Policies under the Physician Payment Schedule and Other Changes to Part B Payment and Coverage Policies

Dear Administrator Brooks-LaSure:

The New York Health Foundation (NYHealth) appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) on the Notice of Proposed Rulemaking regarding the Medicare Physician Fee Schedule for Calendar Year 2024, namely the creation of a Community Health Integration (CHI) service to be conducted by Community Health Workers (CHWs) and other “auxiliary professionals.”

NYHealth is a private, independent, statewide foundation dedicated to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized. NYHealth has long supported efforts to strengthen the CHW workforce across New York State and enable CHWs—trusted members of communities uniquely equipped to form relationships with patients—to contribute to improved patient care and outcomes. NYHealth previously supported approximately 40 organizations representing CHWs, health care providers, community-based organizations, payers, and policymakers to develop recommendations regarding CHW employment, training, and financing in New York State. An ensuing report, “Paving a Path to Advance the Community Health Worker Workforce in New York State,” includes especially relevant recommendations about CHW training and a standardized scope of practice.

NYHealth is now focused on enhancing the role of CHWs and integrating them into primary care teams. Doing so is one important way to expand patients’ access to primary care, improve patient health outcomes, reduce strain across the care team, and enhance equity for CHWs themselves through career advancement.

Through this proposed rule, CMS will leverage its role as the largest health care payer in the country to expand access to services provided by CHWs and to drive innovation by other payers. In New York, a recently CMS-approved State Plan Amendment will also support new CHW services for pregnant and postpartum Medicaid beneficiaries. CMS’s proposed Medicare benefit will be a critical, complementary source of support for other CHW services.

We commend CMS for proposing to establish a Medicare benefit that will allow providers to code and bill for CHI services provided by CHWs—an important first for Medicare beneficiaries. We support these especially noteworthy provisions:

• CHWs employed by both health care providers and community-based organizations (CBOs) would be eligible to provide CHI services. This expansive eligibility will allow providers and partner CBOs to integrate CHWs into care teams in ways most aligned with their organizations’ needs, resources, and constraints. We applaud CMS’s requirement that providers and CBOs have “sufficient clinical integration” to allow them to coordinate these CHI services. In our experience, partners have been most successful when they have sufficient data-sharing and routine communication to promote effective collaboration. We encourage CMS to consider marshalling its resources to build the IT and related capacity needed for CBOs to integrate with providers.
• CMS has defined new billing codes that are applicable to federally qualified health centers (FQHCs) and rural health centers (RHCs). Our partners in New York State confirm that existing definitions of care management for FQHCs and RHCs do not fully encompass the range of CHI services; the new benefit will help fill this gap.
• CHWs can provide these services under the general, rather than direct, supervision of a billing practitioner. This model of supervision will afford CHWs the flexibility to provide patient support in clinical, community, and home-based settings and mitigate against increased administrative burden on billing practitioners.

We offer the following recommendations for CMS to consider as it finalizes and implements this benefit:

• We encourage CMS to consider expanding the eligibility for CHI initiating visits to include annual wellness visits and emergency department visits. It is in these types of visits where patients often reveal their barriers to care, challenges, and social needs—precisely the clinical encounters where initiating CHI would be most valuable.
• Include telehealth services as a modality for CHI service delivery, in addition to in-person services. Allowing for CHI to be delivered in a hybrid format, including by telehealth, will benefit patients who face barriers to in-person care. Telehealth also enables CHWs to leverage technology to expand their reach in the face of workforce strains. The inclusion of audio-only, in addition to audio-video, services will ensure that virtual care is accessible to and equitable for marginalized patients. The New York City Health and Hospitals Corporation, the largest public hospital system in the country, found that three-quarters of telehealth visits in its primary care settings were scheduled as audio-only visits. Patients who were Medicare or Medicaid beneficiaries, Black or Hispanic, or spoke a language other than English were more likely to use audio-only visits ^[1]
• Further consider if CMS can waive cost-sharing requirements for CHI services as an additional preventive service. If not, CMS should require patient consent to receive CHI services given the potential for cost-sharing requirements. While we appreciate that CMS is attempting to remove administrative barriers, enabling patients to make informed decisions about their care must remain a central tenet.
• Consult with CHWs and providers as decisions are finalized on service length of time, frequency limits, duration, and required training for CHWs. The experience of NYHealth partners has shown that it takes time—often for multiple hours, with many regular touchpoints, and over many months—for CHWs to earn the trust of patients and to address the multiple challenges they uncover when providing support services. CHWs should be equipped with the knowledge, skills, and defined core competencies to provide high-quality patient support. At the same time, we recognize that CHWs with longstanding professional experience and no formal training may already be capable of providing high-quality patient support. CMS should ensure that training requirements do not pose practical and financial barriers to CHWs. As CMS considers the question of training—whether formal or informal—it should work directly with CHWs to define requirements and to develop the content and delivery modes for training.

We commend CMS for its leadership in uplifting the potential of CHWs to improve health outcomes and equity with a reliable source of payment. We thank you for the opportunity to provide comments on these proposed regulations. If you have additional questions, please reach out to Ali Foti, Program Officer, at foti@nyhealthfoundation.org or (212) 584-5659.

Sincerely,

David Sandman, Ph.D.
President and CEO
New York Health Foundation

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^[1] Chen, K.; Zhang, C.; Gurley, A.; Akkem, S.; Jackson, H. (2023). Patient Characteristics Associated with Telehealth Scheduling and Completion in Primary Care at a Large, Urban Public Healthcare System. Journal of Urban Health, 100(3), 468-477. doi: 10.1007/s11524-023-00744-9.

A group of independent philanthropies, including NYHealth, called on the U.S. Department of Health and Human Services to release its Action Plan for Primary Health Care. In addition to any new federal initiatives called for in the Action Plan, its release would give structure, coherence, and acceleration to numerous other public and private sector initiatives already underway to systematically strengthen primary health care.

September 8, 2023
The Honorable Xavier Becerra
Secretary, U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

Dear Secretary Becerra:

We are a group of independent philanthropies committed to promoting a high-performing U.S. health system, built on a strong foundation of accessible, equitable, high-quality, and comprehensive primary care. We are writing to encourage the release of the U.S. Department of Health and Human Services (HHS) Action Plan for Primary Health Care. Release of the Action Plan would send a clear signal that the Administration believes primary care is a priority area and one in need of federal policy action, help identify key strategies and priorities for re-building the foundation of primary health care, and serve to coordinate and build momentum for public and private initiatives.

As the 2021 National Academy of Sciences, Engineering and Medicine (NASEM) Report “Implementing High-Quality Primary Care” notes, primary care is an essential health service associated with improved life expectancy and health equity. Evidence is clear that improving the capacity and quality of primary health care so that it can improve the health and wellbeing of whole persons and whole populations is essential to successfully addressing the nation’s most pressing health crises and the Administration’s health priorities including:

• Ending the decline in life expectancy in the U.S.;
• Reducing the cost of health care for patients and families;
• Advancing health equity;
• Addressing a burgeoning mental health crisis;
• Responding to the opioid epidemic; and
• Developing a reliable system for identifying and mitigating the next health-related emergencies, including pandemics.

Primary care is the most fair, efficient, and accessible way for all people – regardless of race, ethnicity, or income – to enter the health care system and obtain the services they need. Decades of evidence link primary care’s defining elements – continuity, coordination, comprehensiveness, and whole-person care – to improved health equity, as recently summarized by The California Health Care Foundation.

Yet the state of primary care is fragile and weakening. The recent National Primary Care Scorecard from the Milbank Memorial Fund found the portion of U.S. healthcare spending going to primary care is just five to 12 cents on the dollar and has declined in the last ten years. Moreover, the reliance on fee-for-service fails to reimburse, or inadequately reimburses, physicians for services that contribute to high-quality, comprehensive, and personalized care. Fewer people can identify a usual source for their care, and the gap between communities with adequate and inadequate supplies of primary care clinicians is widening. Research supported by the Commonwealth Fund has found that, compared to other high-income countries, U.S. patients are among the least likely to have a usual source of care or a longstanding relationship with a primary care provider. This trend is only likely to worsen as providers leave the workforce in historic numbers due to burnout and more physicians reaching retirement age, particularly in communities with historically few primary care clinicians like rural areas.

The NASEM Report was clear that federal policy leadership across all agencies of HHS will be essential to address the gap between primary health care’s status and its potential. We are pleased that HHS leadership has signaled the important aims of the Action Plan, which are aligned with the NASEM Report’s recommendations and would be a major step in making clear the Administration’s commitment to rebuilding the U.S. primary health care system through a coordinated, cross-agency effort.

With federal leadership – and in partnership with the private sector and state government – this rebuilding of the primary care infrastructure can be realized. The Action Plan could serve to chart the course to meaningfully strengthen primary health care. Multiple stakeholders across the country have reviewed, provided feedback, and articulated enthusiastic support for the Action Plan. Upon release, to ensure successful implementation of the Action Plan, and as the NASEM Report recommended, HHS could create a Secretary’s Council on Primary Care to execute the initiatives of the plan and ensure coordination across HHS agencies to re-build primary health care in the U.S.

In addition to any new federal initiatives called for in the Action Plan, release of it will give structure, coherence, and acceleration to numerous other public and private sector initiatives already underway to systematically strengthen primary health care, including:

• The newly funded NASEM Standing Committee on Primary Care, authorized by statute to advise the Action Plan.
• The recently announced “Making Care Primary” Model from the Center for Medicare and Medicaid Innovation which will shift primary care payments from fee-for-service to capitated payments and transform primary care delivery in 8 states.
• Proposed federal rules modifying the Medicare Physician Fee Schedule, awarding of Graduate Medical Education slots, and Medicaid provider access standards.
• The 20 states that have passed legislation to measure and/or increase primary care investments across all payers, as supported by the New York Health Foundation and California Health Care Foundation, among other private funders.
• Section 1115 Medicaid waivers granted to Oregon and Massachusetts which authorize primary care payment reforms.
• Upcoming Congressional reauthorization of the Community Health Center, Teaching Health Centers and National Health Service Corp programs.
• The recent guidance on financing whole person, whole population health detailed in the NAM Report “Valuing America’s Health.”

We hope these activities are clear signals that there is pent-up demand for action to strengthen primary health care, many ready partners, and an urgent need for coordinated federal leadership. Releasing the Action Plan will build momentum and signal the Administration’s commitment to addressing its stated priorities.

Thank you for your public service and your attention to our request.

Sincerely,

Mark E. Miller, Executive Vice President of Health Care, Arnold Ventures
Sandra R. Hernández, President and Chief Executive Officer. The California Health Care Foundation
Joseph R. Betancourt, President, The Commonwealth Fund
Wayne Jonas, President, Healing Works Foundation
Christopher F. Koller, President, The Milbank Memorial Fund
David Sandman, President and Chief Executive Officer, New York Health Foundation