"Don't act like you empathize with me," Tina LaValliere told Susan Nordstrom Lopez angrily as the two talked at an April 26 meeting at the Bethlehem United Church of Christ.
Lopez, the CEO of Advocate Illinois Masonic Medical Center, was there to answer questions about Advocate Health and Hospital Corporation's policies on collecting debts from patients at the ten Cook County hospitals it operates and to respond to allegations that Advocate was charging patients who didn't have insurance much more than it charged insurance companies for the same services.
LaValliere was at the meeting, which had been called by the Lakeview Action Coalition, to tell how her life had been turned upside down after she had surgery on her eyelids in 2000. She has a mild form of multiple sclerosis that had weakened the muscles in her eyelids, and she'd had silicone slings implanted to correct the problem. She told the crowd of more than 100 that she'd been given excellent care at Illinois Masonic and now her eyelids functioned normally. She said she'd been self-employed at the time, making custom stationery and creating party favors, and that she'd had insurance for two years. But, she said, after the surgery her insurer retroactively dropped her coverage and refused to pay her bills, which totaled $28,000.
LaValliere started trying to pay them herself, even though she was a single mother of two making only a few thousand dollars a year. Hoping to work out a payment plan, she called Advocate, a national nonprofit conglomerate. She said she was given the name and number of a financial counselor, but she left numerous messages and never got a return call. In early 2002 she started getting threatening letters from a debt-collection agency, saying that if she didn't pay, her credit would be ruined. She talked with a counselor at the agency and agreed to pay $300 a month. She said she was told that if she missed even one payment, the full amount of the bill would come due immediately.
In the meantime she'd put her house in her mother's name to avoid losing it and taken a job with a property-management company so that she would have insurance again. Afraid she'd fall behind on her other bills, she started paying them with credit cards; she maxed out three and wound up paying huge amounts in interest every month. "It's like a snowball--it affected my whole life," she says. "I consolidated three charge cards in the area of $30,000." She adds, "When you hear these stories you have a different picture in mind, like someone who has trouble keeping a job or doesn't speak English well. I've always had a job and insurance. I'm a perfect example of how it can happen to anyone."
Last summer she saw a TV news story that claimed Advocate was overcharging uninsured patients and mentioned that the Service Employees International Union had started what it called the Hospital Accountability Project to pressure Advocate to lower its prices for the uninsured--a big issue given that 1.2 million people in the metropolitan area don't have insurance. She called the SEIU and talked to an attorney for the project, who advised her to stop making the monthly payments immediately--by then she'd paid around $4,800--while they tried to work out a better arrangement.
In April, LaValliere was added as a plaintiff to a class-action suit filed by attorney Thomas Geoghegan on behalf of uninsured and underinsured people who claim they've been overcharged by Advocate. He says that on a typical hospital bill for someone who has insurance, there's a charge and then an amount paid that's usually far less--the amount paid being the price the insurance company negotiated with the hospital. He says that for uninsured people there's only one charge--the higher one. The suit calls this practice a "violation of the Consumer Fraud Act" as well as "immoral, unethical, oppressive and unscrupulous."
Advocate openly acknowledges that it negotiates bulk discounts with insurance companies, and the Hospital Accountability Project reports in a study published in May 2003, "Uninsured and Overcharged," that this is common practice at hospitals across the country. The study also shows that Advocate's undiscounted charges "are the highest...among hospitals in Cook County." The suit alleges that these rates "can be up to twice or more the discounted rates paid by patients who are covered by private health insurance companies" and that these prices "are significantly in excess of costs."
The suit relates the story of plaintiff Tiffany Montgomery, who had no income and no insurance in 1995 when she gave birth to her first child at Advocate's Bethany Hospital. The bill was $3,338, and she never paid it. In 2002 Advocate sued her for that amount, and she lost. By then she was working at a food-service company, and Advocate eventually garnished well over $2,000 of her wages. The suit claims she was asked to pay much more than an insurance company would have had to pay. Montgomery was insured in February 2002 when she had her third child at Bethany Hospital. Advocate apparently thought she didn't have insurance and billed her $4,900; according to the suit, when the misunderstanding was worked out her insurance company got a bill for only $2,100, and she was charged an additional $500--a total that was little over half the original bill.
Adam Beebe, also a plaintiff in the suit, told the people at the April meeting that he'd been a self-employed figure-skating instructor making $10,000 a year who thought "paying rent was more important than paying for insurance." In 1997 he broke his leg in three places in a skating accident, had surgery at Ravenswood Hospital, and was billed more than $16,000. When he couldn't pay the whole bill, his case was turned over to a collection agency, and in November 2002 Advocate filed a lawsuit against him. Geoghegan says Beebe's bill appears to have been about double what an insurance company would have been charged. "I felt like I was trying to erase eternity with this debt," Beebe told the audience. "I felt like I'd never be able to own a home, that I'd always have to get a cosigner on a loan. That contributed to depression and other problems like alcoholism."
Members of the Hospital Accountability Project argue that many uninsured patients shouldn't be charged at all, because Advocate, as a tax-exempt institution, is supposed to provide a significant amount of charity care. There are no enforceable guidelines on exactly how much hospitals should provide. But the Illinois Hospital Association has published recommendations, and Advocate meets its standards.
Advocate spokesperson Nahlah Daddino says the company gave $55.9 million in charity care last year. And she says that last summer, largely in response to concerns of the Lakeview Action Coalition, it raised the eligibility requirements for charity care from 200 percent of the federal poverty line to 400 percent, meaning a family of four making $75,400 would be eligible. Eligible patients can get their bills reduced by 50 to 100 percent. "Our charity-care program is one of the most compassionate in the country," she says.
But members of the Hospital Accountability Project say that every year hundreds of low-income patients who should get charity care don't. "Advocate's policy on paper is significantly more generous than IHA's guidelines," says Joseph Geevarghese, director of the project. "But there's a difference between having a policy and actually implementing it." For one thing, he says, Advocate doesn't make sure that all patients who are eligible for charity care know that they're eligible.
But Daddino says notices are posted in English and Spanish in all emergency rooms and on all hospital bills. A bill sponsored by Barack Obama in the state legislature--which has already passed the senate but not the house--sets requirements for notifying patients about charity care, and Advocate's Susan Nordstrom Lopez says, "We are doing most if not all of them."
Nevertheless, many low-income Advocate patients have told members of the Hospital Accountability Project that they never had any idea charity care was available. Adam Beebe told the audience at the April meeting that he didn't know he might be eligible. Another woman at the meeting, who asked to be identified only as Nancy, said she and her husband had both lost their jobs at Kmart in early 2002. That June her husband, who was 46, died of a heart attack, and that December she became homeless. In September 2003 she was hospitalized at Illinois Masonic for heart problems. When she came back to the emergency room for a follow-up visit a few days later, as she says she'd been told to do, the hospital refused to admit her because she didn't have insurance, which is legal because it wasn't an emergency. "Then I received a bill for over $14,000," she told the audience. "I was so scared. I couldn't see myself going back to living in abandoned buildings."
When Nancy was hospitalized again the following January, because she was having difficulty breathing, she happened to find an old brochure mentioning charity care in a drawer. She told the audience she contacted Advocate but was told it was too late to apply for charity care for the earlier hospitalization. She did the paperwork anyway, and this past February she got a letter telling her the bills for both hospitalizations had been forgiven. "But none of this would have happened if I wasn't lucky enough to find a crumpled-up piece of paper in a drawer," she said. "They made no effort to tell me about charity care."
Geevarghese says Advocate should not only post notices about charity care but tell patients when they come into the hospital that they might be eligible. "They ask every patient if they have insurance," he says. "If the patient says no, they should notify them about charity care."
Members of the Hospital Accountability Project complain that even when patients know to apply for charity care there's no guarantee they'll get it. Susan Matta, an attorney who used to work for the project, says that a panel of representatives appointed by Advocate decides who gets charity and how much. "It's all done in private," she says. "No one ever knows why they make the decisions they do." Daddino responds that 98 percent of patients who apply for charity care get it.
Matta argues that many of the people who are eligible aren't given enough time to collect and submit the required paperwork, which includes recent tax returns, pay stubs, mortgage or rent receipts, credit card bills, and utility bills. "If the person can't produce the documents in ten days they say the patient isn't cooperating and they can turn him down," she says. "These are working-class people working paycheck to paycheck. It's almost impossible for them to get their records together that quickly. They really make it unduly burdensome to get charity care."
Lopez says that Advocate gives patients 120 days to respond to offers to apply for charity care before their bills are sent to collection agencies. But Matta points to numerous 2004 letters from Advocate hospitals sent to patients who applied for charity care that include statements such as "Note that failure to provide all the required documents within the next 10 days may result in a denial of your request."
People at the April meeting were also concerned about the number of lawsuits Advocate has filed against patients--at the time 150 suits were pending. According to an October 2003 Hospital Accountability Project report, "Insult to Injury," Advocate had only 16.5 percent of the county's market share but filed a quarter of the suits to collect unpaid bills. Lopez was asked several times if she would agree to a moratorium on filing suits and drop the existing lawsuits. She declined, saying, "We need to reserve our legal right to pursue collection, including lawsuits when necessary. But let me reiterate that 99.9 percent of our cases do not result in lawsuits."
Advocate PR material says the corporation never sues unemployed people, but Chris Kuczynski was a laid-off autoworker collecting unemployment checks in October 2003 when he was sued by Advocate for $1,742 in bills he hadn't paid for arm, shoulder, and other injuries from a 2001 motorcycle accident. His medical insurance had paid part of the bills, and his motorcycle insurance was supposed to have picked up the rest.
After the meeting Lopez and Daddino said they hadn't known of any unemployed people who'd been sued and offered to look into any cases they were notified of. Daddino added that she couldn't comment on individual cases because of privacy rules and the pending class-action suit.
Advocate hasn't filed any new lawsuits since last October. LaValliere and members of the Hospital Accountability Project think this is because they've been so vocal and because the City Council held hearings last summer on whether Advocate was overcharging the uninsured.
Tina LaValliere says that since she stopped making her monthly payments she hasn't heard anything from Advocate or the collection agency. "Since this all came out, I think they knew they had to back off," she says. "They were being real pit bulls before the story broke. Now you don't hear a peep from them." Nevertheless, she says, "It's clear we need major changes in this system. A health-care system where this can happen is a horrible system."
Art accompanying story in printed newspaper (not available in this archive): photos/Bruce Powell.