Should hospitals be judged by their billing practices?

When people go to the hospital, their primary concern is getting high-quality health care — but affordability is a close second. In a country where prices vary significantly from place to place, surprise bills are common, and patients are routinely sued for not paying their bills fast enough, the fear of high costs leads many patients to avoid needed medical care.

Although affordability and price transparency are undoubtably important to patients, these factors are rarely included in hospital evaluations. The most popular hospital ranking does not take cost of care into account at all, let alone whether hospitals have sued patients or garnished their wages.

In a recent viewpoint in JAMA, Simon Matthews and Marty Makary from the Johns Hopkins School of Medicine argue that price transparency, high costs, and aggressive billing practices should be measured and included in hospital quality rankings. They suggest the following criteria for billing quality:

  1. Does the hospital routinely provide patients with itemized bills in plain English?
  2. Can patients ask for and receive prices for elective procedures before they have the procedure?
  3. Can patients reach a billing representative promptly if they have a concern about their bill?
  4. Does the hospital sue patients, garnish wages, or put a lien on their homes for unpaid medical bills?
  5. Do out-of-network patients paying out-of-pocket get charged a vastly higher amount than other hospitals in the region charge?
  6. Do patients get billed for complications caused by a medical error that is the hospital’s fault (e.g. operating on the wrong leg)?

Other potential metrics include whether or not hospitals outsource emergency care (which often leads to unexpected out-of-network charges), and how much more they charge for an elective procedure (such as an MRI) compared to what Medicare pays.

Incorporating these metrics would be extremely helpful for patients to protect their financial security. It would also put serious pressure on hospitals to change unfair billing practices to keep their reputation and business alive.

“The financial harm of medical care should not be separated from the clinical consequences of care, because both outcomes can have a major influence on the health and well-being of patients,” Matthews and Makary write.


Judith Garber is the Health Policy and Communications Fellow at the Lown Institute. She holds a masters degree in public policy from the Heller School of Social Policy and Management.

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