# Patient Repayment of US Hospital Bills From 2018 to 2024

## TL;DR

This study examines how US patients have repaid hospital bills from 2018 to 2024, finding that repayment rates have decreased over time and vary with bill size and insurance type.

## Contribution

The study provides new insights into trends in patient repayment of hospital cost-sharing obligations and their implications for medical debt and hospital finances.

## Key findings

- Mean patient repayment rates were around 54% before the pandemic and have since declined.
- Repayment rates were highest for mid-sized bills and lowest for the smallest and largest bills.
- Patients with private insurance had higher out-of-pocket liabilities than those with Medicare Advantage.

## Abstract

How has patient repayment of owed cost sharing changed over recent years, and how does it vary with patient, clinician, and service characteristics?

This cross-sectional study of patient accounts at 217 US hospitals from 2018 to 2024 found that prior to the COVID-19 pandemic (January 2018-February 2020) mean repayment rates were approximately 54% and declined in recent years. Repayment rates varied by bill size with lower repayment rates on the smallest and largest bills, and higher repayment rates on midsized bills.

These findings suggest that changes to insurance design and consumer protections removing medical debt from credit reporting may contribute to recent trends of incomplete and decreasing repayment rates, which contribute to medical debts and hospital collection shortfalls.

This cross-sectional study measures US patient repayment of cost sharing from 2018 to 2024, and how that varies across patient, hospital, and service characteristics.

Patient cost sharing liability has risen in recent years, increasing the costs associated with care for patient households and imposing collections challenges for hospitals and clinicians.

To measure patient repayment of cost sharing over recent years, and how that varies across patient, hospital, and service characteristics.

This cross-sectional study of billing and payment data from a revenue cycle management company examined patient accounts at 217 US hospitals from 2018 to 2024. Participants included 24.5 million and 6.2 million patient episodes of care with positive patient out-of-pocket liability for individuals with private insurance and Medicare Advantage, respectively.

Percentage of owed patient cost sharing actually paid among patients with private insurance and Medicare Advantage measured over time, for inpatient and outpatient care and by bill size.

Across the full sample of 217 US hospitals (30.7 million patient episodes), mean (SD) patient liability per person, including those with no liability, was higher for individuals with private insurance ($375.41 [$51.55]) than those with Medicare Advantage ($172.50 [$14.84]). Consistent with high-deductible plan design with annual resetting, mean patient liability was higher for visits in January than December, particularly among the privately insured (eg, mean [SD] patient liability for visits among the privately insured in January: $479.44 [$29.21] vs December: $321.63 [$14.29]). Prior to the COVID-19 pandemic (January 2018-February 2020), mean repayment rates were 53.9% and 54.0% for patients with private or Medicare Advantage insurance, respectively, and repayment rates declined in more recent years. Across the entire sample, patients with private or Medicare Advantage insurance paid either 0% or 100% of their owed cost sharing in 92.2% and 94.1% of cases, respectively. Repayment rates varied by bill size with lower repayment rates on the largest bills and the smallest bills, and higher repayment rates on midsized bills.

This cross-sectional study found that patient cost sharing repayments were incomplete and have fallen in more recent years, which result in both medical debts for patients and collections shortfalls for hospitals and clinicians. These findings suggest that changes to insurance plan design or the treatment of medical debt are among several factors that may contribute to observed results; if declines in cost sharing repayment continue, hospitals and clinicians may increasingly seek payment of cost sharing ahead of service, when allowable.