Patient Repayment of US Hospital Bills From 2018 to 2024.

Importance: 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.

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

Design, setting, and participants: 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.

Main outcomes and measures: 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.

Results: 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.

Conclusions and relevance: 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.