ROCHESTER, Minn. — Between January of 2018 and the end of July in 2020, Mayo Clinic took over 900 patients to court for unpaid medical bills. That's according to a new analysis of America's largest 100 hospitals titled "How America's Top Hospitals Hound Patients with Predatory Billing."

The report, issued last week by researchers at the Johns Hopkins University Bloomberg School of Public Health and the news website Axios, found that during the period of study Mayo Clinic Hospital-St. Marys Campus took court action against 904 individuals in pursuit of $4 million in total unpaid bills.

Those actions led Mayo to be included on the publication's list of just 10 hospitals responsible for 97% of all U.S. court actions against patients in the analysis, according to Michelle McGhee, a reporter at Axios.

"We have seen this across the nation, that about a quarter of all hospitals are suing patients," said Christi Walsh, clinical director of research at Johns Hopkins for Healthcare and Policy research. "... It was not surprising that we found Mayo on this list. Many of the good academic medical centers have been on these lists."

"But it's really important that these centers that are getting money from the government to provide charity care, and that are supposed to be a safe haven for the poor and sick, that we hold them all accountable. We just want people to stop suing patients."

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Christi Walsh, CNP, Clinical Director for Research at Johns Hopkins University. Submitted photo.
Christi Walsh, CNP, Clinical Director for Research at Johns Hopkins University. Submitted photo.

The study, which Walsh said is currently under review by a medical journal, selected the nation's 100 largest hospitals according to revenue as determined by the American Hospital Directory, a listing of over 7,000 hospitals. "So it was at random that Mayo was selected," she said. "We had not looked specifically at Mayo before."

Mayo Clinic spokesperson Jay Furst said the clinic "disagrees with several of the conclusions of the unpublished study cited in the Axios story," adding that a lack of methodology transparency for the news report made the findings "difficult to assess."

In all, 23 of the 100 hospitals profiled had taken court actions against patients in the analysis.

VCU Medical Center in Richmond VA was first on the list, with over 17,000 patients having been taken to court. It was followed by University Hospital in Charlottesville, which filed over 7,000 claims.

Froedtert Hospital in Milwaukee was reported to have filed over 3,000 actions, followed by five hospitals in New York, Virginia and Kentucky each filing over 1,000 actions during the period of study. With 900 actions over the course of two and a half years, Mayo was ninth on the list.

Furst said those actions, when spaced over two and a half year period, comprised a small percentage of the 1.3 million patients the Clinic treats each year.

The investigative project is the third such effort from a research group led by Johns Hopkins surgeon, healthcare reform proponent and Medpage Today editor-in-chief Dr. Marty Markary.

In a 2019 article published in the Journal of The American Medical Association, the group publicized a similar investigation limited to lawsuits against patients in Virginia. In 2020, the group released a study of legal actions against patients in Texas.

The current paper is the group's first attempt to take the question nationwide, a logistical challenge given the country's decentralized court system for pursuing unpaid bills.

It tackled the undertaking over a three-year period, Walsh said, utilizing a community-based network of over 20 externship participants who dug into county and state court records in regions supporting a hospital under review.

The project also developed special software that scraped the internet for relevant court actions.

"I am invigorated by a research team of millennials," Makary said of the work in a recent interview on the podcast Plenary Session. "If you know anything about millennials, social justice is a generational value. They want to be a part of something bigger. So as we discovered (these legal actions), my students were like, 'Marty, we want to go to the courthouse and see how many of these records there are."

Legal action, garnishing wages

It is the second critical look in recent months at lawsuits brought by Mayo against patients, the first being a lengthy investigation published last summer in the LaCrosse Independent.

That article reported that Mayo Clinic Health System-Franciscan Healthcare had in 2018 and 2019 taken 96 patients to court in LaCrosse County, Wisconsin, seeking $770,000 in unpaid bills and garnishing the wages of seven employees.

"In many of the cases it took to court, Mayo received permission to garnish wages, sometimes from people working two jobs," the article stated, adding that Mayo had garnished wages for employees of Kwik Trip, Sam’s Club and local school districts.

"What kind of culture are you promoting in the workspace that your own job is suing you?" Walsh asked. "It's not fair, and it's not how the people who are delivering health care would like health care to be. It's just wrong for so many reasons."

"Legal collection action against a patient is a last resort that is used in rare situations after other measures to assist patients in resolving payment issues have failed," Mayo's Furst said in a statement responding to the two articles.

Furst also pointed to the clinic's "robust financial assistance programs" in place for patients who do not have the ability to pay for care.

"We work with patients to create reasonable and extended payment plans when needed, and we often provide financial assistance if a patient is unable to pay their bill," Furst wrote.

"Mayo only pursues legal action involving patients who have the ability to pay and refuse or ignore requests for payment," he stated. "We will consider charity care and financial assistance at any point in the collection process."

Furst added that all new patient collection lawsuits were suspended in March 2020 in response to the COVID-19 pandemic and did not resume until the end of June 2020.

The Johns Hopkins research wasn't entirely critical of Mayo Clinic. On measures of safety, billing quality and not excessively marking up fees higher than the cost of services, the report gave Mayo higher marks than most hospitals in its analysis.

But it hit the clinic hard on giving back, awarding Mayo 1 on a scale of 5 "on the amount spent on charity care and other community health investments as a share of total expenses."

It also ranked Mayo near the bottom for the report's central subject of interest — the aggressive pursuit of unpaid bills via the courts in spite of a charge as a nonprofit to treat hardship balances as charity.

After having considered "a hospital’s filed lawsuits, wage garnishments, and personal property liens against patients for unpaid medical bills," for it's "Predatory Billing" grade, Mayo Clinic was one of just eight hospitals in the analysis to be assigned a grade of D.

Walsh said the effort is intended to push hospitals into changing practices that are sometimes carried out in search of a fraction of the hospital's bottom line, while highly damaging to those of patients.

"The people who are providing the services, the doctors, the nurses, the people who are billing, would much rather not have their patients going bankrupt," she said. "Then they avoid care and don't pay the bill anyway. So I don't see any benefit."

"Our study in Texas showed it was 0.01% of all revenue they were suing patients (to recover). They don't need that money to keep the lights on. But guess what, they are taking it out of people's mouths and bankrupting them. It is ruining their life."

Editor's note: This piece has been updated to include two elements of Mayo Clinic’s original response noting that the 900 court actions between 2018 and July 2020 occurred within the course of treating 1.3 million patients a year, and that it suspended all new patient lawsuits from March until the end of June in 2020 in recognition of the COVID-19 pandemic.