Hospital-level Variation in Medical Debt After Acute Traumatic Injury

OBJECTIVE: To determine whether the treating hospital contributes to patients' medical debt following injury. SUMMARY BACKGROUND DATA: Trauma patients often have little or no choice in where they receive care. However, variation in hospital billing and collection practices, and their association with patient medical debt, remains poorly characterized. METHODS: We conducted a retrospective cohort study of adult trauma patients hospitalized from January 2019 to December 2020 at 29 Level I and II trauma centers within a statewide quality collaborative. Trauma registry data were linked to quarterly consumer credit reports from 12 months preinjury through 18 months postinjury. The primary outcome was change in medical debt in collections from baseline to months 9-18 postinjury. Hierarchical mixed-effects models with empirical Bayes shrinkage and reliability adjustment estimated risk-adjusted hospital-level changes, adjusting for demographics, injury severity, and treatment intensity. Hospitals were classified as outliers if 95% confidence intervals for observed-minus-expected differences excluded zero. RESULTS: Among 20,613 patients (mean age 63 y; 49% female; 82% non-Hispanic White), mean change in medical debt was $314 (SD $3464). Four hospitals (14%) were high outliers, generating $365-$566 more debt per patient than expected, while 4 (14%) were low outliers, generating $292-$676 less. Low-outlier hospitals cared for younger, lower-income, and higher-risk patients yet produced less debt than predicted. Findings were robust across sensitivity analyses. CONCLUSIONS: Substantial hospital-level variation in postinjury medical debt persists after adjustment for clinical and demographic factors. Billing, financial assistance, and collection practices may represent modifiable targets to reduce financial hardship after trauma.