Having just moved back to San Antonio, the 30-something searched for a doctor to manage her Crohn’s disease, an inflammatory bowel condition that is successfully managed with medications and lifelong monitoring — including regular colonoscopies.

Mariel booked an appointment and learned she would be on the hook for a $1,100 colonoscopy — about three times what she had paid for the same test in a different state. Almost three-quarters of the bill would be a “facility fee” for the in-office procedure at a colonoscopy clinic. (KHN agreed not to disclose Mariel’s last name because she is concerned speaking out might affect her doctor’s willingness to manage her medical condition.)

Preventive colonoscopies are covered without patient cost sharing under the Affordable Care Act, but colonoscopies for patients with existing conditions, like Mariel, are not. patients with inflammatory bowel diseases, including Crohn’s disease, incur about $23,000 in health care costs a year. Medication treatments alone tens of thousands of dollars annually.

But shopping around proved frustrating. Although San Antonio has plenty of gastroenterology offices, are controlled by the same private equity-backed group.

In 2018, one of the nation’s largest independent gastroenterology practices, Texas Digestive Disease Consultants, with the Chicago-based private equity firm to expand by offering management services to other physicians. At the time, the Dallas-based practice had 110 locations, mostly in Texas — including San Antonio. Today its management group, , operates in a dozen states with more than 400 locations — and is .

With market dominance comes the business opportunity to set and maintain high prices. “It’s pretty much the only game in town,” Mariel said.

Private equity, known for making a profit on quick-turnaround investments in struggling businesses across many industries, has taken an increasingly active interest in health care in the past decade. It has invested in gastroenterology practices in recent years to tap into the revenue potential in meeting growing demand.

“We are in the of older rectums,” one investment manager .

Tired of having to manage the increasingly complicated business of running a practice and, often, lured by the sweet deals investors offer, more and more doctors have partnered with or even sold their practices to private equity funds. So investment managers now control the financial decisions for many medical offices caring for patients with digestive ailments. With profit the primary driver, patients may find they pay much more for the same — or less — care.

The Centers for Disease Control and Prevention recently at which healthy Americans are urged to begin routine screenings for colon cancer — ensuring that most will undergo regular colonoscopies beginning at age 45. And the population is aging, meaning more people will be needing the procedure.

For those 65 and older, Medicare picks up the tab. But even when a benign polyp is found during a simple screening, patients sometimes end up with an unexpected bill. And less-than-scrupulous providers often find ways to bill for some services, such as out-of-network anesthesia monitoring.

that private equity investment in health care results in and overall higher costs for patients. Surprise billing is the practice of charging insured patients for out-of-network care unknowingly received, including in emergencies and at otherwise in-network facilities.

Before a federal ban on surprise billing took effect this year, it was common for patients to get slapped with an expensive bill after being treated by an emergency room doctor employed by a private equity-owned staffing service — a problem that policy experts say was not a glitch but rather a for private equity companies.

Nearly 10% of the nation’s 14,000 gastroenterologists were partners in or employed by a private-equity backed organization as of last fall, according to a report by Physician Growth Partners, which represents independent physician groups in transactions with private equity.

In 2021, the number of private equity acquisitions of gastroenterology practices grew by 28% over the previous year, according to .

Complex government regulations, technological innovations, and insurance industry practices have driven many gastroenterologists to sell shares in their practices, said Praveen Suthrum, who runs a consulting company for physician practices. Many physicians argue reimbursement rates are too low to keep up with complex negotiations with insurers and the other rising costs of operating an independent practice.

Private equity typically purchases a stake in a health care practice, then adjusts its operations to make it more profitable. It may switch to cheaper suppliers, shorten appointment windows, bill aggressively, or lay off staff, to name a few strategies — the kind of changes that save money at the expense of patient care.

In December, on how one private equity-owned group of dermatology practices overbooked patients, lost test results, and leaned on cheaper labor from physician assistants and nurse practitioners who .

A study out last year from the National Bureau of Economic Research when private equity owned a nursing home, patients were more likely to die in their first months there and much more likely to be prescribed antipsychotic drugs — which are known to increase mortality among the elderly. Taxpayer spending per procedure or service in a private equity-owned facility goes up about 11%.

Private equity has shown a lot of interest in health care practices that perform high-volume procedures, especially those with growth potential.

“Lots of people are needing injections in the eye for macular edema, and lots of people need colonoscopies, and lots of people need skin biopsies,” said Dr. Jane Zhu, a health services researcher at Oregon Health and Science University in Portland who has studied the role of private equity in health care. “And these are things that will only grow in volume over time as the population ages.”

Zhu said usually the investors start by acquiring a well-performing practice, or group of practices, in one geographic area — called a “platform practice.”

“It’s well established. It has some brand recognition,” Zhu said. “It has good market reach. There may be multiple sites. It has lots of patients that are already affiliated with that practice, and they buy that up, and there are opportunities for consolidation.”

Mergers create larger groups with more power to negotiate rates with insurance companies and charge what they’d like. The possibility of capitalizing on the good name of a respected practice alone may make it a valuable investment.

Zhu said these medical practices are considered a short- to medium-term investment, with an average period of three to eight years before the investors sell.

Suthrum said private equity firms are good at making their case to doctors, assuring them they’ll let the doctors do the medicine while the businesspeople do the business.

Doctors think, “If I’m going to survive, then I will either have to sell myself to the hospital or, what is the alternative?” Suthrum said in an interview. “The alternative is private equity.”

This article was adapted from a of “,” a podcast about the cost of health care, produced in partnership with KHN.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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La Ley de Cuidado de Salud a Bajo Precio (ACA), también conocida como Obamacare, requiere que los hospitales sin fines de lucro pongan a disposición de los pacientes de bajos ingresos asistencia financiera, y que publiquen esas políticas en línea.

En los Estados Unidos, , y en algunos estados todos o casi todos los hospitales lo son. Pero muchas personas que califican para recibir asistencia financiera —o “atención caritativa”, como también se la llama— nunca la solicitan.

Jared Walker está ayudando a correr la voz. Ha fundado , una organización que ayuda directamente a las personas a utilizar las normas de asistencia financiera de los hospitales para hacer frente a las facturas médicas imposibles de pagar. Walker se ganó la atención del público a principios de este año a través de un TikTok viral que hizo una noche de manera informal.

En , Walker expone los aspectos básicos de la solicitud de asistencia financiera hospitalaria, en respuesta a un aviso que le pide a los TikTokers compartir “algo que hayas aprendido y que pareciera ilegal saber”.

“La mayoría de los hospitales de los Estados Unidos no tienen ánimo de lucro, lo que significa que deben tener políticas de asistencia financiera o de atención caritativa”, dice en el video. “Esto va a sonar raro, pero lo que esto significa es que si ganas menos de cierta cantidad de dinero el hospital tiene la obligación legal de perdonar tus facturas médicas”.

En el video se explican los fundamentos de la solicitud de atención caritativa en los hospitales, y eso es lo que él dice que utiliza para “erradicar” las facturas médicas.

“”, un podcast sobre el costo de la atención médica, ha estado cubriendo el trabajo de la desde que el video se convirtió en viral, así como la batalla de décadas por establecer las reglas de caridad.

Las siguientes son cinco estrategias que Walker comparte durante las sesiones mensuales de formación de voluntarios:

1. ¿Cómo encontrar estas normas?

El truco de Walker para encontrar la política de asistencia financiera de un hospital es muy sencillo: búscalo en Google. Escribe el nombre del hospital, seguido de “política de asistencia financiera” o “política de atención caritativa”. Los primeros resultados de la búsqueda serán probablemente un resumen de la política y una aplicación.

Tu primera intención puede ser ir a la página principal del hospital. Pero probablemente sea un error. Según Walker, estas normas suelen estar ocultas en los menús de los sitios web de los hospitales. En muchos estados, las leyes de atención caritativa son más específicas que lo que se indica en ACA, y los hospitales pueden estar obligados a destacarlas de manera prominente.

Es raro que estas normas no estén disponibles en línea en absoluto, pero en algunos casos, dijo Walker, puede que tengas que llamar al hospital y pedirles una solicitud.

2. ¿Quién califica?

La mayoría de las políticas de atención caritativa de los hospitales se basan en los ingresos, para definir la elegibilidad. En un ejemplo, Walker mostró las directrices del , donde los pacientes que ganan el 200% de los niveles federales de pobreza son responsables del 0% de su factura. Esa cifra era de poco más de $2,000 al mes en 2021. Aquellos que ganan entre el 201% y el 300% eran elegibles para ciertos descuentos.

¿No tienes claro cómo se comparan tus ingresos con los niveles federales de pobreza? Hay que te ayudarán. Recuerda que tu hogar eres tú, más tu cónyuge, y cualquier persona que declares como dependiente en tus impuestos. Quienes comparten la vivienda no cuentan.

Las solicitudes suelen requerir documentación que demuestre tus ingresos. Los hospitales piden cosas como talones de pago recientes, prueba de desempleo, cartas de concesión de la Seguridad Social y declaraciones de impuestos, según Walker. Los documentos exactos que puede pedir el hospital pueden variar. Pero un hospital no puede negarte la ayuda por no proporcionar un documento que no se especifica en la solicitud.

3. ¿Presionado por los pagos? Todavía puedes tener tiempo

El exige a los hospitales sin fines de lucro que den a los pacientes un período de gracia de 240 días (unos ocho meses), a partir de la fecha de facturación inicial, para solicitar asistencia financiera. Pero los hospitales están autorizados a enviar las facturas a las agencias de cobro mucho antes, a menudo después de sólo 120 días.

En ese momento, los pacientes suelen sentirse acosados por las notificaciones de las agencias de cobro. Aun así, les pueden quedar meses para solicitar asistencia financiera, y avisar a las agencias de que se está tramitando una solicitud con el hospital puede, a veces, frenar el envío de cartas.

“El hospital puede sacarte de los cobros con la misma facilidad con la que te mete en ellos”, afirmó Walker.

En algunos casos, los hospitales perdonan las facturas que tienen más de 240 días. E incluso de varios años atrás, dijo Walker. No está de más pedir ayuda.

4. ¿Parece que no vas a calificar? Escribe una carta

Si no cumples los requisitos basados únicamente en los ingresos, pero sigues sin poder pagar las facturas del hospital, no te desanimes. Lo mismo ocurre si la política de ayuda financiera del hospital especifica que sólo pueden calificar las personas no aseguradas; es posible que tengas un seguro, pero que aun así te encuentres con facturas gigantescas que no puedes pagar.

Walker aseguró que mandar una carta explicando las dificultades financieras junto con la solicitud puede ser de gran ayuda. De hecho, anima a todos los pacientes a que adjunten una carta, aunque su solicitud parezca sólida.

“Hay otros seres humanos que las leen y las cartas son de gran ayuda”, dijo. En última instancia, cada hospital decide quién recibe la asistencia que está legalmente obligado a proporcionar. Presenta tu caso.

5. Sí, es posible que tengas que enviarla por fax

Aunque muchos hospitales disponen de portales digitales que permiten pagar las facturas en línea, no suele haber un equivalente para solicitar asistencia financiera. Muchas solicitudes sólo ofrecen una dirección postal. Pero Walker y su equipo han comprobado que las solicitudes enviadas por correo se pierden con frecuencia.

En su lugar, recomiendan llevar la solicitud al hospital y entregarla en mano o enviarla por fax. Las bibliotecas públicas, los locales de FedEx y ciertos servicios en línea hacen posible el envío por fax incluso si, como la mayoría de la gente, no ha utilizado un aparato de fax desde finales de los años 90.

Cuando se trata de acceder a la atención benéfica, “vas a tener que pasar por saltar un montón barreras”, señaló Walker, “pero vale la pena”.

Emily Pisacreta es reportera y productora de un podcast sobre el costo de la atención sanitaria que es coproducido con KHN.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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The Affordable Care Act, the health law also known as Obamacare, requires nonprofit hospitals to make financial assistance available to low-income patients and post those policies online. Across the U.S., — and in some states all or nearly all hospitals are nonprofit. But many people who qualify for financial assistance — or “charity care,” as it is sometimes known — never apply.

Jared Walker is helping get the word out. He founded , an organization that directly helps people use hospital financial assistance policies to overcome unaffordable medical bills. Walker earned the public’s attention early this year through a viral TikTok he made on a lark, late one night.

In the , Walker outlines the basics of applying for hospital financial assistance, in response to a prompt that asks TikTokers to share “something you’ve learned that feels illegal to know.”

“Most hospitals in America are nonprofits, which means they have to have financial assistance or charity care policies,” he says in the video. “This is going to sound weird, but what that means is if you make under a certain amount of money the hospital legally has to forgive your medical bills.”

The video outlines the basics of applying for hospital charity care, which he says he uses to “crush” medical bills.

“,” a podcast about the cost of health care, has been covering Walker and his since the video’s viral moment, as well as the decades-long fight to establish charity care rules that preceded it.

Here are five strategies Walker endorses and shares during monthly volunteer training sessions:

1. How do you find the policy?

Walker’s trick for finding a hospital’s financial assistance policy is as straightforward as it gets: Google it. Enter the hospital’s name, followed by “financial assistance policy” or “charity care policy.” The first search results are likely to be an outline of the policy and an application to submit.

Your first instinct might be to go to your hospital’s home page. But that’s likely a mistake. Policies tend to be hidden from hospital website menus, according to Walker. In many states, charity care laws are more specific than what’s outlined in the ACA, and hospitals may be required to display their financial assistance policies prominently.

It’s rare for the policies not to be available online at all, but in some cases, Walker said, you may need to call the hospital and ask for an application.

2. Who qualifies?

Most hospital charity care policies are income-based, using percentages of the to define eligibility. In an example, Walker showed the guidelines for , where patients earning 200% of the federal poverty guidelines were responsible for 0% of their bill. That figure was just over $2,000 a month in 2021. Those making 201% to 300% were eligible for certain discounts.

Not sure how your income compares to the federal poverty guidelines? Remember, your household is you, plus your spouse, plus anyone you claim as a dependent on your taxes. Roommates don’t count.

Applications typically require documentation to prove your income. Hospitals ask for things like recent pay stubs, proof of unemployment, Social Security award letters and tax returns, according to Walker. Exactly which documents the hospital may ask for can vary. But a hospital can’t deny you for failing to provide a document that isn’t spelled out in the application.

3. In collections? You may still have time.

The requires nonprofit hospitals to give patients a grace period of 240 days (about eight months) from the initial billing date to apply for financial assistance. But hospitals are allowed to send bills to collection agencies much earlier than that — often after just 120 days.

At that point, patients often feel as though they’re being hounded by notifications from collection agencies. Still, patients may have months remaining to apply for financial assistance, and alerting the collection agents that an application with the hospital is in process can sometimes stop the letters.

“The hospital can take you out of collections just as easily as they put you there,” Walker said.

In some cases, hospitals will forgive bills that are much older than 240 days. When in doubt, applying may be worth it even for bills that are several years old, Walker said. It does not hurt to ask for help.

4. Looks like you won’t qualify? Write a letter.

If you don’t qualify on income alone but you still can’t afford your hospital bills, don’t rule yourself out. The same applies if the hospital’s financial aid policy specifies that only uninsured people qualify; you might have insurance but are still looking at giant bills you can’t pay.

Walker said a letter of financial hardship attached to an application can help. In fact, he encourages each patient to attach a letter, no matter how strong their application seems.

“These are real people reading these and the letters go a long way,” he said. Ultimately, each hospital is making a judgment call about who gets the assistance it is legally obligated to provide. Make your case.

5. Yes, you may need to fax it in.

While many hospitals have digital portals to enable online bill-paying, there’s usually no equivalent for applying for financial assistance. Many applications offer only a mailing address. But Walker and his team have found that applications sent by mail frequently get lost.

Instead, they recommend either walking the application into the hospital and delivering it by hand or faxing it. Public libraries, packaging stores like FedEx and certain online services make faxing possible even if, like most people, you haven’t used a fax machine since the late 1990s.

When it comes to accessing charity care, “you’re gonna have to jump through a lot of hoops,” Walker said, “but it’s worth it.”

Emily Pisacreta is a reporter and producer with “,” a podcast about the cost of health care that is co-produced with KHN.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).