Medical Billing Undermines Care and Trust
Health learners spend years studying human anatomy and physiology but rarely learn the anatomy of the health system or a medical bill—billing frustrates most who interact with health care. Patients admitted to the hospital may receive unclear and unfair bills or huge uncovered charges for out-of-network providers or facilities. As reported by the Kaiser Family Foundation, about 51% of adults skipped or delayed medical care in 2021 due to cost and 26% of adults in 2019 stated that they or a household member had problems paying medical bills in the past year.1 Understandably, this erodes patient trust in health care. Through the lens of a medical bill, we can learn about health systems factors that influence the value of care, defined as the outcomes that matter to patients divided by the total costs of care. A medical bill reflects many components of health care and can be used to understand pieces of the system.
Formal health education includes little to no instruction on medical billing, medical costs, and patients’ experiences of health care insurance and billing. Medical trainees do not learn about billing requirements until they are residents or attendings. At this point, their schedules are so overextended that most do not see the bills generated from their services, let alone have time to become familiar with the impact of billing on their patients. Medical training would be the optimal time to introduce future medical professionals to these concepts.
The Solution: Anatomy of a Bill
We are medical students at Dell Medical School (Dell Med) at The University of Texas at Austin. Choosing Wisely STARS (Students and Trainees Advocating for Resource Stewardship) is a collaboration between Dell Med and Costs of Care aiming to catalyze student-led initiatives to advance value within medical education. Based on our backgrounds before medical school—Rebekah as a Patient Advocate/Health Consultant, Christina as a Strategy & Operations Consultant—we knew that billing is a sore spot for most who interact with health care. As part of the STARS program, we have created a tool that we ourselves would want to use—one that can humanize and contextualize the complex and disjointed nature of American health care. Anatomy of a Bill2 is an online case-based tool to help health learners and health professionals (and hopefully one day patients) to understand the healthcare system through the lens of a medical bill while promoting conversation about value-based care. Our site development approach shares elements of Kern’s six-step approach to curriculum development.3 Recognizing the paucity of discussion around billing and insurance during training, we have featured a patient story and medical bill. We interviewed the patient about her experiences receiving care and bills, created a story board, worked with a web development group to create interactive site elements, and worked with a second web developer to place the content online.
Anatomy of a Bill lives on the Costs of Care4 website—its landing page includes a summary of value-based care and a link to the first case, featuring a patient’s journey through having a deep venous thrombosis and receiving medical diagnoses. The case includes an interactive version of the patient’s real bill. Interacting with the bill prompts pop-ups with definitions, calculations, and explanations to help users understand billing, reimbursement, and their health systems contexts. For example, clicking on “insurance adjustment” defines an insurance contractual rate in relation to total charges and what the patient owes. The tool can be included in educational modules or class sessions or shared as a standalone link for independent learning. Building the case and website has been a valuable learning experience: we problem-solved issues such as accessing a real patient’s medical bill and building the site on a reasonable budget and timeline—a challenge while completing clinical rotations.
We have used Anatomy of a Bill to hold interactive workshops for medical students of all levels at our own institution and nationally. We ourselves have conducted these workshops over Zoom after recruiting students from Dell Med and the national Choosing Wisely STARS cohort to participate voluntarily. After hour-long sessions, we have collected de-identified qualitative feedback for quality improvement, enabling us to evaluate the tool’s effectiveness and to understand how we can improve the site and workshops. In workshops to date, we have measured success based upon attendees’ written feedback on what they learned and whether it correlated with the stated objectives to learn about billing terminology, billing’s relationship to value, and about value-based care pathway improvements. We plan to expand our scope to hold workshops for other health professionals and trainees. Collecting data on the workshop participants’ needs and experiences surrounding health care billing and insurance will allow us to assess gaps in understanding for incorporation into future site iterations.
Through the Choosing Wisely STARS program, we are now mentoring peers at medical schools across the country through case creation for Anatomy of a Bill. Current STARS representatives submitted ideas to us for value-based cases that they would like to create, and we have invited several STARS representatives to join as case authors. We are meeting with case authors and building a longer-term framework for student-led case development. The student-authored cases will be included in the Anatomy of a Bill site, creating a case repository for use in workshops, independent study, and perhaps even formal curricula. With these additions, we envision growing the project into a cohesive set of cases to represent different billing scenarios across the care pathway of a chronic condition, such as diabetes. By highlighting stories of patients who are underserved and underrepresented in medical discourse in future cases, we plan to highlight inequities in care. We also hope to expand the project to include all the types of billing that a patient receives over a care cycle. Aggregating bills from all the patient’s providers—facility, physician, anesthesiologist, imaging center, lab, and others—illustrates the frustrating and fragmented story of medical billing.
Future Physicians Lead the Charge
Anatomy of a Bill embodies many potential utilities. On a literal level, it educates users about basic billing terminology, while humanizing the topic with real patient stories. Of particular interest to us, Anatomy of a Bill provides a platform for medical students to further educational impact in value-based care through a grassroots movement, empowering students to teach classmates and even school leadership about value and costs. These formative experiences early in medical school provide a forum for medical students to rethink how medicine traditionally presents a patient case. Students can practice identifying healthcare system problems, use a patient story as the foundation, build the patient presentation and case, and build learning objectives around value-based topics. Topics might range from the individual level (prevention, chronic illness exacerbations) to the systems level (how insurance coverage differences impact access, rural vs. urban care experiences).
The site creation process exemplifies a radical variation on the theme of a flipped classroom: the medical student does not simply teach a topic to herself ahead of class—she also creates the case to teach classmates, medical school leadership, and the community at large. This ownership enables students to share and discuss value-based cases in their community, further socializing the concept of value-based care.
Looking into on-the-ground patient billing experiences enhances understanding of patients’ medical environments, including factors that influence what appears on bills. We envision a healthcare experience in which physicians understand and prioritize patients’ need for simplified care cycles and pathways to promote proactive rather than reactive care. We believe Anatomy of a Bill can help future physicians lead the charge.
Acknowledgements: We would like to acknowledge our mentors Dr. Chris Moriates, September Wallingford, and Adam Zeiner, whose guidance and contributions have been essential in the creation of Anatomy of a Bill. We would also like to thank Natalie Weston, our classmate, who graciously donated her bill and story to promote learning about value-based care.