The Fredericksburg General District Court is a red-brick courthouse with Greek columns in a picturesque, Colonial Virginia town. A horse and carriage are usually parked outside the visitor center down the street.

On a sunny morning — the second Friday in June — the first defendant at court is a young woman, Daisha Smith, 24, who arrives early; she has just come off working an overnight shift at a group home for the elderly. She is here because the local hospital sued her for an unpaid medical bill — a bill she didn’t know she owed until her wages started disappearing out of her paycheck.

The hospital, Mary Washington, sues so many patients that the court reserves a morning every month for its cases.

Inside the courthouse, it’s not hard to figure out where to go. Right through court security, there are signs on colored paper: “If you are here for a MW case, please register at the civil window.” When the elevators open, there’s another Mary Washington sign. Wearing name badges, Mary Washington billing staff members walk through the halls. They’ve set up a kind of field office in a witness room at the back of the courtroom, where they are ready and waiting to set up payment plans for defendants.

On June 14, only a handful of the 300 people summoned to court show up. Most of the lawsuits were filed by the hospital, along with some others from medical companies affiliated with Mary Washington Healthcare.

The hundreds that did not come have default judgments made against them, meaning their wages can be garnished.

Those who did sit scattered throughout the bright, mostly empty courtroom, under the schoolhouse lamps.

At 9 a.m., the judge walks into court, and everybody rises.

“Good morning,” he says. “This is what we call the hospital docket.”

Bill collection through the courts

Not every hospital sues over unpaid bills, but a few sue a lot. In Virginia, 36% of hospitals sued patients and garnished their wages in 2017, according to a study published Tuesday in the American Medical Association’s journal, JAMA. Five hospitals accounted for over half of all lawsuits — and all but one of those were nonprofits. Mary Washington sued the most patients, according to the researchers.

Mary Washington defends the practice as a legal and transparent way to collect bills. It says it makes every effort to reach patients before it files papers to sue.

But others who observe and research the industry find it troubling that hospitals, especially nonprofits, are suing their patients.

“Hospitals were built — mostly by churches — to be a safe haven for people regardless of one’s race, creed or ability to pay. Hospitals have a nonprofit status — most of them — for a reason,” says Martin Makary, one of the JAMA study’s authors and a surgeon and researcher at Johns Hopkins Medicine. “They’re supposed to be community institutions.”

There are no good national data on the practice, but journalists have reported on hospitals suing patients all over the United States, from North Carolina to Nebraska to Ohio. In 2014, NPR and ProPublica published stories about a hospital in Missouri that sued 6,000 patients over a four-year period.

Typically these aren’t huge bills. In Virginia, the average amount garnished was $2,783.15, according to the JAMA study. Walmart, Wells Fargo, Amazon and Lowe’s were the top employers of people whose wages were garnished.

“If you’re a nonprofit hospital and you have this mission to serve your community, [lawsuits] should really be an absolute last resort,” says Jenifer Bosco, staff attorney at the National Consumer Law Center.

Bosco explains that IRS rules require nonprofit hospitals to have financial assistance programs and prohibit them from taking “extraordinary collection actions” on unpaid medical bills without first attempting to determine patients’ eligibility for financial assistance.

Nonprofit hospitals, Bosco says, “have to provide some sort of financial help for lower-income people, but the federal rules don’t say how much help, and they don’t say how poor you have to be to qualify [or] if you have to be insured or uninsured.”

As a result, she says, nonprofit hospitals have “a lot of free rein to make up their own policy of what they think is appropriate.”

“Hospitals sometimes can legally sue their patients for medical debts,” Bosco says. “The question is whether that’s something that they should be doing.”

For Makary, as a doctor, the answer is simple: “It’s a disgrace every place where it happens,” he says.

The “hospital docket” at the Fredericksburg court illustrates how far hospitals will go to pursue debts, he says: “It’s almost as if the courthouse has converted into a taxpayer-funded collections agency.”

“Who’s garnishing my check?”

Smith is unflinching when she talks about Mary Washington and what happened to her after she went to the hospital in 2017.

At the time she didn’t have insurance. She was working part time at Walmart for $11 an hour. She doesn’t want to give the details about why she ended up at the hospital. “I was not myself,” she says. “So I walked myself into Mary Washington to get help — to get myself on track.” She says she was admitted for two weeks.

Smith says no one told her about the financial assistance program or talked to her about her bill. According to the hospital’s policy, someone making less than $25,000 without health insurance should qualify for “free care.” But the hospital sued her for $12,287.68. She had a default judgement against her and did not realize she had been sued until she saw her paycheck mysteriously disappearing.

“When I looked at my pay stub, I’m like, ‘Why do I only have like $600-something in my account?’ ” She noticed “garnish” written on the bottom of her pay stub. “So I called my company and asked them, ‘Who’s garnishing my check?’ ” They told her it was Mary Washington.

With the garnishment, her take-home pay for a month of work comes to about $1,400. Her rent is $1,055. “I literally have no food in my house because they’re garnishing my check,” she says.

She knows she is not the only one that Mary Washington has gone after for an unpaid bill. Her relative had one, too, and got on a payment plan. Her co-worker was also sued.

“And that’s crazy,” she says, shaking her head. To Mary Washington Hospital, she says: “People need help. You all are just money hungry.”

A thin slice of revenue

In the courtroom, on hospital docket day in June, the judge ran through the cases quickly. One man owed $1,500 after an emergency room visit. A nurse was on the hook for over $20,000 after one of her children had a mental health evaluation. Another woman wasn’t sure why she was being sued for $1,400 — it could have been from an outpatient surgery she had three years ago. The day’s hearings are all over in 45 minutes.

Mary Washington Healthcare stands by its practice of suing patients and says that lawsuits are relatively rare.

“It’s important to us, as a small community, and a safety net hospital, that we’re doing everything we can for our patients to avoid aggressive collections,” says Lisa Henry, communications director for the health care system.

Henry says Mary Washington has a months-long process for trying to reach patients before it takes legal action. “By phone, by mail, by email — any access point we’re given from them when they register,” she says.

“Unfortunately, if we don’t hear back from folks or they don’t make a payment we’re assuming that they’re not prepared to pay their bill, so we do issue papers to the court,” she says.

Mary Washington Healthcare includes two hospitals, a network of physician practices, specialty care and outpatient centers.

Henry says the “vast majority” of patients who are eligible do get signed up for their financial assistance program, getting discounted or free care or setting up a payment plan. “A small percentage then goes on to collection and then even smaller goes to litigation,” she says. “We see thousands of patients a year and less than 1% go to litigation.”

In fact, Henry says that the revenue the hospital got from garnishing people’s wages was only 0.21% of its $624 million total revenue in 2018. That’s slightly higher than the average collected by other Virginia hospitals, according to the JAMA study, which found hospitals collected an average of 0.1% of their total revenue from garnishments.

Erin Fuse Brown, a law professor at Georgia State University whose work focuses on health care costs, says there are bigger philosophical questions here about a hospital’s role.

“There has to be a balance between getting their bills paid but also being a reasonable community member,” she says. Regarding lawsuits, she adds: “It doesn’t seem to be worth the effort, and it’s so ruinous to the patient — not just the financial obligation but the effect on your credit, on your record, the emotional effect of being sued.”

Mary Washington Healthcare has chosen to go through the legal system intentionally, Henry says. “We selected to do this because we think it is a fair and appropriate way to help our patients reach out to us — to open the lines of communication,” she says. “There are many cases resolved before litigation. The court summons alone is enough to open that door of communication so that we can work with them.”

Henry says the Virginia hospitals that don’t sue patients are probably outsourcing their collection of unpaid bills. “Most sell their debt. We have elected not to ever sell our debt in small claims,” she says. “The reason for that is the collections agencies can be aggressive.”

Fuse Brown says IRS rules for nonprofit hospitals don’t distinguish between whether a hospital is trying to collect an unpaid bill directly or using a private collection company. “They’re recognized to be fairly harsh tactics, whether the hospital is the one doing the suing or whether it’s a debt collection agent,” she says. “Certainly to the patient, all of that feels equally stressful and burdensome.”

She says it’s hard to know at a national level how many nonprofit hospitals sue patients who haven’t paid their bills, how many sell the debt, and how many write it off. “I haven’t seen any good studies that tried to estimate the number of hospitals that are doing this or the percentage of patients who are subjected to this type of debt collection activity,” Fuse Brown says.

She adds, it’s a shame information about hospitals’ collection practices isn’t widely available. “Wouldn’t you like to know that if you were a patient?” she asks.

“Do you owe this money?”

On June 14, a group of doctors, pre-med students and a lawyer headed to the Fredericksburg court early, and as patients collected in the hall outside the double doors of the courtroom, the group approached them, asking, “Are you here because you’ve been sued by Mary Washington?” Nearly everyone nodded cautiously. And most were open to talking about and sharing what happened to them.

This group is part of an advocacy campaign to support patients who are being sued by the hospital. The effort is led by Johns Hopkins researcher Makary, the author of the JAMA study.

He first found out about this hospital’s lawsuits last fall while working on The Price We Pay, his forthcoming book on dysfunction in the American health care system. He was so outraged by what is happening to patients in Fredericksburg that he has started showing up every month when hospital cases are heard in the court.

“To see these aggressive, and even predatory, collection strategies affect everyday teachers, farmers, even nurses — it’s heartbreaking and it’s wrong and it needs to stop,” Makary says.

Part of the advocates’ strategy to help patients fight these lawsuits is to encourage them to contest their bills, rather than admit they owe the money.

“The No. 1 thing we need them to do is when the judge asks that initial screening question, ‘Do you owe this money?’ the answer they need to say is, ‘No,’ ” Makary explains. “That allows us to make the arguments and to have a hearing.”

If they say yes, which many of them do, “That’s kind of the kiss of death — you’re going to get a judgment against you,” says Joseph Kirchgessner, the local attorney working with the advocacy team.

The underlying thinking is that patients rarely have a chance to negotiate the cost of medical services in advance and that bills may be unreasonable, especially in light of their financial circumstances. A patient who contests may be able to negotiate a better price or have the bill forgiven.

Kirchgessner says he plans to argue that hospital contracts, often signed under duress during a medical crisis, aren’t valid. Makary is ready and willing to be an expert medical witness, to testify about whether there are hospital markups or unnecessary procedures.

But Kirchgessner hasn’t had a chance to defend a Mary Washington case in court yet, he says, because each time he gets close to a trial date, the hospital withdraws its case against the patient. This leaves the issue unresolved. The hospital can still try to collect, or bring a future lawsuit.

The advocates are also politely asking hospitals like Mary Washington to end the practice of suing over unpaid bills. Makary has chatted with doctors in the hospital cafeteria, imploring them to tell their administrators to stop. (Makary has been doing that himself, at his own hospital — Johns Hopkins Hospital — which was also recently reported to be suing patients over their bills.) He sent a letter to Mary Washington Healthcare’s CEO and board members asking that they stop the suits.

“We’ve told the hospital that we will plan to be there on every single court date until the hospital decides to stop suing low-income patients for bills that they simply can’t afford,” Makary says.

Mary Washington’s Henry says that because all of the court records are public, they are subject to more scrutiny than hospitals that use collection agencies.

“We’re really unclear as to why Mary Washington Healthcare in particular has become the face of this,” she says. “I don’t think we’re alone — all hospitals are struggling with, ‘How do we collect appropriately from our patients to stay open as a safety net hospital?’ “

A “wild card” case

Thanks to the volunteer advocates, Smith now has an attorney — Kirchgessner.

He says taking her case “was a bit of a wild card” since it’s too late for her to contest the bill. All he can do for her now is try to get the garnishment lowered or removed altogether. “There are certain laws in Virginia about how people are garnished, how much they can take,” he explains.

The next step is to meet with Smith to work out her income and expenses and make a plan.

Since her paycheck started being garnished, Smith had to take on another job to keep up with her rent. “The second job’s not helping much, but it’s something,” she says. She is also now working full time at the group home and is enrolled in Medicaid.

If her check weren’t being garnished, she says, “I’d be fine. I would have everything that I needed — saving money, everything would be paid, food would be in the house.” She’s glad to have a lawyer helping her with her case. There is a new hearing date set for July.

Now, if she has a medical issue, “I go to urgent care,” she says. “I stay away from Mary Washington.”

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Anyone who has tried to shop around for hospital services knows this: It’s hard to get prices in advance.

President Trump signed an executive order Monday that he says would make such comparisons easier, and make the pricing process more transparent.

The order directs agencies to draw up rules requiring hospitals and insurers to make public more information on the negotiated prices they hammer out in contract negotiations. Also, hospitals and insurers would have to give estimates on out-of-pocket costs to patients before they go in for nonemergency medical care.

“This will put American patients in control and address fundamental drivers of health care costs in a way no president has done before,” said Health and Human Services Secretary Alex Azar during a press briefing Monday.

But just how useful the effort will prove for consumers remains unclear.

If the executive order leads to finalized HHS rules, proponents say it could encourage competition and lower prices.

Other health care analysts say much depends on how the administration writes the rules over the next several months — rules that govern what information must be provided and in what format. Trump’s executive order already is running into opposition from some hospitals and insurers who say disclosing negotiated rates could drive up costs.

As health care consumers await more details on those rules, here’s what we know:

Q: What does the order do?

It may expand price information consumers receive.

The order directs agencies to develop rules to require hospitals and insurers to provide information “based on negotiated rates” to the public.

Currently, such rates are hard to get, even for patients, until after medical care is provided. That’s when insured patients get an “explanation of benefits,” which shows how much the hospital charged, how much of a discount their insurer received and the amount a patient may owe.

In addition to consumers being unable to get price information upfront in many cases, hospital list prices and negotiated discount rates vary widely by hospital and insurer, even within the same region. Uninsured patients often are charged the full amounts.

“People are sick and tired of hospitals playing these games with prices,” says George Nation, a business professor at Lehigh University who studies hospital contract law. “That’s what’s driving all of this.”

Some insurers and hospitals do provide online tools or apps that already can help individual patients estimate out-of-pocket costs for a service or procedure ahead of time. But research shows few patients use such tools. Also, many medical services are needed without much notice — think of a heart attack or a broken leg — so shopping for price simply isn’t possible.

Administration officials say they want patients to have access to more information, including “advance EOBs” that outline anticipated costs before patients get nonemergency medical care. In theory, that would allow consumers to shop around for lower cost care.

Q: Isn’t this information already available?

Not exactly. In January, new rules took effect under the Affordable Care Act that require hospitals to post online their “list prices.” These are prices hospitals set themselves, and have little relation to actual costs or what insurers actually pay.

What’s resulted are often confusing spreadsheets that contain thousands of a la carte charges — ranging from the price of medicines and sutures to room costs, among other things — that patients have to piece together (if they can) to estimate their total bill. Also, those list charges don’t reflect the discounted rates insurers have negotiated, so they are of little use to insured patients who might want to compare prices from hospital to hospital.

In theory, at least, the information that would result from Trump’s executive order would provide more detail based on negotiated, discounted rates.

A senior administration official at the press briefing said details about whether the rates would be aggregated or relate to individual hospitals would be spelled out only when the administration puts forward proposed rules to implement the order later this year. It also is still unclear how the administration would enforce the rules.

Another limitation to the executive order: It applies only to hospitals and the medical staff they employ. Many hospitals are staffed by doctors who are not directly employed, or rely on laboratories that are also separate. That means negotiated prices for services provided by such laboratories or physicians would not have to be disclosed.

Q: How could consumers use this information?

In theory, consumers could get information in advance that would allow them to compare prices for, say, a hip replacement or knee surgery.

But that could prove difficult if the rates are not fairly hospital-specific, or if they are not lumped in with all the care needed for a specific procedure or surgery.

“They could take the top 20 common procedures the hospital does, for example, and put negotiated prices on them,” says Nation. “It makes sense to do an average for that particular hospital, so I can see how much it’s going to cost to have my knee replaced at St. Joe’s versus St. Anne’s.”

Having advance notice of out-of-pocket costs could also help patients who have high-deductible plans.

“Patients are increasingly subject to insurance deductibles and other forms of substantial cost sharing. For a subset of so-called ‘shoppable services’, patients would benefit from price estimates in advance that allow them to compare options and plan financially for their care,” says John Rother, president and CEO at the advocacy group National Coalition on Health Care.

Q: Would the availability of this extra information push consumers to shop for health care?

The short answer is maybe.

“The evidence to date shows patients aren’t necessarily the best shoppers, but we haven’t given them the best tools to be shoppers,” says Lovisa Gustafsson, assistant vice president at the Commonwealth Fund.

Posting negotiated rates might be a step forward, she says, but only if the information is easily understandable.

It’s also possible that insurers, physician offices, consumer groups or online businesses would find ways to help direct patients to the most cost-effective locations for surgeries, tests or other procedures based on the information.

“Institutions like Consumer Reports or Consumer Checkbook could do some kind of high-level comparison between facilities or doctors,” says Tim Jost, a professor emeritus at the Washington and Lee University School of Law.

But some hospitals and insurers maintain that disclosing specific rates could backfire.

Hospitals charging lower rates, for example, might raise them if they see competitors are getting higher reimbursement from insurers. And insurers say they might be hampered in their ability to negotiate if rivals all know what they each pay.

“We also agree that patients should have accurate, real-time information about costs so they can make the best, most informed decisions about their care,” said the lobbying group America’s Health Insurance Plans, in a written statement. “But publicly disclosing competitively negotiated, proprietary rates will reduce competition and push prices higher — not lower — for consumers, patients and taxpayers.”

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation, and is not affiliated with Kaiser Permanente.

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Across the country, surgeons are learning to use more than just scalpels and forceps. In the past decade, a growing number of medical institutions have invested in the da Vinci robot, the most common device used to perform robot-assisted, or robotic, surgery.

Compared to traditional open surgery, robotic surgery is minimally invasive and recovery time is often shorter, making the technology attractive to patients and doctors. But the da Vinci surgical system is expensive, costing as much as $2 million, and recent studies show that for certain procedures it can sometimes lead to worse long-term outcomes than other types of surgery.

Even so, the robot has become common practice in some specialties, such as urology and gynecology, and that growth is expected to continue, which means more surgeons are learning to use the device.

“It’s not necessarily, ‘Is robot better?’ ” says Dr. Kenneth Kim, director of the robotic training program at UAB Hospital in Birmingham, Alabama. “Robot is just another tool that they need to master just like any other surgical tool.”

But “mastering the robot” can be a challenge.

“It never was an issue because open surgery, like scissors — like everyone learns how to use scissors in kindergarten,” Kim says. “Everyone knows, functionally, how to use a knife. But with the robot, it’s a totally different, new tool and it’s more complex, so now that has a separate learning curve.”

The da Vinci robot is not self-operating, at least not yet. Instead, it works almost like a big video game. The surgeon sits at a console station and uses hand and feet controls to manipulate a separate surgical part attached to the patient.

Operating in virtual reality

One way students get comfortable with the device is by operating in virtual reality. At training institutions like UAB, surgical residents use a simulator to complete monthly tasks and practice common procedures.

OBGYN resident Teresa Boitano says the exercises help develop skills that are directly applicable to the operating room. During one of these tasks, Boitano moves the robot arms to precisely place colorful rings onto corresponding spikes.

“And so I’m going now to grab this first ring and at the same time I’m thinking, ‘OK now where do I need to go to get the next one?’ ” Boitano says. “You’re always trying to stay ahead of the game but then also, making sure you’re not doing any errors at the same time.”

If she does make a mistake, the machine will tell her. Kim says the latest simulators come equipped with advanced motion-tracking technology. So while Boitano’s practicing a task or doing a run through a hysterectomy in virtual reality, the simulator records her movement – how accurately she uses the robot arms or how fast she completes the exercise. It provides objective data about surgical performance.

Dr. Khurshid Guru, director of robotic surgery at Roswell Park Comprehensive Cancer Center in New York, says this simulator technology helps standardize the training process.

“The analogy is that now you don’t have to worry about learning how to drive a car because everybody could get onto the street, they are taught the basic principles of driving a car,” Guru says. “The million-dollar question now is, ‘When would you allow them to get onto the expressway?’ “

Guru says that is the next step, when surgeons specialize in different procedures.

Robot-assisted surgery not for every patient

Dr. Monica Hagan Vetter, of The Ohio State University, has studied robotic training programs across the country. She says using a simulator to measure surgical ability helps ensure surgeons have a certain level of skill before they actually operate on people.

“You can learn the steps of the procedure,” Vetter says, “but if you don’t know how the robot works, if you don’t know how to troubleshoot the robot or what to do in an emergency, then even if you can perform the world’s best hysterectomy and you know all the steps and all the instruments, you are not safe to do that.”

Dr. Kenneth Kim says simulators and the data they provide help streamline the teaching process and offer the opportunity to give students more objective feedback. It is a way for surgeons to learn to use the da Vinci robot as a tool, but Kim says they still have to watch and learn.

“The simulator’s good, but it can only simulate so much,” he says.

In the real world, Kim says robot-assisted surgery is not right for every patient. A surgeon needs to know when to use it and when not to use it, and those decisions can change as researchers continue to study patient outcomes from robotic surgery.

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