CHICOPEE -- Beverly Ann Pise, still recovering from a painful kidney condition, stuffs newspapers into plastic bags and piles them on her living room floor before heading out on an 18-mile delivery route. Even though it's her second job, her goal looks unattainable: whittling down her growing medical debt.
In addition to thousands of dollars in credit card and doctors' bills, she and her husband, Joe, owe Baystate Medical Center in Springfield, a Tufts medical school teaching hospital, about $3,000 for her three-day emergency hospital stay in July 2002 and follow-up care.
They said they haven't been able to pay the bill, and in August a sheriff slipped a piece of paper inside the couple's front door notifying them that Baystate had a $3,600 lien placed on their home. The court also tacked on 12 percent annual interest.
''I'm trying to pay the bills, but I need time," said Pise, 51, who said she has stopped seeing all but one of her doctors so she doesn't fall deeper into debt, a decision that brings her to tears. ''Now I'm worried they can take the house."
Despite growing criticism of aggressive hospital collection methods, Baystate often sues patients and has liens placed on their homes over unpaid bills. In the past 15 months, Baystate's collection firm took nearly 300 patients to Springfield District Court and had liens placed on the homes of 46 patients, including one for $24,000, according to a Globe review of court records. The hospital's collection agency, Gold & Vanaria in Springfield, requested another 14 liens during that period, motions that were postponed or withdrawn. Liens allow a creditor to collect its money when a home is sold, or force sale of the property -- although Baystate executives said they have never foreclosed on a home.
''Liens are an unacceptable practice," said John McDonough, executive director of Health Care For All, a nonprofit advocacy group in Boston. ''We're dealing with folks whose only offense is they got seriously ill and weren't able to obtain decent health coverage."
Gold & Vanaria has charged some patients 6 percent annual interest, according to records, and then later raised that to 12 percent, the standard interest rate allowed by Massachusetts courts. This has created situations where patients could never climb out of debt because the charges accrued faster than people could afford to pay them off.
Baystate executives said last week that they did not realize that Gold & Vanaria was charging patients interest until July, and told them not to collect any interest. The firm, which gets one-third of what it collects for the hospital, declined to discuss details of its collection efforts on behalf of Baystate.
Hospital executives say they are in a bind. If patients don't pay, the hospital can't provide expensive and advanced medical care. But like Pise, many of these working-poor patients are stuck too: They earn too much to qualify for many government programs, but their employers offer minimal insurance, or insurance they cannot afford.
When the Globe notified him of the Baystate liens, Paul Cote, state commissioner of Health Care Finance and Policy, said hospitals should use liens only in rare situations. Cote, whose office oversees the ''free care" program, which helps the poor with medical bills, said he plans to review Baystate's methods to determine if the hospital is violating state rules that protect the poor from unfair collection practices.
''They would have to have a compelling case, such as someone doesn't have an income, but has millions of dollars in assets," he said. ''Hospitals should not put liens on poor people's homes."
Keith McLean-Shinaman, Baystate's chief financial officer, defends the hospital's practices. The liens, he said, are a last resort when patients won't pay even a minimal monthly amount toward their bill, and a way for the hospital ''to get in line to be paid" when they sell their house or refinance.
''If you're giving out care that costs money, someone has to pay for it," McLean-Shinaman said. ''I'm not saying the burden should be on the uninsured, but we need to make changes on a societal level to deal with this situation."
As the cost of medical treatment grows, and with health insurance out of reach for many Americans, medical debt is a serious problem. Some health care advocates also blame aggressive hospital billing methods. This summer Congress held hearings on whether nonprofit hospitals, which receive substantial tax breaks in return for their charitable mission, should engage in these practices.
Lawyers have sued hospitals on behalf of poor patients, including a lawsuit attorney Thomas Greene of Boston filed against Baystate in July. ''Some of these hospitals pursue patients relentlessly," he said.
Massachusetts healthcare executives said they don't have a good handle on the scope of aggressive hospital billing, although many said the problem is less severe than in other states because of the state-run free-care pool. The special fund helps uninsured and sometimes even insured patients pay all or part of their medical bills, based on a sliding income scale.
Executives at four large nonprofit Boston hospitals, Massachusetts General Hospital, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, and Boston Medical Center, said they don't have liens placed on homes of patients who don't pay their bills. Otherwise, practices vary. Boston Medical Center and Beth Israel Deaconess do not take patients to court over unpaid bills, executives said, while Mass. General and the Brigham sometimes do when debts are large.
Baystate executives said the hospital does help the poor as part of its charitable mission. For instance, it said, it provides more than $15 million annually in free care for patients. The hospital posted a profit of $24.8 million last year.
McLean-Shinaman said the hospital goes to great lengths to work out payment plans with patients, calling them repeatedly and helping them fill out applications for free care and other financial assistance. He said they do not report unpaid bills to credit agencies, although agencies sometimes search court records for information.
David Lavenburg, a lawyer with Gold & Vanaria, said liens are one of the ''least intrusive methods of collection. I've been a lawyer for 13 years, and Baystate is the least aggressive and most conservative client I have," he said. ''They don't garnish people's wages or pick up vehicles at people's houses or arrest people. These are extreme remedies that deprive people of something. A lien doesn't interfere with their ability to live in a home."
That's little comfort to Bernice Laterreur. Her husband took her to Baystate on Sept. 10, 2001, because she had chest pain and struggled to breathe when climbing stairs. Laterreur, 61, had a blood clot in her lungs, and the hospital's charge for a four-day stay and treatment was $9,112.73, according to records she provided.
Her husband called the hospital, explained they did not have insurance, and Baystate reduced the bill by $4,000, the couple said. They couldn't afford to make many payments on the remainder of the bill, Bernice Laterreur said, but when the hospital sent the case to Gold & Vanaria, she began making $50 monthly payments in May 2003. She stopped the following winter, she said, when she and her husband were laid off from their jobs. In April, Gold & Vanaria had a $6,000 lien placed on her house. She began paying again.
The 12 percent interest that showed up on her bill increased it by at least $720 a year. Meanwhile, her monthly payments total $600 a year. ''I keep paying but my bill is going up, not down," she said.
McLean-Shinaman said he could not discuss her case because it would violate patient confidentiality rules and the couple would not sign a legal release authorizing the hospital to talk about their situation. But he said the hospital offers to help all patients apply for government help.
Since inquiries by the Globe, he said he also is looking into wiping out interest charges the collection firm accumulated on patients before July.
The hospital and collection agency called the Pises dozens of times before taking them to court.
Beverly Pise's original bill for the July hospital stay was between $8,000 and $9,000, the hospital said after she signed a release.
Joe Pise has limited insurance through his job inspecting utility poles for Utility Pole Technologies Inc., a subsidiary of Asplundh Tree Expert Co., which left them with a hospital bill of $2,810, which grew to than $3,600 with interest.
The hospital asked the couple for information on their income and to fill out an application for free care. For months the two sides went back and forth, the Pises providing financial information and the hospital asking for more, hospital executives said. McLean-Shinaman said the hospital has not tried to collect thousands of dollars from the couple for subsequent care.
In the end, they could not agree. The hospital said the couple's annual income was $32,000, which qualifies them for partial free care, but only if they first pay $3,200 out of their own pocket. But the Pises said their income actually was about $26,000.
Joe Pise usually is laid off during the winter months, and they sometimes cover the mortgage, groceries, and other bills, with credit cards. And while the Pises have had tenants rent two apartments in their three-family home, they said the income has been erratic.
During the winter following her hospital stay, Beverly Pise said, the hospital requested that she agree to a payment plan of about $50 a month.
''I told them there was no way," she said. Negotiations broke down, and Pise stopped returning the hospital's calls and letters.
Pise said she's not sure what to do now for medical care, because she doesn't want to rack up more debt. She has suffered from constant problems, including a ruptured disc that required back surgery four years ago, excessively high blood pressure and blocked arteries in her kidneys, for which she was admitted to the hospital two years ago and required angioplasty to open up blood flow. Doctors, she said, told her she had probably suffered a couple of small strokes.
She acknowledges that when the notice arrived that Baystate was taking her to court, she ignored it.
''We can't afford a lawyer," she said.
Liz Kowalczyk can be reached at email@example.com.