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Financial Difficulties - A Patient Safety Risk 


The Norwegian Healthcare Investigation Board (Ukom) received a concern from a mother. Her son had taken his own life a few years earlier. After his death, she discovered a series of unpaid bills, reminders, collection notices, and legal claims. A large portion of these demands came from the healthcare services where he had received medical help for diabetes and depression. Many of the invoices that had gone to collections were fees for appointments he had failed to attend at the hospital. 

In his suicide note, the son wrote that he wanted to live but couldn't endure any longer. He had several suicide attempts behind him. It was known to several of the practitioners that financial difficulties were a contributing factor to his feelings of guilt and shame, leading to a lack of will to live. 

The mother questions how the same healthcare service that was supposed to help her son, referred to in the report as Kristoffer, also contributed to his deepening despair and loss of hope for survival. Based on Kristoffer's story as conveyed by his mother, we have examined the practice of healthcare institutions charging fees for missed appointments, and whether this practice can affect patient safety for patients with financial difficulties. 

In conducting this investigation, we based our work on Kristoffer's story as told by his mother. We also reviewed Kristoffer's patient record. To illuminate the extent of patients with financial difficulties, we gathered data from healthcare institutions and their internal routines for assessment and collection of patient payments, conducted a survey, and held four focus group interviews. 

Throughout, we also engaged in dialogue with other stakeholders, such as researchers, patient organizations, professional, and trade organizations, and other interested parties. 

There has been little attention on how patients' ability to pay can affect access to necessary healthcare and the impact of patient payments, such as copayments and "no-show" fees, on patient safety. 

Key Messages in Our Report 

  • There is a correlation between financial difficulties, unmanageable debt, and health. This should receive more attention so that the healthcare service can identify patients who need help managing their finances. There is no effective system to detect patients with financial difficulties, and patients do not always disclose this themselves. It is random which patients are identified by the healthcare service. 
  • The copayment system prevents some patients from seeking and receiving necessary healthcare. 
  • After the turn of the year, many patients cannot afford healthcare, and there is a need for legislation to allow for automatic entitlement to exemption cards for the impoverished. 
  • There is significant variation in the practice of the "no-show" fee, both within each hospital and among different hospitals. This can challenge the principle of equal treatment. 
  • The "no-show" fee system has not been evaluated. It is, therefore, unknown whether the fee leads to the desired increase in attendance, or if there might be other measures with a greater effect. 
  • The report is relevant for everyone in the health and care services, politicians, the Norwegian Labour and Welfare Administration (Nav), health authorities, and educational institutions. 

The translation from Norwegian to English is based in AI. Ukom has reviewed, edited and quality assured the translation.