Under Minnesota's "Hospital Agreement," the bland name given to the state's pioneering protections for health care consumers, oversight of billing and debt collection practices is a key responsibility of a nonprofit medical center's board of directors.

These duties include reviewing policies at least once a year, ensuring that patients are treated respectfully and providing accurate information about their options even if they fall behind on payments.

A recent New York Times story spotlighting a disturbing Allina Health billing practice has put an unfortunate spotlight on these critical nonprofit governance obligations — one requiring vigorous follow-up from Minnesota Attorney General Keith Ellison and legislators. Among the many questions raised by the story is whether Allina's board was aware that the system suspends nonemergency access to its medical providers for patients who have accrued $4,500 or more in medical debt.

If they knew about this policy, how does it comply with both the letter and spirit of the Hospital Agreement, not to mention the mission of a nonprofit health care system, of which Allina is one? If board members didn't know, are they comfortable with the policy now?

An editorial writer contacted many members of the Allina board and has yet to receive a response. And while Allina CEO Lisa Shannon defended the system's practices and her financial stewardship responsibilities in an interview with an editorial writer, an in-depth investigation by the state Attorney General's Office is in order. While patients do need to pay their medical bills, those who are sick still merit compassion and assistance. A better balance needs to be struck.

The New York Times story focused on Allina. But Allina is not unique among health care systems in Minnesota or nationally in suspending outpatient care for nonemergency patients who are behind on bills.

In a statement, HealthPartners said it employs scheduling holds "as a last resort, and only in non-urgent circumstances, to engage with patients and try to connect them with assistance."

Mayo Clinic appears to have a similar policy, saying in a statement this week saying it is used "only in situations where the services were determined by the care team to be non-urgent or not unique to Mayo would an appointment possibly be delayed because of an outstanding balance."

An alarming 2022 story by the Rochester Post Bulletin raised questions as well about whether Mayo does enough to make patients aware of its charity care options when medical debt piles up. The Star Tribune Editorial Board has similar questions about other Minnesota health care systems.

To their credit, state lawmakers passed legislation this session to improve awareness of charity care programs. But the examination necessary in the Times story's wake should include whether more can be done.

It is important to note that nonprofit status, which most of Minnesota's health care systems enjoy, confers substantial tax benefits. In return, however, these institutions are expected to provide a community benefit.

We recognize that nonprofits, even with their special status, still have to run sound businesses. That includes collecting dollars owed. At the same time, it's fair to ask if Minnesota's nonprofit health care institutions can do more to assist struggling patients and minimize the number who wind up in a place where nonpayment jeopardizes care.

The Attorney General's Office has broad authority over the state's nonprofits and in enforcing the Hospital Agreement. Ellison should open a wide-ranging investigation into billing practices across Minnesota. Questions that need answers:

How many of Minnesota's health care systems have a policy like Allina's?
How many Minnesotans have had care access cut off? Allina, for example, estimates about 2,000 patients on average may be affected by this policy at any time. That's too many, and that's just one system.
Are there commonalities among those who have had care access interrupted? An editorial writer's early analysis suggests that many have insurance with high deductibles, leaving them with thousands in out-of-pocket expenses. If these patients are falling through the cracks of current assistance programs, solutions should be crafted to make their financial obligations more manageable.
Is a broad ban on clinical care interruptions merited?
Are Minnesota's nonprofit health care institutions providing a community benefit commensurate with the tax advantages they receive? Specifically, should they provide more charity care than they currently do?

To his credit, Ellison is asking Minnesotans to submit information on problematic billing experiences to his office. He should wield his office's authority energetically beyond that to seek answers from all of the state's health care systems. State lawmakers should hold a public hearing and pass remedies in the 2024 session.

On Friday, Allina announced it would "pause" the policy scrutinized in the Times article. That is a responsible step given the outrage and debate the story spurred. Broader solutions are in order, however. Minnesota should lead the way in finding them.