Tough Times Prompt Patients to Skip Care
By Benjamin Brewer, M.D.
The Wall Street Journal
Wednesday, July 23, 2008

With gas prices hovering around $4 a gallon, my patients are cutting back on medical care.

A 59-year-old woman decided not to have a mammogram this year.  At her age, she should be screened for colon cancer, too, but she is holding off until she becomes eligible for Medicare at 65.

Despite having some medical insurance as a self-employed cleaning woman, she is pinching pennies by scrimping on preventive care.  If she develops cancer of the colon or breast she won't have saved anything.  This year she is taking her chances.

Rising deductibles, stiff drug co-payments and increasing prices for just about everything are forcing some hard choices about health.  Care that doesn't strike patients as critical is getting delayed.  As the economy squeezes my patients, they are showing up sicker.

A patient quit smoking so he could afford gas for the 40 mile commute to work in a packaging plant.  He has been living paycheck to paycheck for years and his rent just went up.  I was glad that something finally motivated him to stop smoking.

The bad news was that he came to the office with severe pneumonia two days after refusing to let an E.R. doctor admit him to the hospital.  My patient was afraid of the expense and all the time he would go without pay from work.

To make matters worse, he didn't fill the antibiotic prescription he was given either.  The $50 co-payment was unaffordable, he said.  This is a case when an insurer would have been better off picking up the antibiotic tab to avoid a larger expense.  But there's no easy way for a doctor to override a plan's co-pay or to let an insurer know its rules are about to make something very expensive happen.

When the patient came to see me, his condition had deteriorated.  I persuaded him to let me admit him to the local hospital.  He was in such bad shape that he was soon transferred to the ICU of a large medical center.  His care will end up costing tens of thousands of dollars.

It was no surprise to me to read recently that claims severity and costs for health insurers took an unexpected jump this year.  Many patients are not able to bear even a moderate expense to save their insurance companies the cost of major claims.

A 53-year-old patient couldn't avoid a trip to see me when his finger was fractured in a log splitter.  After X-rays and having his fingertip sutured together, the man required several trips to the office for dressing changes and monitoring for infection.

He's been unable to work as a laborer in the month since he got hurt.  With no money coming in, he's racked up $200 in office co-payments for visits that his insurance won't be covering.  We're carrying his balance until he can get back to work.

He isn't the only one in arrears.  As a result of lean times, accounts receivable from uninsured patients in my practice is trending up.  About 5% of our patients are uninsured.

Patients are still having babies at the same rate.  But elective procedures, preventive exams and compliance with prescriptions are all down.

Some of my patients are taking themselves off medications.  Just last week I encountered patients who stopped their cholesterol medication and urinary incontinence medications.  I'm getting fewer refill requests for E.D. drugs, like Viagra, too.

I noticed an uptick in patients canceling appointments and just not showing up over the last few weeks.  More people are asking for advice over the phone and trying to avoid an office visit.

Many of our patients travel 20 or 30 miles to see us, and I think gas prices are affecting no-show and cancellation rates, particularly with low income patients.

My total number of office visits is off 5% from last year.  Another indication of the slowdown is that I'm getting my nursing home rounds done.  I'm pretty well caught up on my daily deluge of paperwork, too.  When things are busy, I almost never get those things accomplished.

It occurred to me in an idle moment that I would be a lot busier if the $600 government stimulus checks had been spent on a basket of basic primary care services.  That would have paid for 130 million people to have had most of their health needs met for a year.  Instead, folks around here seem to be spending more on $4 gas.

Due to his schedule and the volume of email he receives, Dr. Brewer may not be able to respond to all reader email. He does participate in his forum, where readers are urged to post. His email address is thedoctorsoffice@wsj.com.

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