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
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
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
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
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
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,
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
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.
to his schedule and the volume of email he receives, Dr. Brewer
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