Practices feel financial pressure as patients ration their own care

When administrative staff quit the nine-physician practice of Joseph Stubbs, MD, an internist in Albany, Ga., they are not replaced. To generate additional revenue, a room that contained paper charts before the practice switched to electronic medical records has been rented to a vascular surgeon.

The group has had to take these actions because, although sick patients are coming in for care, they are not returning when they are well. They are foregoing check-ups and other preventive services.

"I'm not kicking anybody out of the practice because they cannot pay me, but a lot of people just are not coming in," said Dr. Stubbs, who also is president of the American College of Physicians.

The national unemployment rate hit 9.4% in May, and medical society surveys indicate Dr. Stubbs' experience is not unique. Patients are delaying or skipping all kinds of health care, and as a result physician practices are having to take steps to maintain financial viability.

"Health care in general was protected from major changes in the economy. This [recession] has been a lot slower coming to health care, but ... clearly we are starting to catch up," said Cecil B. Wilson, MD, an internist in Winter Park, Fla., and a member of the American Medical Association's Board of Trustees.

Practice patterns are changing

The issue isn't just patients cancelling or failing to schedule appointments. Physicians also are noticing changes in who shows, and why, for routine care.

For instance, Michael Barrow, MD, a Dayton, Ohio, family physician specializing in sports medicine, is caring for more people on Medicaid because long-standing patients have lost their employer-sponsored insurance.

The effect on the bottom line for his practice at Samaritan North Family Physicians means no more overtime pay for hourly staff. In addition, Dr. Barrow is having trouble staying on schedule because patients are trying to get more issues cared for in a single visit.

"They try to do a lot of things in one visit," said Dr. Barrow. "Sometimes it's overwhelming. It's harder and harder for me to keep on time."

Data back up anecdotal stories

An American Academy of Family Physicians survey released in May found 89% of its members were seeing more patients expressing concerns about their ability to pay for health care, and 58% were seeing an uptick in appointment cancellations. Patient coverage also has changed, with 73% of the family doctors reporting more patients without insurance, and 38% seeing an increase in patients on Medicaid. Overall, 54% of the doctors said they were seeing fewer patients, and 44% were cutting services and reducing staff, or considering doing so.

"When it comes down to paying for gas or buying food, some people are putting off that health care visit until they feel like they are really dying," said Ted Epperly, MD, AAFP president. "I know of colleagues who have reduced services, cut staff and reduced hours. For the most part, nobody has just closed up shop, but [the recession] clearly has impacted them as well."

About 35% of family physicians also reported that more of their pediatric patients were missing regular check-ups. The American Academy of Pediatrics is querying its own members on this subject.

The first signs that health care would not go unscathed in this economic downturn emerged in data on elective procedures such as cosmetic surgeries.

According to a report issued March 25 by the American Society of Plastic Surgeons, the amount of money spent on cosmetic procedures declined 9% from 2007 to 2008. A report from the American Hospital Assn., issued April 27, found 59% of hospital chief executive officers reported a moderate or significant decrease in elective procedures.

Anecdotal evidence suggests this is not just because some patients have lost their jobs and private insurance. Most people -- physicians and patients -- have had some kind of financial loss in this recession. Patients who have insurance have higher co-pays. Some of those who still have jobs have seen their salaries reduced. They also may have been impacted economically if other household members have lost their livelihoods.

"Most people have taken some sort of hit financially. They're feeling less secure or more vulnerable," said Dr. Epperly, program director and CEO of the Family Medicine Residency of Idaho in Boise. "I've lost 45% of my retirement savings. My job is secure. My retirement right now is kind of iffy. I don't know anybody who has not been impacted."

Some insurance relief

For those who have lost their jobs, the COBRA subsidy passed as part of the American Recovery and Reinvestment Act of 2009 has helped some, but by no means all.

People who lose their health insurance as a result of being laid off between Sept. 1, 2008, and Dec. 31, 2009, will only have to pay 35% of the COBRA premium rate for up to nine months. But many physicians say it is still unaffordable for many who need it.

"Even with the subsidy, for some it is out of the question," Dr. Stubbs said.

Physicians say, however, that paying for services is not the only issue interfering with patient access to care. Time may become even tighter as patients take on multiple jobs to piece together a living.

"Many patients are emotionally and financially hunkered down," said Iffath Hoskins, MD, a former vice president of the American College of Obstetricians and Gynecologists and chair of the ob-gyn department at Lutheran Medical Center in Brooklyn, N.Y.

ACOG released a Gallup poll at its 57th annual clinical meeting in Chicago May 5 that found 14% of women ages 18 to 44 were postponing their annual ob-gyn checkup. In addition, 15% of women in this age group reported cutting back or stopping taking a medication because of cost.

While physicians are taking steps toward their own economic survival, they also are taking steps to help their patients weather the crisis with their health intact.

The AAFP survey found 71% of family physicians are providing more uncompensated care. Some physicians said they were downcoding visits to fit a patient's budget or working out no-interest payment plans. Free medication samples are being pursued more aggressively, and physicians and staff are gathering resources on free or low-cost health services to share with patients in need.

The biggest concern, however, is about the patients who stop showing up completely.

Medical society officials want physicians to encourage patients to make the appointments they need, then deal with any necessary financial arrangements. Physicians are being urged to ask patients about economic difficulties they may be experiencing.

Patients "don't necessarily bring financial hardship to the attention of the physician," Dr. Epperly said. "But all of us should ask about this."