Trends in physician office visits shift as money worries affect behavior
■ A Florida doctor has seen patients in his office with broken wrists or hips. "These people would have generally gone to the emergency department."
The economic downturn has kept many cash-strapped patients from seeing their physicians or caused many to delay treatment, research has shown. Studies and reports from doctors provide insight into how patient behavior has been affected by the 2007-09 recession and its slow recovery.
For example, a poster presented Feb. 7 at the American Academy of Orthopaedic Surgeons meeting linked increasing unemployment rates in Tampa, Fla., with a decrease in patient volume at a level 1 trauma center. When unemployment went up, orthopedic trauma volume went down, from a peak of 2,065 cases in 2007, just before the recession, to 1,743 in 2009 when it was in full force.
These patients are usually so severely injured they don't decide where or whether to receive medical care.
"We're still very busy," said Daniel Chan, MD, lead author and an orthopedic surgeon with the Florida Orthopaedic Institute in Tampa. "It's not a huge difference, but it is enough to notice."
Construction is one of the top 10 most dangerous occupations, according to the Bureau of Labor Statistics. But construction was hard-hit during the recession, particularly as new-home building -- an economic staple in Florida -- dried up. A total of 86,700 people worked in construction in the Tampa area in 2007. The number decreased to 59,200 in 2009.
For less severe traumatic injuries or illnesses, physicians report that patients are trying to treat themselves or receive care in venues that may be less costly or more convenient than the emergency department. Nevertheless, statistics have noted an increase in emergency department use. The Centers for Disease Control and Prevention said the number of ED visits grew from 124 million in 2008 to 136 million in 2009, the largest growth on record. But primary care physicians say that cost concerns are bringing more emergency cases to their practices.
For instance, Sergio B. Seoane, MD, a solo practice family physician in Lakeland, Fla., said more people have come into his office with broken wrists in the past 18 months than during the past decade. Two patients even limped in with broken hips.
"They are calling and seeing if they can come in today or the next day," Dr. Seoane said. "That never happened before. These people would have generally gone to the emergency department."
In such situations, he does the x-ray in his office and refers them to the emergency department or a specialist.
Physicians who run urgent care centers also have noticed growth in patient volume because convenience has become more important than ever as people fear losing a job if they take too much time off from work. Some of this growth has been tempered by patients putting off accessing services or trying to care for themselves.
"Patients are self-medicating," said Nathan Newman, MD, a family physician and chief medical officer with Solantic, which runs 32 urgent care centers in Florida.
Industry watchers say these trends may continue even if the economy recovers, because patients with employer-provided health insurance are paying more out of pocket for care.
"It's not clear whether we've reached a new normal or this really is a function of the economic downturn," said Larry Levitt, senior vice president of the Kaiser Family Foundation. "Even if the economy comes back, cost-sharing is not going to go down."
A report issued Nov. 15, 2011, by the Kaiser Family Foundation said visits to physician offices by insured patients declined 17% from the second quarter of 2009 to the second quarter of 2011 to 129 million visits.
Although workplace injuries have decreased during the recession, "the message is not that unemployment is good for us," said Ellen MacKenzie, PhD, professor of health policy and management at Johns Hopkins University in Baltimore and former director of the institution's Center for Injury Research & Policy.
Meanwhile, the number of people injured because of violence in the workplace has been edging up, from 16,560 in 2003 to 16,910 in 2010, according to the BLS. The agency recorded 180 workplace suicides in 2005, when the economy was doing well. That grew to 258 in 2010.
Other studies have documented increases in injuries related to abuse and violence as well as significant impacts on mental health.
A report in the October 2011 Pediatrics found that the number of children under age 5 treated for abusive head trauma went up during the recession. A study in the December 2011 American Journal of Public Health linked mortgage delinquency among people over 50 with an increased risk of symptoms of depression, worse health status and problems accessing care. A report in the November 2011 Psychological Medicine correlated home foreclosure rates with symptoms of major depression and generalized anxiety disorder.