When Patients Finally Get Care They Postponed, Might It Come Too Late?

Cheryl Clark, for HealthLeaders Media , April 16, 2009

With so many patients deferring routine screening or medical attention for their aches and pains, will it eventually be more difficult to give, or too late?

Will treatment be more complex, with longer and poorer recovery, more invasive with longer stays in acute settings, higher risk of infections and other unintended consequences? Will it then be more expensive for everybody?

Might undetected cancer be given time to spread or untreated cholesterol turn into life-threatening artery blockages, or high blood pressure evolve to a stroke?

Lots of questions but few answers with hard data so far, physicians and hospital officials say. The economic downturn is still too short-lived. It depends on how long it lasts, how long patients put off care, and whether the Obama administration will find any broad solutions.

But there is no question that the volume of patients seeking care is down in physicians' offices.

In hospitals, elective procedures are down 31% between the third quarter of 2008 and the third quarter of 2007, according to an American Hospital Association survey last November. Admissions are down 38%. And that can't be anything but harmful to public health.

Patients are putting off regular mammograms, colonoscopies, pap smears, blood sugar, and cholesterol tests.

Dr. Robert Epsten, gastroenterologist in San Diego, worries about his many patients he said haven't gotten necessary colonoscopies over the last year because, they told him, they can't afford their $250 deductibles or $30 co-pays.

"It takes seven to 10 years for a polyp to become cancerous," he says. "But the problem is that you don't know until you see the patient where they are in that time frame. We like to say, only two things can happen when you don't get a colonoscopy: nothing or something very bad."

And they also are putting off procedures.

"We are seeing patients delay treatment for things like torn rotator cuffs or knee cartilage, because they lost insurance or can't afford to miss work because a spouse was laid off or work is spotty," says Longview, WA, orthopedic surgeon William Turner, MD.

"Paradoxically we also get patients who are pressing to have surgeries that seem premature because their insurance is running out in a few months," he says.

Marc DeHart, MD, an orthopedic surgeon based in Austin, TX, says, "The people we worry about are those rare cases with gnawing, aching pain that is really a tumor, that isn't known without expensive diagnostics." When patients lose their jobs and become uninsured or are strapped for cash, they do defer care, he adds.

"Our elective cases are down 20% to 30%" between the first quarter of 2008 and the first quarter of 2009," DeHart says. "If they had the resources, they might come in sooner, but they may put it off. And this economy makes that problem worse."

DeHart says he hasn't noticed a decline in patients getting hip or knee replacements so far. That may be because those surgeries in general occur in people who are eligible for Medicare, and by the time they come in, they really need those operations.

"When people think of having an operation that big, they're waiting until they're ready and they can't go on much further without having that done," he said. "They wait until they can't walk anymore," DeHart says.

But for those who are cash strapped or uninsured, many stoically soldier on, enduring pain, perhaps engaging in activities less or not at all.

Even if they still have insurance, the economic crisis may mean the money they would have spent on medical or drug co-payments must be used instead for rent or mortgage payments.

Cecil Wilson, an internist in Winter Park, FL, and American Medical Association board member, says it's a fair assumption that in general, people who postpone care will need it more acutely when they finally get it.

"We do know from studies that people who approach Medicare age and know they'll be covered by Medicare, may put off care" until age 65, he says. "There's always a boost in the amount of care they need then."

"We already know that the reason we treat these diseases early—especially high blood pressure and diabetes—is that untreated down the road we see an increased risk of heart attacks and strokes. Interruptions in regular care and treatment do put patients at risk," Wilson says.

"We have the evidence that the sicker people are when they do get care, it's usually in a much more expensive setting like an emergency room, and there's a higher risk of complications down the road. There's a higher risk of dying," Wilson says.

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

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