BANGOR, Maine — Things are not good in the auction business right now. Linda Payson, owner of the Brooder House Auction Service in Union, knows this firsthand.
“We thought in December this could be a very busy year, as people would be digging out everything that wasn’t nailed down to sell for cash,” she wrote in a recent e-mail. “Wrong.”
The reason?
“Well, I’m guessing it’s closely tied to the nonexistent real estate sales. If no one is moving, or selling the house of a deceased loved one, they do not need the items sold,” she said.
Recently, Payson took an outside job that provides health coverage for her and her family. But until that happened, she wrote, many of their health care needs got put on the back burner.
It’s a situation more and more Mainers are facing: deferring the frontline health care they know they should have, putting themselves at risk for worse problems — and greater expense — farther down the road. The economic downturn has only worsened their ability to pay for health care or insurance.
Payson’s husband hadn’t had a physical exam for about 25 years. They worried about prostate cancer and knew he should be screened.
“It’s a risk to go without it, but we just can’t afford the initial visit or the costs of any serious testing at this time,” Linda Payson wrote.
The couple’s 19-year-old son has allergy problems, which worsened over this past winter. They tried to manage his symptoms with inexpensive over-the-counter medicines, but finally “had to take the plunge” and schedule a medical appointment.
Payson herself underwent a hysterectomy four years ago, and only recently finished paying off the bill. Since then, she hasn’t had a mammogram, a Pap smear, any other recommended routine screenings or a general physical exam.
“It’s a huge risk, but what can you do? We just can’t afford it,” she said.
It’s not a new story, according to one local health care official, but the overarching economic crisis adds a nasty twist.
“Anytime there is an economic recession, there will be a more cautious use of health care resources, especially on the elective side,” said Dr. James Raczek, vice president and chief medical officer at Eastern Maine Medical Center in Bangor.
“The difference today is that we already have more economic responsibility on patients” in the form of higher monthly premiums, co-pays, deductibles and other out-of-pocket costs, as well as a growing number of people without any coverage at all, he said.
The upshot is that many Mainers — even those with insurance coverage — may forgo nonessential health care. Those without coverage, as the Paysons were, are likely to postpone treatment until symptoms become intolerable or a crisis hits. And hospitals — committed to providing care to all regardless of ability to pay — see more critically ill patients and more who cannot pay their bills in the high-cost emergency department.
Raczek said EMMC has seen a small reduction in recent inpatient admissions, while emergency room visits, day surgeries and outpatient procedure schedules have stayed full.
“Where we have seen the most decrease is in patients extending the time between visits to their primary care providers,” he said. Instead of scheduling a follow-up visit for the assessment and management of chronic diseases such as diabetes or heart disease, he said, some cash-strapped patients will simply call for a refill of their prescriptions in order to save the cost of the office visit. Others just fall off the radar — not being seen, not taking their medications, not complying with diet and exercise recommendations.
These invisible patients are the most likely to get into serious trouble, Raczek said.
Ironically, current economic pressures are driving patients away from their primary care providers just at a time when the medical world is underscoring the importance of primary care as a way to hold down costs and improve health.
The concept of a “patient-centered medical home” is catching hold, with many primary care offices in Maine exploring ways to provide more support, not less, to patients with chronic illnesses. Many studies show that patients whose care is well managed are less likely to become acutely ill and wind up in the emergency department or on an inpatient unit. But many effective interventions — such as using in-home technologies to provide vital signs and other data to the doctor’s office, or making follow-up phone checks to patients with new prescriptions — are not paid by insurance companies or public payers such as Medicare or Medicaid.
Raczek said it’s too early in the medical home movement to have reliable procedures in place to compensate for the current decline in patient visits. But especially in these hard financial times, he said, primary care physicians have a responsibility to assess their patients’ financial ability to afford medications, eat appropriate foods, return for scheduled checkups and in other ways comply with recommended treatments.
Persuading overscheduled doctors to adopt this important — but time-consuming and unbillable — financial assessment can be a challenge.
“We need a revolution in how medicine is paid in this country,” Raczek said.
That revolution might help people like Dan Williams of Bangor, a 61-year-old sign language teacher and interpreter who hasn’t been able to afford health insurance for years. Slowing demand for his services means he thinks twice about paying out-of-pocket health costs — even when the stakes are high.
When Williams recently broke out in a cold sweat accompanied by chest pain, nausea and shortness of breath — classic symptoms of an acute heart attack — a friend wanted to call an ambulance.
“I told her, ‘No, I don’t have insurance,’” Williams recounted in a recent interview. But when his symptoms worsened over the next few minutes, the friend called anyway — which turns out to have been a good thing.
“I flat-lined on the way to the hospital,” Williams said. Within a couple of days, he had racked up a $25,000 hospital bill — not including his physicians’ fees or the cost of the ambulance ride that saved his life. Added to his other unpaid medical bills — for an emergency room visit related to his diabetes, among other things — Williams owes something like $35,000. He’s paying it off a little at a time, but declining to undergo any unnecessary care.
“My doctor wants me to have a colonoscopy,” he said. “But it would cost me about $2,800, and I just can’t take on another doctor’s bill.”
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