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Avoiding the doctor's office

Somewhere in the midst of the national conversation about health care costs and effective, evidence-based care, Americans started going to the doctor less often.

Surveys and reports have been trickling in for at least three years, documenting a persistent decline in the number of office visits and the slowest spending growth on office-based physician services since 1960.

Just how pervasive this trend has become was summed up last week by American Medical News, which reviewed several studies and found one thing in common: Patients are staying away from the doctor's office because they're afraid of being saddled with a large bill.

From the article:

Even two years after the official end of the recession, the studies report patients struggling to handle medical bills, or fearing they won't be able to handle them. Physicians might not notice the decline on a day-to-day basis - perhaps it's one or two fewer patients a day - but the numbers add up over time.

The evidence goes contrary to the popular belief that most Americans seek medical care for anything and everything and are spending the health care system into oblivion.

In one of the studies cited by American Medical News, the Centers for Medicare and Medicaid Services found that national spending on health care increased by 3.8 percent in 2009 and 3.9 percent in 2010. This was the lowest in years, and reflects slowdowns in almost every category, from office visits to prescription drugs to hospital procedures.

The decline in office visits isn't just among the uninsured; it also includes those with health insurance. What's particularly worrisome, according to a Commonwealth Fund study issued late last year, is that many of the individuals avoiding the doctor's office are sicker and might not be receiving needed care.

I was interested to learn recently that the we're-all-spending-less-on-health-care trend apparently isn't confined to the human species. The American Pet Products Association reported this month that spending on veterinary services in the U.S. is growing only in the single digits and is projected to slow in 2012.

It's not hard to draw the obvious conclusion: The recession has taken an enormous toll on people's financial security and they're attempting to cut costs wherever they can.

I suspect there's more going on here than simple economics, however, and a recent column at The Health Care Blog more or less reinforces this. In a piece titled "It's NOT the Economy, Stupid!", J.D. Kleinke of the American Enterprise Institute writes that health care spending "has been cooling, slowly and steadily, since 2002."

Oops! Turns out the recession has had nothing to do with a 10-year trend - one driven not by government inaction and then the recession and threat of "ObamaCare" - but by slow, steady, cumulative improvements in medical care and, as importantly, by the introduction of marketplace disciplines into the demand for and purchase of that health care.

Kleinke also posits that what we're seeing is "health care simply self-correcting, slowly and tediously, nearly a decade after the failure of the great managed care experiment of the 1990s."

He makes a number of compelling points. I'm not convinced, though, that "marketplace disciplines" are solely responsible for what's happening. More Americans are uninsured, probably because of increasingly unaffordable premiums and deductibles, the recession or both, and people who are uninsured generally are slower to seek care. I'm also sensing a growing backlash among people who feel health care in the U.S. has become too aggressive and who are becoming more outspoken about the need for a "less is more" approach.

Or maybe what's really happening is what a Health Care Blog commenter described as "a tired, bloated industry running out of gas."

Either way, some caution is called for. The decline in physician office visits could be good if it means medical practices are being more efficient about when and how often patients need to be seen, and patients are thinking twice about the necessity of the visit. But it could be not so good if it means people are avoiding or delaying necessary care - and possibly incurring higher costs for problems that are allowed to escalate into something worse.

In health care, cost and utilization are closely intertwined. It's hard to change one without changing the other. Ideally, there should be a point of equilibrium, but we haven't found this yet and may not ever reach it. In the meantime, lower cost and utilization do not automatically equate to a healthier population. This seems to be a case of being careful what you wish for.