More heart attacks, fewer breast implants. More ER visits, fewer trips to the doctor's office. More aspirin, fewer echocardiograms. And many people are afraid to miss work for healthcare because they fear it might cost them their jobs.

A doctor walks through a mock graveyard at a rally against health care cuts in February 2009 in San Francisco. (AFP/Getty Images/File/Justin Sullivan) That's the anecdotal evidence from several dozen healthcare providers in South Florida about how the deepening recession is effecting treatment.

While it has been well-publicized that many people are losing health insurance when they lose their jobs, doctors and hospital leaders have been surprised about how many who still have coverage are scrimping on care because they can't afford the co-pays or time away from work.

Take South Dade Realtor J. Berry Hamilton, 57. She's gone to a policy with a $5,000 deductible, meaning she has to pay most costs out of her own pocket. Recently, she brushed off her doctor's request for a diagnostic exam when she got a sinus infection. As her business has declined, she figures: ``Let me see if the antibiotic works first, and if it doesn't then maybe I'll have the X-ray.''

''Patients are spending less, no question about it,'' says Bernd Wollschlaeger, a primary care doctor in North Miami Beach. ``A patient needs a echocardiogram. And they say they can't afford the $100 or $200 co-payment, so they're deferring. In the long run, this just can't be good for healthcare.''

People are certainly pinching their pennies. For the five hospitals in Baptist Health South Florida, Vice President Karen Godfrey reports that patients are now hesitating on tests and procedures even with co-pays as low as $15, ``which is very surprising.

''One of the registration managers was telling me some are negotiating for services. If a woman gets a prescription for a mammogram and an ultrasound, she wants to know the co-pay for both,'' then pick the test with the cheaper co-pay.

Some experts wonder whether stress caused by economic worries is leading to more heart attacks. South Florida facilities in the HCA hospital chain, which include Aventura and Plantation General, reported seeing 20 percent more heart attack patients in the fourth quarter.

At Baptist Hospital, Becky Montesino, vice president for nursing, says, ``we have experienced an increase in all cardiac and stress related illnesses. . . . In two of the months thus far we have seen double the STEMIs [a type of heart attack] over last year.''

Some other large hospital groups, however, are not seeing any change in heart attack rates, and the Centers for Disease Control, which collects health data, says it will be several years before 2008-2009 statistics become available. Still, a Plantation interventional cardiologist, Murry Drescher, believes the recession is taking a toll on the heart.

''I've noticed a lot more heart attacks over the last six, seven months,'' says Drescher, who is on call for Broward emergency rooms to insert stents to prop open clogged arteries of heart-attack patients.

''Stress is worse than high cholesterol. Especially the kind of stress that you can't do anything about -- like when you can't find a job or you're in a financial hole you can't get out of,'' says Drescher.

For some, the stress comes in dealing with expensive care. ''As a man in my mid-40's living in South Florida, I'm as angry as I am terrified,'' says Kevin Dunleavy, a contract worker in Key West, who knows that in today's economy he may soon be unemployed and uninsured.

His insurance deductibles keep going up, and his care keeps going down. ''I've always been proactive about healthcare: Early detection is best.'' But now he's thinking he needs to save his money for unforeseen circumstances.

When he hurt his toe in an accident, he went to rehab until the insurance stopped paying. He's still in pain, but he refuses to pay $200 for each rehab session. ''When it hurts, every step you're reminded of it,'' says Dunleavy, ``but that's just the way it is.''

Many women, meanwhile, are deciding against cosmetic surgery, which is rarely covered by insurance. Stephan Baker, a plastic surgeon in Coral Gables, is one of several who reports seeing a ''significant drop in breast augmentation. It's one of those luxury items'' that women often can't afford now.

Breast implants tend to be a younger woman's concern -- something that can be put off, says Baker. ''They're nervous about spending the money. We are hearing a lot of requests for financing. And everyone's shopping around. A lot of requests for discounts, trying to find a decent deal.'' He says he occasionally offers a discount, ``We're trying to offer some flexibility without being too silly about it.''

Face lifts tend to be older women, who have sometimes saved up, says Baker. 'They're in a better financial position to start with, and they think there's more of a sense of timing. `I'm 65. I'm not going to wait until the recession is over.' ''

EYES ON THE PRICE

Another area of decline: The University of Miami reports fewer people are seeking Lasik eye surgery to correct their vision because that's usually something the patient pays for.

Last fall, as the economic crisis exploded, Mercy and the five hospitals in Baptist Health South Florida saw spikes in some outpatient procedures. ''We had a very strong October,'' says Godfrey at Baptist. ``That surprised us a little bit.

''I would guess to some extent people were rushing to get elective services done while they still had a job and still had insurance.'' But then Baptist system saw a ''significant drop'' in outpatient services in November.

Meanwhile, the Memorial Healthcare System, Baptist and Mercy report that ER patients tend to be sicker these days. ''We are seeing the phenomenon of very sick people waiting too long to seek treatment for fear of missing work,'' says Baptist's Montesino.

They're also more likely to seek free care as the ranks of the uninsured grow. Charity care for the five hospitals in Baptist Health South Florida is up 27.9 percent in the most recent quarter compared with the same period a year ago. In South Broward, people seeking treatment in Memorial's public clinics has risen 27 percent in the past year.

SAME STORIES

Everywhere, administrators are being told the same stories. At the Memorial system, which has seen a significant decline in outpatient procedures, in everything from hand surgery to arthroscopic procedures on the knees, Chief Financial Officer Matt Muhart says: 'We're hearing two things. No. 1: `I don't have the money for the deductible.' No. 2: 'My job pays me when I'm there. I don't want to take a week off. I don't want to be noticed as missing, anything that interrupts the natural flow of things. I'm worried my boss isn't going to keep me around.' ''