Health care is not immune to the economic downturn. In a recent survey of 349 physicians, RBC Capital Markets found 40 percent expect fewer patients will seek treatment.

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Health care has lived up to its reputation as a defensive sector — sort of. But its 24 percent drop this year, compared with a 35.6 percent loss for the S&P 500, is hardly something to cheer about.

Health care is not immune to the economic downturn. In a recent survey of 349 physicians, RBC Capital Markets found 40 percent expect fewer patients will seek treatment.

Most predict higher generic-drug use, a potential blow to big pharmaceutical firms, while nearly 80 percent forecast problems with bill payments.

Physicians and hospitals also expect to spend less on medical equipment. In a Credit Suisse survey of 50 hospital executives released in October, three-quarters said they’d seen increases in bad debt, with nearly 20 percent saying it “increased significantly,” says analyst Ralph Giacobbe.

Last week, Tenet Healthcare released disappointing results, hurt by higher bad debt and a decline in managed-care admissions.

Morningstar analyst Jeffrey Stafford says these non-Medicaid patients with “high copays and deductibles are delaying nonemergency care, hurting hospital profitability and pricing.”

Some health-care stocks are less vulnerable to the downturn than others. In a recent report, RBC’s Kantor outlined defensive characteristics to look for, as well as red flags.