Reducing Poverty In Primary Care: What all Family Doctors Can do to Address Their Patients’ Poverty

1. Reducing Poverty In Primary Care: What all Family Doctors Can do to Address Their Patients’ Poverty Gary Bloch MD CCFP St. Michael’s Hospital DFCM Assistant Professor, DFCM, UofT

2. funding and collaboration St. Michael’s Hospital Family Medicine Associates Linda Rozmovits PhD, Qualitative Researcher Broden Giambrone MHSc, Research Assistant

3. objectives Examine arguments for intervening in poverty in primary care. Explore practical ways primary care health providers can intervene into poverty, with an emphasis on tools for use in the family practice office.

4. Outline • Arguments for addressing poverty in primary care and some evidence – 15 minutes • Understanding the reality of living in poverty – 5 minutes • A three step approach to addressing poverty in our offices – 30 minutes

5. arguments for addressing poverty in primary care

6. argument 1: this is required by the fundamentals of family medicine

7. Principles of familymedicine • “... understanding of human development and family and other social systems to develop a comprehensive approach ...” • “... responsibility to advocate public policy ...” • “... an understanding and appreciation of the human condition.”

8. in the scientific literature Dionne S. Kringos et. al., “The breadth of primary care: a systematic literature review of its core dimensions,” BMC Health Services Research 2010, 10:65: “The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency of care; and 10. equity in health.” (among 10 overall dimensions of primary care).

9. and by the academy Future of Medical Education in Canada (2009) • Address Individual and Community Needs • Social responsibility and accountability are core values … physicians and faculties must respond to the diverse needs of individuals andcommunities throughout Canada

10. argument 2: poverty is a major risk factor for disease, so requires intervention

11. risk factors for disease routinely addressed by family medicine poor diet lack of exercise alcohol and drug use high risk sexual behaviour We routinely screen for and intervene in these risky behaviours ... Should poverty be treated as an equivalent risk factor, similarly warranting intervention?

12. argument 3: poverty is a disease or illness or disorder, and warrants treatment like any other

13. what are comparable “diseases”? • Are high blood pressure, diabetes, high cholesterol diseases? Disorders? Risks for disease? • Place people at high risk for disease ... only directly cause illness at extremes • Is poverty similar? ... Let’s look at the evidence

14. the big picture “There is strong and growing evidence that higher social and economic status is associated with better health. In fact, these two factors seem to be the most important determinants of health.” Public Health Agency of Canada, Social Determinants of Health (2004)

15. Person Years of Life Lost Wilkins R, Berthelot J-M, Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Reports (Statistics Canada). 2002:13(Supplement): 10. Adapted from: Dennis Raphael %

16. Cardiovascular Disease • Prevalence:17% higher than Canadian average. • Mortality: If everyone had the mortality rates of the highest income category there would be 21% fewer premature CVD deaths per year in Toronto. Lightman, E., Mitchell, A. & Wilson, B. (2008). Poverty is making us sick: A comprehensive survey of income and health in Canada. Wellesley Institute. City of Toronto. (2008). Unequal City: Income and Health Inequalities in Toronto (http://www.toronto.ca/health/map/pdf/unequalcity_20081016.pdf)

17. How much of Cardiovascular disease mortality is poverty estimated to be responsible for? On par with smoking and hypertension Peter Tanuseputro, et. al., “Risk Factors for Cardiovascular Disease in Canada,” Can J Cardiol 2003; 19(11):1249-1259. 1-2% 5-10% 15-20% 25-30%

18. Diabetes • Prevalence: Lowest income more than double highest (10% vs. 5% men, 8% vs. 3% women). • Mortality: Women 70% higher (17 vs. 10/105); Men 58% higher (27 vs. 17/105). Bierman, A.S., et. al. (2009). Burden of Illness. In: Bierman, A.S., editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto.

19. Mental Illness • Prevalence: Consistent relationship between low SES and mental illness. • Depression: Prevalence 58% higher than Cdn average (14.5% vs. 9.2%). • Suicide: Attempt rate on social assistance 18 times higher than higher income individuals. Fryers, T., Melzer, D., & Jenkins, R. (2003). Social inequalities and the common mental disorders: a systematic review of the evidence. Social Psychiatry and Psychiatric Epidemiology, 38, 229–237. Smith, et. al., (2007) “Gender, Income and Immigration Differences in Depression in Canadian Urban Centres,” CJPH, 98(2): 149. Lightman, E., Mitchell, A. & Wilson, B. (2009). Sick and Tired: The Compromised Health of Social Assistance Recipients and the Working Poor in Ontario. Wellesley Institute.

20. Cancer • Prevalence: Higher for lung, oral (OR 2.41), cervical (RR 2.08). • Mortality:Lower 5-year survival rates for most cancers. • Screening: Low income women are less likely to access mammograms or Paps. Krzyzanowska, M.K., et. al. (2009). Cancer. In. Bierman, A.S., editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto. Conway, D.I., et. al. (2009). Significant oral cancer risk associated with low socioeconomic status. British Dental Journal, 206(6), 2811-2819. Shack, L., et. al. (2008). Variation in incidence of breast, lung and cervical cancer and malignant melanoma of skin by socioeconomic group in England. BMC Cancer, 8, 271. Singh, G.K., et. al. (2003). Area Socioeconomic Variations in US Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975-1999. NCI Cancer Surveillance Monograph Series, No. 4. NIH Publication No. 03-5417. Bethesda, Md: National Cancer Institute.

21. pregnancy and infancy • Prevalence of Low Birth Weight: 43% higher • If all babies in Toronto were born with the LBW rate of the highest income categories there would be 1,300 or 20% fewer singleton LBW babies per year. Wilkins et. al. (2002). City of Toronto. (2008).

22. Other Chronic Conditions Bierman et. al. (2009).

23. children • Growing up in relative poverty associated with increased adult morbidity and mortality from: • stomach, liver, lung CA; diabetes; CVD; CVA; respiratory diseases; nervous sx conditions; GI disorders; alcoholic cirrhosis; unintentional injuries; and homicide. • Children living in poverty suffer cumulative health effects throughout their lifespans, regardless of later socioeconomic status Currie J, Lin W. (2007). Chipping away at health: more on the relationship between income and child health. Health Affairs, 26(2), 331-344. Lemelin, E.T., et. al. (2009). Life-course socioeconomic positions and subclinical atherosclerosis in the multi-ethnic study of atherosclerosis. Soc Sci Med., 68(3), 444-51. Emerson, E. (2009). Relative child poverty, income inequality, wealth, and health. JAMA, 301(4), 425-6. G. Davey-Smith & D. Gordon, “Poverty across the life course and health,” in Pantazis, C. and Gordon, D. (Eds), Tackling Inequalities: Where Are We Now and What Can Be Done?, 2000, Bristol, U.K., Policy Press.

24. Isn’t it Just that Poor Health Causes Poverty? “All [the studies reviewed] conclude that … the main direction of influence is from poverty to poor(er) health.” Phipps S. The impact of poverty on health: a scan of the research literature. Ottawa: CIHI; 2003.

25. Isn’t it just poor people’s unhealthy lifestyles? “lower income ... leads to a significant increase in mortality risk, yet the influence of major health risk behaviors explains only a modest proportion of this relationship.” “It is not the consciousness of men that determines their existence, but their social existence that determines their consciousness.” Paula M. Lantz; James S. House; James M. Lepkowski; et al., “Socioeconomic Factors, Health Behaviors, and Mortality: Results From a Nationally Representative Prospective Study of US Adults,” JAMA. 1998;279(21):1703-1708. Karl Marx, A Contribution to the Critique of Political Economy, Progress Publishers, Moscow, 1977.

26. so is poverty a disease? • Just like high blood pressure, diabetes, cholesterol: • Puts sufferers at risk of high morbidity and mortality through various pathways • No other cause accounts for all the elevated risk • At extremes it can cause direct harm • Groups that move out of poverty experience a decrease in disease • The finding is consistent across time, geography, and different population groups ...

27. why intervene in poverty? A disease? An illness? A risk factor? On the basis of principles of family medicine? If one of these arguments holds water, we should be treating poverty But can we do anything about it???

28. interventions into poverty

29. First: Understand the reality!!! “[Family doctors] might see [poverty] ... in terms of a theoretical academic construct but I don’t think they’d actually understand the real reality of it in terms of what it actually means for a person to get X amount of dollars and be forced to try to live on those dollars.” -- Community Worker, Low income Drop-in Centre, Toronto

30. ©Edward Gajdel, www.edwardgajdel.com

31. ©Edward Gajdel, www.edwardgajdel.com

32. ©Edward Gajdel, www.edwardgajdel.com

33. What is the average monthly income for a single individual on OW? $ 585 $ 735 $ 925 $1,125

34. What does that translate to for a daily budget? Pinto, A., G. Bloch, J. Polsky, T. Svoboda. “Paying for food after other expenses: social assistance recipients in Ontario,” Submitted for publication. Toronto, ON: 2010. OW recipients report having less than $1 per day to spend on food. ODSP recipients report having less than $4/day..

35. three Steps to addressing poverty in primary care Screen Adjust Risk Intervene to increase income

36. Step 1: Screen “I suspect that most physicians would be reluctant or it would not be in their consciousness to enquire about people’s economic circumstances, employment, income, debt, nature of their housing ... it’s not in people’s consciousness to look, to gaze beyond the individual patient and try to see what the circumstances of their life are that might be making them sick.” -- Family Physician, Inner City Toronto

37. Why Screen • Poverty is often hidden ... we can’t make assumptions • Poverty is everywhere … in Toronto, 29% of families live in Poverty • Poverty affects health on a gradient: Income negatively affects the health of all but the highest income patients. United Way (2007). Wilkinson, R. (2003). Social determinants of health: the solid facts. 2nd edition. World Health Organization Report.

38. Step 1: Screen Screen everyone!!! “Do you ever have difficulty making ends meet at the end of the month?” (Sensitivity 98%, Specificity 64% for living below the poverty line) Brcic, Vanessa and Caroline Eberdt, “Developing a tool to identify poverty in a family practice setting,” Unpublished. Vancouver, BC: 2009.

39. “why can’t there be tick boxes for socio-economic status, housing status, employment status ... when people are audited by the regulatory bodies for meeting adequate standards of care those boxes should be completed. If they’re not then the doctor can be told, “You’re not meeting the standard of care” ...” -- Family Physician, Toronto

40. Screening Tools - CPP

41. Screening Tools - AHE

42. Step 2: adjust Health Risk If a patient smokes, does that change your screening and diagnostic decision-making? Should poverty similarly affect clinical decision-making ...

43. two cases • A 41-year-old woman with no PMHx, no FHx, non-smoker presents with occasional Right CP on exertion, variably reproducible on chest compression. • Would you order a stress test? • What if she were a smoker or had high cholesterol? • What if she has lived on social assistance for 5 years? • A 38-year-old man without FHx of diabetes, not obese, no PMHx, presents for an annual health exam. • Would you order a fasting Glucose? • What if he only earns $12 000/year, through part time work?

44. See Clinical Tool Step 2

45. Step 3: income nterventions • With Individual patients (our focus today) • With our communities

46. a case • 42yo woman, single mother of a 5 year old. • New patient, no previous family MD. Complains of occasional SOB, fatigue, generalized muscle aches, vague abdominal discomfort. • Works part time, earns $12 500/year. Rents bachelor apartment, $600/mo. • Should we consider intervening into this woman’s poverty directly? Is this likely to improve her health? How can we intervene?

47. interventions requiring direct physician input Disability applications: ODSP, CPP-D, WSIB Welfare supplements: Transportation, Medical Supplies, Special Diet Disability Tax Credit application

48. these interventions require specific knowledge and skills • e.g. ODSP: • Do you know the eligibility criteria? • Do you know who assesses the forms you fill out? • Do you know what health conditions are likely to automatically qualify a patient for ODSP? • Do you know how to increase your patient’s likelihood for acceptance on the first try? • Do you know the initial rejection rate, and the acceptance rate on appeal? • Do you understand the appeal process? www.cleo.on.ca/english/pub/onpub/PDF/socialAsst/ods-prof.pdf

49. indirect interventions ... A few questions with big impact (see tool) For everybody: Have you filled out and mailed your income tax forms??? For Low Income Seniors: Do you receive Old Age Security and Guaranteed Income Supplement? For Families with Children: Do you receive the Child Benefit on the 20th of every month? For people with Disabilities: Do you receive Disability Benefits?

50. Filing a tax return ... the key to income supports The Toronto Star, Feb. 20, 2010