Last fall when I visited Canada, I met a Toronto doctor named Gary Bloch who has developed a poverty tool for medical practitioners. The tool assesses what patients might need other than prescriptions for the newest drugs. Bloch's idea was to zoom in on the social determinants of health -- food, housing, transportation -- all poverty markers linked to bad health and poor health outcomes.
The tool, a four-page brochure, notes that poverty accounts for 24 per cent of a person's years of life lost in Canada and offers three steps for doctors to address poverty. The first step is to screen every patient by asking them, "Do you ever have difficulty making ends meet at the end of the month?" The next two steps urge clinicians to factor poverty into clinical decisions like other risk factors and to ask questions about income support by age/family status, such as whether seniors have applied for supplemental income benefits they may be entitled to.
"We've created an advocacy or interventional initiative aimed at changing the conversation about poverty and how doctors think about poverty as a health issue," Bloch explained. "It's one of those cultural shift things."
The first blog post I wrote about Bloch and his "diagnosing poverty" tool received more than 3,000 hits on the Prepared Patient blog. Clearly, his message resonated in the U.S. and Canada. I wanted to circle back to Bloch and see whether a cultural shift in Canada was really taking place. Indeed it is. I was wowed by the acceptance of an intervention that seems so simple and could maybe lead to better health. "It's been a wildfire effect," Bloch told me.
Bloch ticked off a laundry list of provinces and organizations that were using or about to use the tool. He described a "pretty amazing" and broad coalition that came together to promote the tool, including public health leaders, pediatric and family doctors, community health centers and regional health authorities. A doctor in British Columbia has developed a version for his region. Manitoba is about to roll out its own adaptation. A public health officer in Nova Scotia is pushing for the tool in that province. The tool is getting attention is Saskatchewan, too.
Physician groups have signed on, like the College of Family Physicians Canada and the Registered Nurses' Association of Ontario. The Canadian Medical Association (CMA) has developed a continuing education module based on these poverty interventions. On his website, CMA president Dr. Chris Simpson says, "Dr. Gary Bloch is one of those guys who walks the talk and speaks about 'prescribing money' as a way to help patients who are economically disadvantaged."
Simpson told me that Bloch's approach is the first clinically relevant tool to address social determinants of health. To support Bloch's work, the CMA's conversations and advocacy about the tool are heightening awareness among Canadian physicians that they need to address these risk factors. Simpson added that Bloch and his team also conduct trainings to help doctors learn how to use the tool.
In a phone interview last week, Bloch observed that adding the steps in the tool to clinical practice is just a beginning. "It was never an end unto itself. It was a stepping stone to other interventions." Bloch described what his family health group in central Toronto is doing. They hired an income security health promoter who meets with patients about their financial situations and works with them on becoming more financially literate. She works with the rest of medical team to acquaint doctors with patients' needs. For example, a person with diabetes without adequate housing will have trouble storing healthy food and insulin supplies.
Bloch and his team are beginning to study the tool's impact with a randomized trial and collecting data on the social determinants of health for people in central Toronto. "This will allow doctors, health planners and epidemiologists to draw out data and learn about who they are serving," he said.
The American Academy of Pediatrics and the Academic Pediatric Association are considering adopting some aspects of Bloch's tool and are studying the development of a poverty curriculum for physicians. There are also a few programs like "Health Begins," which is a group of doctors working on treating social and economic causes of poor health. But the U.S. has a long way to go to match the progress of Canada.
Differences in our two health insurance and payment systems may account for lack of interest or movement in the U.S. "We feel rooted in the communities we serve," says Bloch. "We're not worried about insurance for the patients we provide care to."
In the U.S., even with the Affordable Care Act offering access to care to more people, doctors should pause to consider how high deductibles and other out-of-pocket costs affect low income patients. "Will patients be able to afford the care they need?" is still very much an open question.
In the U.S., we don't like to talk about any aspect of the Canadian health system unless it's waiting lists. It would be great if next year I could report there was real progress in the U.S. towards embracing the poverty tool that Gary Bloch has moved his profession to adopt across Canada.
This first appeared in the Prepared Patient Blog.
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