Why doctors should screen for poverty

“A 41 year-old woman with no documented medical history or family history of disease presents to you complaining of occasional chest pains on exertion. How many would order a stress test to rule-out cardiovascular disease?” asks Dr. Gary Bloch, to a captivated audience of resident physicians currently in training at an academic learning day – a few hands go up.

“Now how about if she were a smoker or had high cholesterol?” – several more hands go up. “Now how about if I told you she earned less than $12 000 per year through part-time work, while renting a $600 per month bachelor apartment?” While some more put their hands up, many in the group look at each other, unsure of how this information would impact their diagnostic decision-making.

Dr. Bloch, a family physician at Toronto’s St. Michael’s Hospital and a founding member of Health Providers Against Poverty (HPAP), is an advocate for poverty screening.  “Just as screening is important for other conditions or risk factors, like smoking, high cholesterol or domestic violence, so too is screening for poverty,” he says. Dr. Bloch and HPAP have been instrumental in producing a primary care intervention tool on poverty that is now endorsed by the Ontario College of Family Physicians and will likely soon be made available to every Family Physician in the province of Ontario for use in clinical practice.

How do healthcare and poverty interrelate?  Why bother with poverty reduction as a health intervention?  Because everyone should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education or ethnic background.  We know that families struggling to get by face considerable barriers in making healthy lifestyle choices, and people’s health is significantly affected by the quality of their homes, jobs and schools.  In Canada, where I am a resident physician in Family Medicine, low income has been shown to account for 24% of person years-of-life lost, second only to 30% for neoplasms, out of all potential causes of illness.  I suspect things are probably not so different in the United States.  Dr. Bloch points to a growing body of research evidence showing the impact of financial struggle on the risk of a variety of diseases (this research is largely Canadian, so US statistics will differ, though the themes are likely similar):

  • Cardiovascular disease: there is a 17% higher rate of circulatory conditions among the lowest income quintile versus the average
  • Diabetes: prevalence among the lowest income quintile is more than double the rate in the highest income quintile
  • Mental Illness: the suicide-attempt rate of those living on social assistance is 18 times higher than higher-income individuals
  • Cancer: low-income women are less likely to access screening interventions like mammograms or Pap Smears
  • Development: infant mortality is 60% higher in the lowest income quintile neighborhoods

Regardless of this compelling evidence, why is there a need to screen for poverty? “Simply because we don’t know which patients live in poverty and if we don’t ask, we won’t find out,” says Dr. Bloch.  Since the recession of 2008, many hard-working people have been squeezed out of the middle class.  A November 2011 report by Wider Opportunities for Women entitled, “Living Below the Line,” highlighted the fact that nearly half of Americans struggle to make ends meet. It is clear that having full-time, year-round employment and health insurance does not guarantee that a family doesn’t have to struggle to get by.  In these tough times, those who live in poverty are not only those patients on Medicaid.

There is a lot physicians can do to give all of our patients the chance to live healthy lives.  We can connect patients with organizations and resources that will assist them in maximizing their incomes.  Dr. Mark Ryan, a family doctor working with underserved populations in Richmond, Virginia, explains “We can ensure patients participate in any federal, state and local programs that provide assistance, including WIC (Women and Infant Children supplemental nutrition program), food stamps, general relief programs, etc.  We can also guide patients towards faith-based and other non-governmental non-profit organizations whose missions include supporting low income individuals and families.”  He also points to the value of including a social worker as part of the treatment team. Physicians that screen for poverty are in a unique position to provide opportunities for interventions that can increase income and thereby provide our patients with the opportunity to make healthy choices, while advocating for government policies that can raise the bar for everybody.

I look forward to the day when screening for poverty as a risk factor for health becomes the standard of practice in every setting, whether it be in the emergency room, on the wards of a hospital or in primary care clinics.

Naheed Dosani is a family medicine resident.  Both he and Jeremy Petch write at Healthy Debate, and can  found @NaheedD and @jeremypetch respectively, on Twitter.

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  • http://pulse.yahoo.com/_3CY2U67646G7UIAHBQVTT2UP4Y Kristy S

    This is an excellent article, and I think it’s a good idea for doctors to screen for poverty.  At the same time though I think that it might be hard for doctors to do this because of the fact that talking about money matters is a very personal thing among families.  Alot of people don’t like to talk about things like this even though they should, and the reason that they don’t like to talk about it is because they feel that it’s no one’s business. 

    So it seems to me that it becomes a fine line as to when to step in and ask, “how are things financially”.  What also makes this rough is that like for those that have health insurance yes, the insurance covers the majority of the cost for services rendered, but then the co-insurance that the patient must pay many times is a financial burden.  Many people think that if a patient has health insurance and can afford the premium that comes with that insurance that they can afford all the other costs that come with it.  That is not always the case, and as a result some forms of treatment such as necessary surgery can’t get done that would help the patient live a longer, and healthier life. 

    However, even in spite of that I hope that one day that this becomes a regular part of the conversation between healthcare providers and patients as the author suggested. 

  • http://twitter.com/timsenior Tim Senior

    Thanks for this post on a really important topic. I work in Australia and trained in the UK, and these issues are just as relevant there, though GPs will often work in areas where they know that almost everyone in that community will be struggling.
    While I think it is really important to do what we can for individual patients, I’m not sure that this is enough, for two reasons.
    One is that many patients in this group may not have access at all to a physician, because of cost or because of other issues such as lack of transport. This population will miis out altogether if we only advocate for those who make it through the door.
    The second reason is that there is good evidence that it is inequality, rather than poverty that causes ill health. If we are only advising those who get to see us, we run the risk of increasing inequality (as those who don’t see us, or see our colleagues who don’t do this, fall further behind.
    For this reason, I think it is essential that we also speak out about the political and cultural systems that lead to poverty, and that the measure of a society is how well it allows all its members to live the lives they want to live, not just those with money and power.
    To take a practical example, in the city that I work in, fresh fruit and vegetables are cheapest in the richest areas of the city and most expensive in the poorest areas. Nutritional advice will only get so far against this, and the demand for charity will only increase during an economic recession.
    It may be difficult, and outside our comfort zone, but people do still listen to doctors, and I think we need to do this public health measure in order to be effective with our individual patients too.
    To pursue the screening analogy further, if we are to screen, then we need to have an effective treatment for the condition we are screening for. Managing the individual needs is only going to have limited effectiveness when pitched against a system designed to make the better off even more better off.
    Thank you for contributing to this important debate.

    • http://twitter.com/JeremyPetch Jeremy Petch

      Thank you very much for your thoughtful comments, Tim.  We agree completely about the importance of physicians using their social capital to advocate for policies that will raise the bar for everyone.  We don’t want to forget, however, just how profound an impact individual physicians can have for their patients who are struggling to get by.  The concerns of equity you raise are important,  but I personally believe that a physician’s responsibility to their own patients must also be respected.  I think a physician’s duty here is to screen your patients for poverty, intervene with the tools at your disposal, all while advocating for policies that will address poverty at a higher level.

  • http://www.facebook.com/abcsofra Deborah Murphy

    I can see that asking someone their income might put them on the defense as we all have some level of pride but perhaps key questions like: when was your last x test (ie-mammogram), can you tell me what you ate all day yesterday (I feel this question is key because here in the US access to healthy foods are almost impossible in low income neighborhoods as regular grocery stores don’t open in really poor neighborhoods), describe to me a typical day at work or at home, etc.  These types of questions would get the answer about poverty to some extent and a better understanding of the entire patient. One of the biggest obstacles to continued healthcare I have found here in the US is that employers change insurance companies constantly which forces patients to doctor hop on a regular basis. This alone interrupts a “long” term relationship with any doctor and puts the patient and the doctor at a big disadvantage. Having to start over from ground zero every year (just about) with new doctors costs alot of money and time and missed opportunities for both the patient and the doctor(s). And now that I think about it…I have NEVER had any doctor EVER ask me what I ate the day before or how many times did I exercise in the past 7 days? And none of this is on any form I have EVER completed. Why? What we put into our bodies will impact our health for sure as well as how much we move daily.

    • http://twitter.com/JeremyPetch Jeremy Petch

      Thank you – those are excellent suggestions about how to go about screening, and you’re quite right that those questions will give a more holistic picture of the patient.  I’d suggest also asking about the home itself as well as school for paediatric patients.

  • http://twitter.com/timsenior Tim Senior

    P.S. Having said that, the HPAP resource is really excellent.

  • http://twitter.com/susanpromislo Susan Promislo

    Great post, and I’m so glad this is being raised again now.  The Robert Wood Johnson Foundation released survey findings in December that were covered on Kevin.MD indicating that the majority of primary care physicians think it’s as important to address patients’ social needs as it is to treat their medical conditions.  Those surveyed felt they lacked the capacity to adequately do so, and wanted the health care system to cover the cost of making connections to needed resources in the community — so we could help remove those social barriers (like access to secure housing, reliable transportation or nutritious food) that hinder people from taking the steps they need to be healthy.

    Tomorrow (4/5) at 1:30-2:30 PM Eastern, RWJF is hosting a Webinar to move this conversation forward to explore solutions that can meaningfully integrate social resource connections in to the delivery of health care.  Speakers include Rebecca Onie of Health Leads (www.healthleadsusa.org), Kavita Patel of the Brookings Institution Englebert Center for Health Care Reform and David Labby of CareOregon.  It should be a great conversation – to register, visit http://community.rwjf.org/community/healthcaresblindside .

    We’re also running a discussion forum now through April 13 on these same topics – please share your thoughts and questions!   http://community.rwjf.org/community/healthcaresblindside

  • http://profile.yahoo.com/WJM2KD62YMFP552HIEL6PUO53A Judith

    Just this morning on the news I heard a representative of 
    http://doctorsforfairtaxation.ca/ calling on the government for higher taxes for high income earners — like HPAP, another worthwhile initiative. He said that many of the low income earners he and his colleagues see are ill because they cannot afford the lifestyles (i.e., decent food) that would keep them healthy and that there is a huge social and economic cost to this. Kudos to these guys. Their humanity and caring brought tears to my eyes. 

  • sFord48

    The 41 year old woman making $12,000 a year working part-time probably doesn’t have private insurance.  She probably can’t afford to pay cash for the stress test and with Medicaid, would probably have a difficult time finding a provider.  I am surprised that the hands didn’t go down at that point.

    As a nation, we don’t like these people who get government handouts.  Wouldn’t it be better to steer poor patients to charities that will provide medical care and food assistance?

    • clpolk

      uh… that 41 year old woman making 12k doesn’t *need* private insurance to pay for the stress test… since she’s *Canadian.* She doesn’t have to pay anything but the premiums paid to the province of Ontario, the only insurer for medical care in the province, and with a salary that low, she’d likely have the cost of her premiums deducted. So don’t worry about the cost of medical care – that’s covered simply by virtue of living in a first world industrialized nation that isn’t the USA.

      shunting people off to charities is like handing over a bandaid for an amputated finger, and honestly, if you were paying over 67% of your income just on your rent, your chest would hurt too. What’s going to help this woman is shelter security, not sample packs of lipitor and bruised apples from the food bank.

      • sFord48

        Free market rules…prices will come down and without all those taxes, charities will pay for that poor woman’s stress test…of course, she won’t be able to get any birth control…

        • clpolk

          free market rules?

          Have you looked around at the capitalist economies lately? I just cannot believe people are *still* falling for reagan’s “trickle down” nonsense. how long is it going to take before you realize that the only thing that’s trickling down is urine?

          • sFord48

            I see you missed my sarcasm…

          • clpolk

            Totally missed it completely. I did. it went zoom, right over my hairdo.

  • itsonlypalliative

    discussing finances is automatically going to put a patient on the defense. it is no ones business but the patients. i would be concerned that providers would treat patients differently…because they already do!  once a provider sees MEDICAID on the paperwork or the screen that he or she is looking at, the wheels in their heads are already turning, thinking about WHAT THEY ARE NOT GOING TO BE PAID FOR, therefore in turn they begin to think of how they are going to undertreat the patient.  do not say that this doesn’t happen either…it happens all the time, everyday.  patients are constantly being turned away or given less than adequate care because state medicaid programs reimbursement levels are much lower than any other third party payer and every provider knows this.

    and finances should already be covered in the patient intake form. if the patient’s finances are not addressed there, then the it should be addressed in the Past, Family, Social History that the provider takes. this is a an important part of the coding/billing process as it is taken into consideration for the level of E/M services (if applicable) for charging the patient for the visit. 

    if you choose to take financial stability into consideration for Dx & Tx a patient, then you should create a separate form for the patient to fill out with their initial paperwork packet, so it doesn’t stick out like a sore thumb. then the provider should review the information BEFORE he or she sees the patient, and not have to ask the patient and make them feel uncomfortable and put them on the automatic defense. then the provider can offer assistance programs at a later time during the visit.  all of this will take up more of the providers’ time…and from what i read on this blog, most providers complain about their time, their reimbursement, and their EMR…so i doubt any of you will do this…

  • http://www.facebook.com/people/Amy-Ziettlow/553632651 Amy Ziettlow

    Great article.  Having served in hospice care for the last decade, I remember being impressed when I first started that financial stress is always included in the initial and on-going care plan and is addressed by all team members from the nurse to the social worker to the chaplain and so forth.  Talking about money can be uncomfortable but addressing financial stresses and giving people knowledge about how they can access benefits can relieve often relieve stress that is making physical or emotional pain worse.  Having lived through several hurricanes on the Gulf Coast I have seen first hand how people can handle adversity but uncertainty can be unbearable.    

  • merc

    I thought your point would be that a person living in poverty would need more screening or testing for various health things that might have been postponed because of lack of money.  I didn’t see that, so I don’t quite see your point.

    Obviously, everyone deserves good and fair health care.  Why should the doctors screen with the patient?  Isnt that the role of the administration or social workers? 

  • http://twitter.com/mzmandygrey Mistress Amanda Grey

    I simply get the impression that screening for poverty will limit a patients options. Social workers typically provide this assistance. Why should it be part of a medical record?

  • dontdoitagain

    Poverty.  I broke my arm 6 years ago and my employer didn’t offer health insurance until I had been there for a year.  Kinda hard when you work seasonal construction and generally jump on the first job offered after winter!  Anyway, I had my 12 dollar an hour job, without benefits when I got involved with a surgeon.  He claimed that the only way I would EVER return to work was if I had an ORIF distal radius.  I warned him that I was uninsured and couldn’t afford intervention, nor was I particularly interested in surgery.  He convinced me that I needed this.  Long story short, not one person involved in my care gave a damn about keeping the cost down.  I actually think I got more intervention BECAUSE I didn’t have an insurance company lawyer…  A simple 70 minute outpatient surgery cost more than I made that year.  I was off work much longer than I would have been if I’d just left my arm alone.  I had to have yet more surgery to correct the defects in the first surgery.  20,000 bucks in the hole, and a 12,000 a year job before taxes.  I know this is a matter of supreme indifference to medical people, but I did try to keep cost down.  They ignored all of my protests.  Nobody gave me an estimate of anywhere near what it actually cost.  How do we “just say no?”  My surgeon actually wanted me to pay for an MRI!  With what?  I asked for a “no frills” surgery with just a block and pain meds.  How did it happen that I was injected with Versed, given general anesthetic and all the cost which this entails.  I had to pay 200 dollars for booties because my blood pressure went too low with all the drugs.  I had to pay 280 dollars for them to print “general anesthetic” on a paper, and I was charged for the g/a itself.  300 dollars for “electronic transmission of data.”  I had to pay for extended PACU time.  I had to pay for extended pre op time because my surgeon was over an hour late.  I got a kidney infection, yet another out of pocket expense that I couldn’t afford.  Counseling because I freaked out over everything…  Talking about poverty DOES NOT HELP!  I wish it did, at least where *I* went.

  • Bradley Evans

    Thanks for the post. While doctors can’t fix the social situation, they need to know what’s going on so they can get treatment for patients who need it. 

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