'Scripts for food' cooks up controversy

MEDICAL POST
November 15, 2005 Volume 41 Issue 39

'Scripts for food' cooks up controversy

Doctors divided over signing form that gives welfare recipients extra 'special diet' money

By Matthew Sylvain

TORONTO | A move by activist physicians and antipoverty groups to use an obscure government health form to help poor patients receive more money from Ontario's welfare system has triggered "dozens and dozens" of calls to the Ontario Medical Association from doctors confronted by patients about signing the document.

As a result of the controversy, on Nov. 4, the Ontario Ministry of Community and Social Services has released an altered version of the form.

According to Dr. Ted Boadway, executive director of the OMA's health policy department, the association began receiving the calls from anxious doctors in early September. Certain patients, the callers said, were demanding the physician fill out a Ministry of Community and Social Services application for a program that lets welfare recipients collect up to $250 more per month in government subsidies.

Doctors were even threatened with physical violence, Dr. Boadway said.

Known as the "special diet supplement," the program provides money to recipients who get the form endorsed by a physician, dietician or registered nurse. The signatory originally needed only tick a box in a list to indicate the patient has any one of a long list of medical conditions, including diabetes, Crohn's disease, HIV/AIDS, cancer, celiac and liver disease for the recipient to qualify for the funds.

The new form requires the medical provider confirm that they specifically have one of those conditions, and which one. It makes it impossible, anti-poverty activists say, to prescribe special diets as a preventive measure for those whose health is compromised by inadequate nutrition.

What was surprising to Dr. Boadway was that the original form had been in use since the late 1990s, and to his knowledge the association had never received any calls from physicians in conflict over the diet.

"Then all of a sudden, it starts—kaboom! Like, a couple (calls) today and more tomorrow and more the next day," he said in an interview in late October, when the Medical Post first learned of the issue.

"This can't be happening after all these years of nothing, not one call," he recalled. "That is when we heard there was a campaign."

The Ontario Coalition Against Poverty (OCAP), which brands itself as a "militant" and "direct-action" lobby group on its Web site, began in late summer to raise awareness of the diet supplement money as part of a wider campaign to heighten concern over the province's welfare rates. On Oct. 1, the group staged a "hunger clinic" on the lawn of the Ontario legislature.

According to media reports, as many as 1,000 welfare recipients attended, and physicians examined them and signed the form for the majority.

Poverty a risk factor

Dr. Gary Bloch, a family physician at St. Michael's Hospital in Toronto who also provides care at a number of shelters and clinics for the city's poor, took part in the clinic. In an interview, he said he believed OCAP raised a valid point.

Anyone on social assistance is living in poverty, and poverty, said Dr. Bloch, "is known to be the largest risk factor for poor health . . . therefore, just about everyone on social assistance, by virtue of having that huge risk factor for poor health, should qualify for the full special diet supplement."

He elaborated: "It's essentially a prescription for food . . . for reducing people's risk for all the health issues associated with poverty. I would like to see an across-the-board rise in welfare rates to at least bring them up to the level that is equivalent to the buying power of what they were 10 years ago."

Dr. Bloch noted a recent Toronto public health department survey supported the position of physicians, such as himself, who advocate for better funding for welfare recipients. According to that survey of grocery store prices in the city, released Sept. 26, the average weekly food cost for a family of four in the city is $124.62 a week, or $539.60 a month.

The $250 supplement can go a long way when a patient is struggling to make ends meet, Dr. Bloch said.

According to Paul Doig, a social services ministry official, recipients of two schemes are eligible to collect the extra money: the Ontario disability support program and the Ontario Works program. He said that as of June, 45,529 recipients of the disability benefit and 19,291 works-benefit recipients were receiving the special supplement.

Under the works program, before accounting for the food bonus, a single employable person receives $536 a month, a single parent with one child yonger than 12 gets $987 monthly and a couple with two children under 12 collects $1,215 every month.

As for disability recipients, without the food supplement a single person collects $959 monthly, a sole parent with one child young than 12 gets $1,468 and a couple with two kids younger than 12 gets $1,825.

The special diet program has been part of the province's welfare system since 1997, said Doig.

Dr. Bloch said despite the campaign by some physicians to actively use the supplement to bolster the incomes of their patients, "none of us feels the main issue here is the special diet supplement. I personally don't think that I, as a health-care provider, should have to spend my time signing these forms to give people special diet supplements."

Dr. Bloch was one of nearly 30 physicians from across the province who signed a letter requesting a meeting on the issue with Ontario Community and Social Services minister Sandra Pupatello in September.

The minister, through officials, told Dr. Bloch and his colleagues she would not meet with them, according to Dr. Bloch.

In an interview with the Medical Post, Pupatello said she was unsure she had received the letter requesting a meeting with the doctors, but did say she had received letters from physicians concerned about welfare rates in general and the special diet supplement in particular.

She agreed welfare rates in Ontario are low: "Not one of us could probably safely live on welfare." However, the public would not stand for welfare abuse, Pupatello said, and noted the Liberals—who boosted rates by 3% when they arrived in office in 2003—are trying to find ways of boosting them again.

Although physicians were welcome to discuss welfare rates with the government, "that discussion . . . will not be in the forum of this special diet," she said.

In light of the panicky calls to the OMA, Dr. Boadway contacted the ministry about changing the controversial form.

Meanwhile, he was so concerned by the potential for violence that he was advising doctors to simply submit to the demands of any angry patients. "The physicians we were dealing with were so anxious with this—and as far as I could figure out with good reason—that I said to them, 'Look, in order to fill that form out you are going to have to break the rules, and maybe even tell a fib, but for gosh sakes go right ahead and do it.'"

Dr. Boadway said imparting the advice to break with sound medical protocol "was something I have never done before." (He informed the College of Physicians and Surgeons of Ontario as well as the government of the recommendation, he said.)

When contacted by the OMA, the government quickly agreed to strike a committee to revise the form.

The committee's goal was to draft a form that by being more precisely and tightly worded would require a clear diagnosis of medical need on the part of the recipient. It would not be a simple checklist and "there is no room for fudging or pushing it," said Dr. Boadway.

"There are people out there who clearly need special diets, and we want them to have it," he explained.

Dr. Bloch said he sees the more restrictive new form as infringing on the autonomy of health-care providers. "We think what they are doing is restricting our ability to make decisions for their own political ends, which concerns us greatly and I think should be a concern for the entire community of physicians."