Oliver Fein, M.D., is a Professor of Clinical Public Health in the Department of Public Health at the Weill Medical College of Cornell University.
His research and policy interests include health system reform, national health insurance and medical education. Dr. Fein has been interested in access to care for vulnerable populations and the social responsibility of the Academic Health Center to its community. He has published work in ambulatory case-mix measurement, different methods of measuring social class and health inequalities, and comparative international health systems.
Question: What are some of the common arguments forwarded by opponents of a single-payer healthcare system?
Fein: Number one, that this is in some ways contrary to American culture that, you know, we are free and independent nation. Secondly that free markets which is what they usually are advocating are the best way to distribute resources within an economy and they argued that that would be best for health care. And thirdly, I think the problem is that they often represent those entities which indeed get the benefit from having our present system. Namely they are insurance companies, private health insurance companies, the pharmaceutical industry, those are the most common folks who speak against a Single-Payer National Health Insurance Program.
Question: What healthcare system do you propose?
Fein: Okay, let’s start with what we’re calling a single-payer National Health Insurance Program and let me be very clear that that’s confusing to people. I’ve had people come up and tell me you mean I have to be single to qualify for your health plan? No.
What we are talking about is a program that essentially provides automatic enrollment for anyone who lives in the United States, that’s what real universal coverage is. Somebody presents to an emergency room they don’t have health insurance, let’s take the opportunity and sign you up right there because you should be automatically enrolled. There is no private health insurance company in the United States that would enroll you when you came to the emergency room.
The second principle is that the coverage should be really comprehensive. Everything from preventive care, through doctor, hospital, mental health, dental, to nursing home care all medically necessary services.
The third principal is that it should be financed by a public system in essence. The way in which we finance private health insurance today is using premiums. And premiums are really relatively unfair. The president of the company pays the same premium as the secretary yet their incomes are so widely different. Public financing means that it would be scaled according to income.
And, the fourth principle is that all of this should be done through a much more simple administration and that’s what single payer is. For instance, the Medicare program, which is our one example of a single payer program in the United States, has a 4% overhead, 3 to 4%, whereas private health insurance can be anywhere from 20 to 30%.
And finally, all of these should be delivered essentially through a, how to describe it, a private delivery system. It’s public financing, private delivery.
Let me say that in addition to that there should be free choice of doctor and hospital and really that’s what a single-payer program would offer. That, right now in private health insurance you are limited to a network of doctors and a network of hospitals. You have to pay, frequently, substantially more if you want to go outside that network, whereas in single payer you can go to any doctor and hospital.
So you might ask the question, “Is there any health insurance program in the United States that resembles what we are talking about?” And I would like to say, “Yes. It’s the traditional Medicare program.” It’s essentially a program that is publicly financed but privately delivered and that’s what we are talking about.
Topic: White House Summit on Healthcare and healthcare reform
Fein: Okay, well let me start with the White House conference. We were invited largely because initially someone representing the single-payer position had not been invited including Representative Conyers who was the major sponsor of H.R. 676, the bill that in the last congress had 93 co-sponsors in the house, it had the most co-sponsors that any healthcare bill but he wasn’t invited, and then no one was invited from our organization, Physicians for National Health Program. So we, you know, call the White House, we had people from around the country get involved, we actually even threaten to do a white coat demonstration outside the White House and we were finally invited, literally, myself the day before the conference itself. So that was how we got there.
When we were there, we were able to be full participants and the essential agenda of the White House Summit on Healthcare I think was three things.
One was it was all broadcast on C-Span so the president was saying, “I am being transparent. I want you to see what’s happening in healthcare reform.”
Secondly, he invited quite a few Congress people, probably 52 if I count correctly, senators and representatives from the house but from both parties. So the second message was, I’m going to try to be bipartisan from the beginning.
And then the third message of the Summit was I am not going to dictate to Congress what they come out with. I’m handing all the significant issues over to Congress.
So, the overall message I think was I’m doing this different from Hilary Clinton and the Clinton’s in general. I’m trying to approach this with transparency, bipartisanship, and letting Congress take the initiative.
Now, the problem with that is that I think the president is going to have to take leadership here particularly if we’re going to get a significant reform and so far the notion that you can include the private health insurance industry and maintain a multi-payer system essentially I think really flies in the face of the evidence that it’s possible to do this.
First, you know, there isn’t going to be the dollars to grant access to all those who are uninsured nor to improve the policies for people who are under insured. The way single payer does that is that it removes a lot of the administrative cost of private health insurance but even more importantly, the administrative cost in my office of having to have an extra person to deal with all the multiple insurance companies each of whom have their own rules. In fact, hospitals will have smaller administrative cost.
We compare Toronto General with a similarly sized hospital in the United States. Toronto General has 3 billers. It is in the single payer system in Canada. We had over 300 billers in the comparable sized, US hospital. So if we convert it to a single-payer program, there would be the funds there without increasing the overall cost to the system. There would be the funds there to grant universal coverage automatic enrollment and to improve the kinds of policies that people have, that they are now getting from private health insurance companies.
Oliver Fein: What is it that allows an individual to express their humanity, to essentially be able to fulfill their human promise? Well, there are certain things, like education, that we think allow for that, like political expression, freedom of expression; but, if you don’t have health, all the education will mean nothing.
My name is Oliver Fein and I am a physician working at the Weill Cornell Medical College where I am the Associate Dean and also Professor of Clinical Medicine and Clinical Public Health.
Question: What obstacles limit access to quality healthcare?
Oliver Fein: The financial access is extremely important as a primary baseline. That’s why I’m interested in the issue of national health insurance. But, once you get over that barrier, there are going to be other barriers that have to be transcended. Among those, it seems to me, are things like health literacy, the degree to which things are interpreted for people so they really understand the decisions that they’re making when they access healthcare. In terms of the rural side of the United States, there is a whole issue of geographic accessibility, the ability to get to healthcare and frankly we’re going to be able to do some great things in that territory, given the whole internet and ways in which consultations should be possible for physicians and nurse practitioners that are in remote areas. They’ll be able to use technology to get to consultations with specialists, that kind of thing.
And then thirdly, there’s the whole issue of the doctor-patient relationship and communication within it. There I think what we should be moving towards is what increasingly is being called the “patient-centered medical home.” Everybody should feel that they have a medical home in this country. What does that home consist of? Not just a doctor, not just a nurse practitioner, but a whole team of people who are there to provide care to people.
Question: How would you design a medical home?
Oliver Fein: The way it works, in my mind, is that there would be a group of providers, so to speak, in an office. If I am dealing with patients who have diabetes and hypertension, a number of chronic illnesses, I will have access, right in that office, to a nutritionist who could advise patients how to alter their diets, to deal with their problems with diabetes, with obesity, with hypertension, those kinds of things.
That in addition, there might be an outreach worker in the office. Someone misses an appointment, they’re called up, and we ascertain why they missed the appointment. We might even arrange for some kind of a home visit to that patient as a way of really having the office extend beyond just the office.
And then thirdly, and very importantly, is that a lot of what we would do is coordinate a person’s care, be able to link them to the appropriate specialist when that was needed, to become a real gateway to care. I’m no talking about this whole idea of a gate keeper that kind of keeps people away from care, but rather facilitates and coordinates the care that people get from specialists.
Question: How can we improve healthcare outcomes?
Oliver Fein: When we measure quality in healthcare, there are kind of three different types of metrics.
One of them is what we call a structural method. Do you have a license? That means have you passed an exam of some kind. Not a very really good measure of quality, to be honest, because it’s not continuing and so forth.
Secondly, are process measures like, did the doctor actually get a mammogram on a woman to rule out breast cancer? Did the doctor do a test for diabetes? Those kinds of measures, and they’re good, but they’re important but the goal standard usually is outcome.
Has there been a difference made in terms of the control of the diabetes, the control of the blood pressure and so on? So increasingly there is discussion about, do we reimburse doctors? Do we pay them in any way relative to quality? And do we pay them to perform well? I think that’s a good idea provided that one is aware of some of the pitfalls, and the vulnerable populations are the pitfalls, frankly. Let’s say we’re going to pay people more if, in fact, they did preventive interventions, had good outcomes, and what happened was that we would pay people less who didn’t have that, doctors who didn’t have that, and those doctors frequently might be serving poor communities where people didn’t always take their medications because they couldn’t afford them. Where there might have been problems with the job they got lost, and they got unemployed and really their health was the second priority, getting the job was the first.
We would have to think of ways to deal with those kinds of circumstances in a, what we will call pay for performance system, so that the doctors serving the vulnerable populations didn’t get paid less and less because they weren’t able to provide the outcomes that somebody who was dealing with an Upper East Side population was dealing with.
Question: Is there hope for a fully integrative medicine?
Oliver Fein: Actually, integrative medicine is an important component of what medicine should be delivering today. By that I mean, let’s think in terms of, again, diabetes, hypertension, obesity, those chronic illnesses that are very prevalent in our society. The physician intervention is frequently, take this pill, or take insulin for the diabetes, and the pill for the hypertension. But we we need to pair that with nutritionists who are helping people deal with their diet, weight loss and things of that sort. We need to pair that, frankly, in high blood pressure, with stress reducers. We should be, in fact, incorporating in our practices referrals for exercise training, maybe even yoga training to deal with stress. That’s why this team-based care that I was describing earlier, the patient-centered medical home, which had really a whole variety of providers in it, not just doctors, seems to me be the way to move. So, integrative medicine should be very much a part of what doctors are involved with.
Question: How important are electronic medical records to your practice?
Oliver Fein: I can say, from my own practice, that we are completely paperless now. The hospital is just about completely paperless.
What it means for patients is that when I’m not able to be on call, let’s say over a weekend, but my partner is, my partner can go directly to my medical record, and see what the patient’s medication are, can see what’s happened recently, what the latest laboratory studies were, and so on. It really provides a way of improving the quality of the relationship between doctor and patient.
Then the other thing is, that it does lead to things that I would call better patient safety. That is to say that, prescriptions that used to be handwritten could be misinterpreted, particularly with my handwriting, by the pharmacist. Now, all of my prescriptions are printed out. There is no chance for this kind of misinterpretation.
What we’re not doing, now, in medical records is that my medical records aren’t accessible if my patient is in Florida, or on the West Coast, or for that matter, frankly, going to another hospital here in New York City.
Somebody is brought by an ambulance to St. Luke’s Roosevelt, rather than to New York Presbyterian, they don’t know what I’ve done. And that interconnectivity of medical records is really the promise of a good computerized medical records system.
Question: What is the next big medical breakthrough?
Oliver Fein: The real thing that I think isn’t talked about a lot is the phenomenon of what is now being called epigenetics. What that means is that the gene may not be as important as the environment in which it develops. That gets back to the medical home, that gets back to trying to truly alter essentially the problem of obesity, which is rampant now in the country. If we can deal with those epigenetic phenomenon, if we can create practices that are really able to embrace dealing with those problems, then in fact, the true benefit of genetic technology will be able to be realized. But up until that time, the epigenetics are going to shape a lot of what’s possible in the genetic revolution.