Dr. Federman: A Physician’s Perspective

Dr Federman

Calleigh: Okay, great, so let’s get started! Can you share a formative experience during your training or practice that shaped, or started, your interest in the social aspects of healthcare?

Dr. Federman: Sure. After I graduated from college, I volunteered in the emergency department at San Francisco General Hospital. It was there that I got interested in this kind of work. I always had some interest in working in resource-deprived communities, but there, you really saw how non-English-speaking individuals were high utilizers of emergency department services, often for routine care. That seemed to me like a problem: it’s expensive, and it’s not the way preventive care should be delivered. That’s what really got me started on this career path.

Calleigh: Yes, obviously, we’re aware of the financial and insurance barriers related to care, especially asthma care. Can you talk a little about how that plays a role in medication affordability, particularly for asthma? And have you seen delayed care in certain communities affecting asthma patients?

Dr. Federman: Yeah, affordability is a big problem. Asthma medications are very expensive, and for most of them, there are no generic options. So people often can’t afford them. Sometimes, even if they have insurance that covers the medication, they still have to meet a deductible. I’ve had plenty of patients with severe asthma who couldn’t get the controller medications they needed and just remained sick, until halfway through the year, when they had spent enough to meet their deductible and their insurance finally kicked in. So yeah, it’s a real problem.

Calleigh: And what about delayed care? Would you say that’s an issue with asthma too? For example, if people can’t afford to see a primary care doctor regularly and that gets pushed back, have you seen people who haven’t been able to get to a doctor end up with more complications?

Dr. Federman: Well, the practice where I work only accepts people with insurance. So while they may still have out-of-pocket costs, they at least have coverage. I don’t personally see a lot of delayed care in my own practice due to cost. More often, it’s issues like lack of education or awareness that get in the way of people seeking care. But we do know that cost is a barrier for many. I don’t know the exact proportion of inner-city adults who delay asthma care because of cost, but I’m sure it’s a significant number.

Calleigh: Looking beyond hospitals and more toward policy, what structural or systemic changes do you think would reduce asthma disparities in New York, in particular? What needs to change?

Dr. Federman: There are a lot of issues, many of which you’ve already touched on. Environmental exposures are a big one: air pollution, for example, which is worsened by global warming. Hotter temperatures lead to more environmental exposures. We’ve made some progress in reducing particulate matter, but industrial pollutants remain a problem. Housing is another huge issue, both the quality of housing and the exposures inside homes, like cockroaches and rodents. So policy changes in those areas are needed. And again, the cost of medications is a very big issue. It’s crucial to get people into government who are willing to advocate for these changes.

Calleigh: Yes, I definitely agree. I also saw that your research focuses on patient-provider communication, especially about healthcare costs. What are some ways clinicians can have these kinds of conversations with asthma patients, being transparent about costs and offering support when needed?

Dr. Federman: It’s really important for doctors to ask patients whether they’re having any trouble paying for their medications. That’s probably the first step. Then, they need to work with patients to find ways to get medications covered. Sometimes that means switching to a different medication that’s covered by the patient’s insurance. Sometimes it means involving a social worker, if that resource is available. There are discount drug programs and pharmacies that offer lower-cost medications, like Target pharmacies, for instance. But those are tough for doctors to manage because we often don’t have the time to sit down with a patient and go through those options together.

Calleigh: Yeah, that makes sense. Also, while looking at your work, I learned about pharmacoepidemiology, which I found really interesting. Have you seen any trends or disparities in how certain medications are used or adhered to across different populations or socioeconomic groups?

Dr. Federman: Definitely. Insurance is a major factor. The better the insurance, the more likely people are to take their medications, simply because they can access them. And who tends to have better insurance? More affluent individuals. So it really comes down to socioeconomic status, which in turn intersects with racial and ethnic disparities. Those are, unfortunately, persistent issues, affecting not just who gets medications, but also what medications are prescribed to whom.

Calleigh: Looking to the future and to innovation, are there any care models or policy interventions you’ve seen that show promise in addressing these social aspects?

Dr. Federman: Over the past few years, Congress allowed the federal government to begin negotiating prices for ten prescription medications through Medicare. I believe one asthma medication was included in that list. Now, ten out of thousands of medications is a drop in the bucket, and this only applies to Medicare, which mostly covers people aged 65 and older. But it does often influence how private insurers adjust their policies. That said, I’m not confident the current administration will continue to expand this policy, but it was definitely a step in the right direction.

Calleigh: Given the current administration and the slowing of research in many areas, which is really upsetting, what would you say are the most important research questions or advocacy goals in asthma, especially when it comes to reducing disparities?

Dr. Federman: One really important question is how Medicaid expansion under the Affordable Care Act has affected access to asthma medications, and what changes in outcomes that may have produced. That kind of research has serious policy implications, especially now, as Congress considers major cuts to Medicaid. If people lose coverage, they’ll end up in emergency rooms when they get sick. That’s expensive, and it shifts the cost elsewhere. There are also broader implications: if someone is frequently sick with asthma, it’s hard for them to go to work, take care of their children, or handle daily responsibilities. That’s a huge burden, economically and socially, and understanding those ripple effects is essential.

Calleigh: This was so informative and inspiring. Thank you so much!

Dr. Federman: You’re very welcome.