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Healthcare Accessibility: Mavis Seehaus
33 Plays5 years ago
Season 1, Episode 15: Mavis Seehaus is a social worker at Hospital for Special Surgery in New York City. Listen to Mavis discuss how Medicaid and the Affordable Care Act have sought to make healthcare more accessible.
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Transcript
Introduction to The Wound Dresser
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare.
Hosts and Guest Introduction
00:00:14
Speaker
I'm your host, John Neery. Today, my guest is Mavis Seahouse.
Mavis Seahouse's Background
00:00:24
Speaker
Mavis is the director of ambulatory care social work at the Hospital for Special Surgery in New York City. She previously has worked in social work and mental health at Mount Sinai Health System and earned a MSW from Hunter College. Mavis, welcome to the show. Thank you so much.
Healthcare as a Human Right
00:00:42
Speaker
I'm actually reading a really interesting book right now that you might be familiar with. It's called The Healing of America by T.R. Reid. I think he's a New York Times columnist. Basically the whole preface of the book is that he's having some shoulder problems. And so he goes to different nations throughout the world and kind of interacts with their healthcare system to try and seek out care for his shoulder.
00:01:09
Speaker
And so, you know, it's a way of kind of just comparing the US healthcare system to ways insurance and so forth is done worldwide. But he kind of says at the beginning of the book, you know, when you're looking at setting up a healthcare system, like the fundamental question you need to look at is, is healthcare a human right?
00:01:29
Speaker
And I was just wondering whether over your extensive work in health care, like how you've grappled with this question, and perhaps what are your thoughts on this topic?
00:01:43
Speaker
I actually think that I heard him interviewed on a podcast, the author of the book that you're mentioning. Yeah, I guess that I don't
00:02:01
Speaker
think of the rest of the world when I think about this question, I think about the United States and how we don't treat it as a right and how we
00:02:17
Speaker
are a very wealthy country and that we could certainly treat it as a right, afford to treat it as a right if it were viewed that way. So I don't know if I exactly grapple with it.
00:02:36
Speaker
the question because I hear in this country, I see it as a right. I mean, it would be wonderful if it were a right everywhere. And I suppose theoretically, I believe it is a human right. But that way of phrasing it is a little confusing to me sometimes because
00:03:04
Speaker
I'm not sure how it applies in the rest of the world. But here, certainly, I see it as a human right.
Healthcare Navigation and Support Programs
00:03:15
Speaker
And I see it as a right that is denied people in a very wealthy country when they aren't wealthy, when they are from disenfranchised groups.
00:03:36
Speaker
Does that answer your question to an extent? Yeah, it does. It sounds like you're very much on board with health care as a right, especially because of the wellbeing of the US, right? It's a wealthy country and people should have access to health care. I think then you start picking through the weeds a little more and say, okay, if we treat it as a right, like what does that look like? So like right now you can go to the emergency room and get health care for acute
00:04:05
Speaker
conditions, but it's then how far, I think most or if all people are on board with keeping that, that you should have that option regardless of your socioeconomic status. But then from there, it's how much further do you go in saying what is a right and what is not? Do you kind of think about that as well in terms of how far you go with it?
00:04:34
Speaker
I don't know that I think about it that way. I think a number of years ago, I read an article in The New Yorker about, I think it was Trenton or a town in New Jersey. I don't think it was Trenton, but it was in Western New Jersey, a town with a lot of poverty.
00:05:01
Speaker
And they collected lots and lots of data about the use of healthcare in this city. And it became very clear that most of the healthcare money was spent on about 6% of the people that lived in that city. You know, they went to the emergency room all the time.
00:05:27
Speaker
They had several chronic conditions each. They lived in poverty, et cetera. And the idea was that it would be quite expensive to provide them with, you know, healthcare navigation support people, people who helped them with their
00:05:55
Speaker
manage their biopsychosocial issues, but that ultimately they felt that it would be worth it.
Role of Social Workers in Outpatient Care
00:06:06
Speaker
And I believe they did implement certain aspects of this program because all the health care money was being spent on them. And when they got increased support,
00:06:22
Speaker
uh, their emergency room visits, which are, you know, super expensive emergency room visits, um, and their use of health care because they had this basic support people who helped them get primary care people, uh, I mean, the, the health care navigators or whatever they titled these people, uh,
00:06:49
Speaker
help them get primary care, help them get food, help them manage their mental health conditions. And I was really impressed by that. So I think, I mean, I haven't heard of anywhere else where they're doing exactly that, but a couple of years ago, I know that New York Hospital was looking at having
00:07:14
Speaker
support for people who constantly came with chest pain and rapid heartbeats that they determined was anxiety and they were going to have a mental health program that provided a lot of support
00:07:31
Speaker
to these people with the goal of having them reduce emergency room visits, these expensive emergency room visits. I don't think it really ever got off the ground. I went to a bunch of presentations on it. But these are the sorts of things that I think about instead of thinking of the limits of health care as a right.
00:07:56
Speaker
We'll get back to some more accessibility stuff later, but now I want to ask you about your work in social work, especially at HSS. Can you just articulate how a relationship is initiated between a patient and a social worker and some of the reasons that relationship comes to be?
00:08:16
Speaker
Well, at HSS, social workers have a variety of roles. And the role that I would like to speak of is the role of the social workers working in the outpatient areas. Now, most of the social workers in my program work in the clinic areas.
00:08:36
Speaker
So they are working with people living in poverty, people who have Medicaid or Medicare and Medicaid, people who are Medicaid eligible because of their disability or being over 65 and older.
00:08:52
Speaker
So these are people, because of their poverty, people living in poverty tend to have more chronic health conditions, et cetera, more limited access to health care, don't utilize primary care as well as they should, or as well as
00:09:20
Speaker
would be helpful to them. So we, the social workers in the outpatient areas, for the most part, get referrals from the physicians, either the surgeons or the rheumatologists or sometimes the primary care doctors that are seeing patients in preparation for surgery. We get referrals
00:09:49
Speaker
of those patients when certain things are the case. Sometimes it's a new diagnosis, but often it is helping them prepare for the road to surgery.
00:10:08
Speaker
or they need certain resources, mental health resources, concrete resources like applying for health insurance or food stamps, etc. So if they express a need, they're very happy to get a social work referral, but
00:10:29
Speaker
When they don't have the have a need that they identify, sometimes they get referred to the social worker anyway, because they have a mental health issue, particularly a substance use issue, which might interfere with them being able to proceed with surgery. So they're not that.
00:10:49
Speaker
necessarily happy to see a social worker. So I think the initial interaction is very, very different depending for very, very different reasons. Let's put it that way. But I think what social workers offer patients is looking at
00:11:14
Speaker
things through the patient's eyes and having empathy for their situation and conveying that to the patient by some very simple things that
00:11:29
Speaker
sometimes don't happen in healthcare settings by some people who interact with patients. Hopefully at HSS we do a pretty good job with this. But what social workers are really good at is listening.
00:11:49
Speaker
to the patient, hearing what they say, reflecting what they say so the patient knows that they've been heard, helping the patient identify
00:12:04
Speaker
the issue, laying out with the patient the plan so that the patient can understand it. One of the roles that our social workers have is helping patients to understand medical information. A lot of people, especially people living in poverty or for whom English isn't a first language or who have
00:12:31
Speaker
in lower education levels, you know, many of those people have difficulty understanding health information. You know, I have difficulty sometimes understanding health information that's provided to me when I'm a patient.
00:12:47
Speaker
So we help patients understand that so that we have many ways of connecting with the patient that allows the building of that trust so we can assist the patient. I always say that our role as social workers is to identify what the patient needs and to help the patient get what they need to improve the quality of their life.
00:13:17
Speaker
because these are people with medical conditions. Yeah, and I can certainly see the listening piece being vital, right, in the health setting because a common complaint is just that, you know, oftentimes doctors appointments are kind of in and out. Exactly. And you just want to sort of sit down and breathe with somebody. And I'm sure, you know, some of the individuals as well don't necessarily have a
00:13:45
Speaker
you know, social support network as least as vast as they would like. So that's got to be huge for them. Right. Absolutely.
Medicaid and The Affordable Care Act
00:13:52
Speaker
Absolutely. Yeah. And we develop really good relationships with the physicians who really rely on social work to
00:14:05
Speaker
help the patients with things that are not the focus of the visit for them because they do have a limited amount of time with the patients and really have another role.
00:14:21
Speaker
All right. You said that a lot of the patients, or some of the patients that you interact with have Medicaid. Can you just kind of paint us a picture of the landscape of Medicaid, including who are the insurers, who are the patients that this program is serving, and some of the kind of important rules involved? Sure. So Medicaid is a health insurance program
00:14:49
Speaker
people who have low incomes, the income income levels are quite low, very low. I mean, these are people with very, very limited income. And, you know, I, you know, I
00:15:05
Speaker
don't have the figure off the top of my head, but it's something like a little bit over, I think, $1,000 a month, that sort of thing, for a family, for a single person. And of course, if you're a single person without child care responsibilities, if you are under 65 and can work, you will be asked to go to work for Medicaid.
00:15:33
Speaker
so to receive Medicaid. But it's a program for people living in poverty. It covers a range of health care needs. Many years ago, probably like 20 years ago or so,
00:15:57
Speaker
uh prior to 20 years ago it was a state-run program still state state administered uh some of the money comes from the federal government but um 20 years ago people had medicaid and you could go to any provider that took medicaid and
00:16:15
Speaker
There are private providers that take Medicaid, but many, many people go to hospital systems who have clinics, which have clinics that take Medicaid and very often, like at HSS,
00:16:31
Speaker
These clinics are places where in teaching hospitals, medical trainees in our hospital, residents and fellows, see the patients with supervision by the attending physicians, the more experienced senior physicians.
00:16:55
Speaker
A little more than 20 years ago, you could go to any provider that took Medicaid, but cost cutting came into existence. And now you almost everybody, there are very few exemptions.
00:17:12
Speaker
They need to enroll in a managed Medicaid plan. So basically you need to see physicians within and use hospitals that are within your plan.
00:17:28
Speaker
And if you go outside of the plan, you need to get an added network authorization, which is a complex process. You know, you have to request that with medical documentation from the insurance company. And plans are...
00:17:50
Speaker
are different in terms of letting you go outside of the plan. Very often we see among the HSS patients, we take several plans, but not all Medicaid plans. And you know, we get
00:18:07
Speaker
we see patients who may have gone to several orthopedists and everyone's saying to them, you know, you really need to go to HSS. So they come into or they want to come to HSS, but their plan doesn't allow them. They say, you know, go in network because HSS is too expensive for us. So
00:18:33
Speaker
You know, that's an issue. Also, people very often have difficulty finding mental health treatment in their plan. The resources are often limited. So, yeah, that can be challenging.
00:18:53
Speaker
So then, you know, you said a lot of the cost cutting occurred, what, 20 years ago? And then, right, fast forward to a decade ago, we had, or so, we had the Affordable Care Act, right? Did you feel like that? I know it's, we'll talk in a sec about how it's kind of getting pushed back at the moment, but did you feel like that filled in?
00:19:15
Speaker
you know the gap for a lot of people who were not making or who are making more than that twenty twenty two thousand dollars a year or or i guess wait no you said about not so like that small amount of money do you feel did you feel like that the a c a did a good job of kind of
00:19:32
Speaker
you know, closing the loop for everybody to get at least some help. I think yes. And, and I'll let me start with Medicaid, because one of the big successes of the ACA is the Medicaid expansion. So that meant that
00:19:48
Speaker
the income requirements went up so more people were eligible for Medicaid and that was done on a state-by-state basis in the United States and New York did participate in the expansion. So many more people were eligible for Medicaid than were previously. Also there were
00:20:11
Speaker
was a plan in New York that was a little for people who made more than you would be able to make for Medicaid eligibility.
00:20:28
Speaker
they would pay a small amount for the insurance. And actually, some of them, because of the Medicaid expansion, even over the previous Medicaid limit, they didn't have Medicaid. It was a more basic plan. I'm trying to think of the name of it. OK, so that was the big success of ACA.
00:20:55
Speaker
People who had fairly limited income did okay with the ACA. People who were uninsured with moderate incomes very often had to pay a fair amount of money. However,
00:21:17
Speaker
they had insurance when before they may not have been able to get any insurance. And of course, the pre-existing, you know, it's being chipped away at, but the pre-existing condition was, you know, you could have a pre-existing condition. The restriction was thrown out.
00:21:39
Speaker
So yes, I think there were many wonderful, wonderful things about the ACA.
Healthcare Accessibility and Insurance Challenges
00:21:46
Speaker
It's unfortunate that it got chipped away at rather than refined. So yes, I do think it was a success, but it needed more work. And unfortunately, it didn't get that more work. It got
00:22:04
Speaker
more restrictive in many, many places. But overall you felt like- A positive development. The ACA in general just made healthcare more accessible, right? Yes, it made healthcare more accessible, but it could have made it even more accessible. And it was disappointing that there were states that did not expand Medicaid, et cetera.
00:22:31
Speaker
Now, as it stands in October of 2020, correct me if I'm wrong, because my understanding of the current legal picture is not the best, but the individual mandate, which requires essentially everybody to have health care, is going to the Supreme Court. So I can still use my health insurance from the ACA today, correct? Yes, correct. Correct. It's still the law of the land.
00:22:58
Speaker
I'm sure, you know, these are questions that you probably get on the daily, right? And, you know, you're probably even checking updates yourself. Well, you know, I have one of the programs that I oversee is a program called
00:23:15
Speaker
voices Medicaid managed care education and it's a wonderful program that helps HSS patients who are coming into our clinics to navigate health insurance.
00:23:33
Speaker
And the supervisor of that program is the co-chair of our department's Affordable Care Act committee. And one of the things we do is publicize it during the open enrollment period, et cetera.
00:23:57
Speaker
Yeah, that's why I don't have some of these facts and figures at my fingertips exactly because that program deals with that data on a daily basis. Patients asked about that, of course, all the time. Yeah.
00:24:15
Speaker
Can you talk about the experience of having to tell somebody they can't receive healthcare at your institution? I know you said that for some people, you don't cover their Medicaid plans. So just kind of turning someone away at the door. It's gotta be heartbreaking.
00:24:31
Speaker
It is really, really heartbreaking when on the rare times that we can't figure something out. I mean, you know, one of the things that some patients do is they decide that they really want to come to HSS. So they
00:24:55
Speaker
wait till they can switch their plan and they switch it to a plan that HSS takes so that they can proceed with, you know, a knee replacement or whatever it is they need. And the thing that's really challenging about that is unfortunately we see many, not just that we see, but there are
00:25:22
Speaker
So many people, particularly older adults that have multiple chronic conditions, so they see a number of specialists on an ongoing basis. And what becomes really challenging for people is when they are in a plan and they need a specialist in this plan or they need a specialist in that plan, et cetera.
00:25:46
Speaker
So some people actually leave their plan so that they have lots of doctors in or a trusted primary care doctor and join a plan that we accept so they can proceed with surgery. And then afterward, they may go back to another plan or then they find new providers and a new primary care doctor. So it's unfortunate that that's necessary.
00:26:15
Speaker
So those are the kinds of things that people do. So most of the time I would say that rather than saying you can't come here, what we say is
00:26:27
Speaker
you know we have a program that will help you figure out what your options are and sometimes an option like that can be found and sometimes we can even expedite the transfer to another plan because usually it takes some time if if there's a really good medical reason for that so
00:26:51
Speaker
But there are times that especially sometimes there are people out of state and that's a challenge. I mean, and, you know, HSS is number one in the country, right? So we get people with public insurance from out of state that want to come for our care. And, you know, their local, their state Medicaid office needs to approve that. And sometimes that doesn't work out.
00:27:21
Speaker
When you think about the Upper East Side, there's just, like you just said, HSS is number one. There's so much world-class healthcare, really throughout, I guess, New York City, right? Do you feel that these institutions are doing enough to make their services available to low-income populations?
00:27:41
Speaker
That's a really tough question. I mean, I used to work at Mount Sinai and that was something, you know, everyone thought about there. I think the challenge, and Mount Sinai made quite a few improvements in that, I think the challenge is not so much the access to the care, it's
00:28:05
Speaker
equity in the care. So people who come in through clinics at hospitals very often have to wait longer for an appointment because the clinics tend to be very busy.
00:28:23
Speaker
A lot of people want to come in for clinic care. HSS a few years ago, more than a few years ago, expanded. They have, HSS has experimented with various ways of making
00:28:43
Speaker
appointments more easily accessible in our clinics, adding certain screening clinics, for example, for knee and hip surgery. So you're not seeing the surgeon first, you're
00:28:59
Speaker
You're seeing someone who assesses, who's not going to be doing your surgery, but assesses the need for surgery. Screening for people with back pain. Are they going to a surgical clinic? Do they need to go to the surgical clinic? Or do they really just need PT?
00:29:24
Speaker
I think we've tried some things, and I think that HSS has really had very recently with all of the social justice issues related to racism in our country and how that's been brought to a higher level of awareness.
00:29:48
Speaker
in many places in this country, I think HSS has an increased focus on diversity and inclusion as it relates to healthcare. And there are quite a few initiatives in progress to address equity in healthcare.
00:30:17
Speaker
And they're in their infancy. They're proceeding now, so I don't really want to get too much into that. But it is an increased focus by HSS and probably lots of places.
Systemic Racism in Healthcare
00:30:34
Speaker
I mean, I attended a meeting at the time
00:30:40
Speaker
discussion session run by a physician at New York Hospital and they are talking about, you know, ways that they can advocate for and support and raise the level of awareness of justice in healthcare.
00:31:10
Speaker
So kind of expanding off that, how do you feel our healthcare system is currently racist and discriminates against people of color?
00:31:22
Speaker
Well, I think all you really need to do is look at the deaths from COVID. You know, African Americans and some other populations of color, Latinx,
00:31:42
Speaker
and natives and Native American populations have much higher rates than white people, higher rates of in section, higher rates of death, and
00:31:57
Speaker
What this is based on are pre-existing conditions that are a symptom of racism, poverty, inadequate health care, nutritional issues,
00:32:27
Speaker
This, you know, I think I've read in the last couple of years about this theory that
00:32:38
Speaker
that, and I think it's more than a theory, that some chronic illnesses, high blood pressure, heart disease, autoimmune diseases are
Economic Pressures on Healthcare
00:32:58
Speaker
really caused by or a huge factor in them is the stress of living in a racist society. Yeah, absolutely. I think, like you said, it's certainly not just in health care, but in the for the nation's forefront of justice on in racial issues.
00:33:26
Speaker
The bigger, when you just talk about healthcare, right? The big culprits that are kind of identified can be like just sort of the government and the way we set up our healthcare system or insurance companies that are for profit or drug companies. But just working in a smaller,
00:33:49
Speaker
setting, you're a lot closer to the healthcare providers. Do you think the physicians need to be kind of pointed out as part of this healthcare issue that we're having, that healthcare isn't accessible if insurance isn't accepted?
00:34:11
Speaker
it's definitely a certainly uh... a hard thing to uh... pinpoint right the cost of medical education is actually high there's their their services are so many years of education and training you know they have skills that no other people have uh... but at the same time do we need to have a discussion of medical compensation and
00:34:39
Speaker
like whether insurance is accepted, that physicians are part of this problem too. Well, you know, it has to be a top-down decision, a direction, a top-down decision. It has to be a decision at the top and it has to be
00:34:57
Speaker
top-down direction, I think, and I do think that some of the cost needs to be borne by health care institutions and medical providers that
00:35:16
Speaker
I mean, you know, I feel for people who have paid that much in medical school loans and training loans too, you know, I know that it's tough, but you know, doctors make a whole hell of a lot of money eventually. And I think that
00:35:43
Speaker
You know, I see some physicians that are committed to, you know, providing care for the poor on at least some care. I mean, do I value that and thinks that that should be the case? Yeah, I do.
00:36:11
Speaker
And some of the physicians that work in our clinics are enormously dedicated and really care about patients and their struggles in living the lives that they live.
00:36:29
Speaker
I have tremendous, tremendous respect for them. And, you know, we live in a capitalist society. I don't, it's hard to
00:36:44
Speaker
to doctors, I think most doctors really go into the field because they want to help people. They want to care for and cure people. I think they are idealistic. I mean, I think there are plenty of people to, you know, working on Wall Street that I feel, insurance companies that I feel
00:37:14
Speaker
you know, bear perhaps greater responsibility. But sure, you know, I remember that there was one attending in particular that, you know,
00:37:32
Speaker
the head of an area at HSS who really emphasized that attending should take some patients with Medicaid and required it. And I thought that that was a really good thing to do.
00:38:01
Speaker
I kind of feel like something will play out on the medical education front, especially if we want to, you know, make it more affordable. Like I was saying in the book, I read that the kind of the juxtaposition other nations around the world, you know, medical education is free or very little, but then the compensation isn't
Mindfulness and DBT in Healthcare
00:38:19
Speaker
as much. So it's obviously no free lunch.
00:38:22
Speaker
Last thing I got for you, I know, uh, I mentioned that you, you've done some work in mental health in the past and you've, I know you're trained, uh, or at least familiar with dialectal behavioral therapy. And for, uh, you know, some of our listeners who might not know it's, it's, it's a mindfulness based, uh, you know, basically course for acutely mentally ill people. And I was wondering, um,
00:38:50
Speaker
If some of the mindfulness skills in VBT, is that some of the low hanging fruit in our healthcare system that's being overlooked? For a lot of people who have chronic conditions, substance abuse problems, these skills
00:39:05
Speaker
could perhaps be pretty useful if they were implemented in our school systems, in other social work settings, but often they're only reserved for acute mentally ill patients. So I was wondering if you see
00:39:22
Speaker
mindfulness and dbt um and and other things of the like you know playing a role going forward in our healthcare system absolutely um and i think that it has been happening on on um more than it's certainly in the past and by the way uh we have a mindfulness and a stress reduction mindfulness based and stress reduction a group that we do for our orthopedic patients particularly those
00:39:52
Speaker
living with pain and in our rheumatology patients. We have someone who is experienced in this area that teaches this class
00:40:08
Speaker
And at the end, the social workers do a little group discussion, which is intended to really help the patients in the group put it into practice in their lives.
00:40:27
Speaker
When are you going to use this? What time of day? Really make a plan. And this group is done on a regular basis. It's been in existence for a period of time now. And patients really find it useful. Also, we have a program for older adults.
00:40:50
Speaker
I don't know if you're aware, our hospital and actually all not-for-profit hospitals in New York State are required to do a community service plan in which people with expertise at the hospital go out into the community and do programs. And one of our community service plan projects, and there are a number of different
00:41:19
Speaker
departments that do community service plans at HSS. It's a huge initiative. And we do several just in our departments, the Department of Social Work programs. But the one I want to mention is that our older adult program is going out into the community and teaching older adults different techniques to manage chronic pain.
00:41:47
Speaker
which many Americans, especially older Americans, are living with, back pain, arthritis, etc. And they are doing two modules, one which is mind-body focused, mindfulness focused, breathing techniques,
00:42:09
Speaker
et cetera, visualizations. And the second one is using CBT techniques to cognitive behavioral techniques, you know, changing thought patterns, et cetera, to change your, to ultimately change your feelings and your behavior to impact pain. Very cool, yeah. And I think
Mavis Seahouse's Personal Insights
00:42:37
Speaker
Especially with what you're saying in pain management with opioid crisis, it seems like a good time to put more emphasis on mindfulness and coping with physical pain at least. So now it's time for a lightning round. A series of fast-paced questions that tell us more about you.
00:42:53
Speaker
I know you worked in the 80s and perhaps 90s with some adolescents. I kind of consider the 80s a golden age of pop culture. So I wanted to know what is your favorite 80s movie?
00:43:09
Speaker
to be drugstore cowboy, who was a star of drugstore, Matt Dillon. And it was a story of a bunch of people who robbed a drugstore so they could get opioids, basically. And it really humanized these people, and it really
00:43:39
Speaker
brought to life and a level of understanding of what it's like to be a drug addict, to be addicted. And it was also extremely entertaining and well-acted. So you should see it, John. Nice. What is your go-to self-care technique?
00:44:05
Speaker
Love a hot bath with Epsom salts. And I like to do a lot of stretching and yoga. What is your favorite article of clothing? Love a nice dress. What is the most used app on your phone? Probably my podcast app. I walk everywhere. I walk to HSS and home every day, 35 minutes. So I listen to podcasts all the time.
00:44:36
Speaker
What is the one change you would make to health care? It's definitely universal health care. Don't have to think about that for a moment. Maeve C House, thanks for joining the show. Thanks for listening to The Wound Dresser. Until next time, I'm your host, Jon Neary. Be well.