My New ER TV Drama

I have a new emergency room (ER) drama for television in mind. In my TV drama, there are no sirens and no gurneys racing through the corridors. There are no overworked doctors or heart-tugging patients or gut-wrenching triage decisions.

Instead, my TV drama commences with a more common ER scene—a crowded waiting room full of bored, sick people, many of them disoriented and distressed. Cut to an angry hospital CFO, operating under new risk-sharing contracts, who pounds the table and demands that the one third of ER patients who could safely be treated in ambulatory settings get moved there—“Stat!”

Teams of data analysts pore through publicly accessible de-identified data looking for telltale demographic characteristics to categorize frequent users of the ER.

Groups of social workers and health services researchers take their findings and prioritize particular social factors that could play a role in causing some of the health conditions seen in the emergency room:

  • Is it homelessness—which can lead to untended diabetes, high blood pressure, and substance abuse?
  • Is it substandard housing—which can trigger asthma?
  • Is no or poor employment—resulting in income instability and poor health care coverage?
  • Is it increasing social isolation—leading to depression and disempowerment?

In my ER drama, hospital administrators, newly liberated from the burdens of maximizing fee-for-service billing, are sent by the CFO to the hospital’s service area to build new referral relationships with culturally competent service providers who excel at evidence-based interventions in priority needs areas. And newly employed workers from the community help refer these former ER patients to the services they really need.

And the drama in this show: how exactly do we pay for these new services? We know how health care providers bill and pay for ER visits and blood pressure medications. Careers are built on “coding,” but how do you cover transitional housing services or job training and coaching? The CFO is turning red with rage.

And every ER show needs a hero. In my show, it is not the resident who excels at the first-time complicated procedure (preferably performed during the power failure), or the janitorial staff who speaks truth to the powerful C-suite official. Instead, an unassuming Medicaid administrator works with committed colleagues to examine Medicaid rules, build community consensus, and assemble the state plan amendment that makes it possible to pay for the prioritized social interventions these ER patients really need. Finish with a smiling CFO thanking the Medicaid official.

I am still waiting for the call back from one of the major networks, but my new ER drama is looking a bit more like a reality show than a fantasy these days—except for that last scene, perhaps.

While we have understood for a while how health is determined by social conditions such as housing, education, and economic security, health care providers in general and emergency rooms in particular have long been the social safety net, catching the victims of social circumstances but unable to connect them to services that would help keep them from falling again.

Conditions have changed however. With the Affordable Care Act and its optional Medicaid expansion, insurance coverage has broadened, giving more patients and their providers access to more benefits. And the advent of alternative payment mechanisms for providers, led by Medicare, has created stronger incentives for them to reduce unneeded medical services.

With a greater willingness on the part of health care officials to look upstream for nonmedical services that will prevent unnecessary ER utilization, attention has turned to Medicaid, the primary payer for the low-income populations that bear the brunt of poor health caused by poor social conditions. What exactly will Medicaid pay for and under what conditions? What is the landscape of interventions Medicaid covers and what are the routes for arriving at them?

In my new ER drama, the hero would certainly be informed by the Milbank Memorial Fund’s latest issue brief, Medicaid Coverage of Social Interventions: A Road Map for States. The issue brief, written by our colleagues at Manatt Health with support from the New York State Health Foundation, sets out in clear and simple terms exactly how the Medicaid program can be a partner for states and communities as they seek to address some of the social conditions that create poor population health. As explained in the issue brief, federal law permits Medicaid to pay for four categories of social interventions:

  • Linkages to social service programs that can offer help with food assistance, rent, child-care costs, heating bills, and other major household expenses;
  • Stable housing provided through services that help people find and remain in homes, including assistance locating a home, making home repairs, and training in navigating relationships with landlords or other tenants;
  • Employment and job stability, including ways to help people prepare to enter the job market or to keep a job; and
  • Peer and community supports, addressed by care coordinators who offer support and assistance in navigating the system, as well as by peer support specialists who come from a beneficiary’s community or have had similar experiences, and who can offer counseling and advice.

The issue brief also sets out the administrative mechanisms by which states can obtain authority to cover these services and gives examples of coverage paths for specific social interventions in specific states

Intended for state officials and community stakeholders as well, the issue brief is instructive and, at times, inspiring but it is only instrumental. Medicaid cannot be used to medicalize all social services. A diagnosis, a procedure, and a coverage determination will not result in stable housing, a solid job, and a stronger community.

Treating or preventing the conditions that can result in homelessness, un- or underemployment, substance abuse and social isolation—and that, in turn, can lead to acute medical conditions and ER visits—requires the hard work of communities that use all the tools at their disposal, including Medicaid financing. It also requires competent service delivery, sensible financial incentives for providers, engagement strategies for clients, and private and public sector leadership. It might not make for prime time drama. But it is heroic work.