States' influences on Medicaid investments to address patients' social needs

Introduction: Relationships between socioeconomic adversity and poor health have been well documented. Given these associations, Medicaid MCOs (MMCOs) have shown increasing interest in addressing social determinants of health (SDH) to improve health and decrease healthcare costs. The authors sought to better understand how contractual relationships with State Medicaid Agencies influence MMCO investments in addressing members' SDH.

Methods: In 52 semi-structured key informant interviews, MMCO executives representing 17 geographically diverse MMCOs ranging in size, commercial status, and state participation in Medicaid expansion were asked to describe existing state and other influences on MMCO SDH-related activities. The authors followed an established iterative coding, thematic development, and interpretation process to analyze all interview transcripts. All data were collected and analyzed between November 2014 and November 2015.

Results: Informants highlighted both general and state-specific regulations that limit MMCOs from incorporating SDH-oriented solutions into care delivery, including regulations governing claimable expenses, rate determination, and enrollment eligibility. MMCO leaders also made recommendations to State Medicaid Agencies to help overcome perceived barriers.

Conclusions: MMCO experiences should inform new strategies to sustainably implement SDH innovations. An initial promise of managed care was that an MMCO that improves member health through cost-efficient innovations would benefit financially. The views expressed in these interviews challenge this framework's suitability for promoting SDH innovations, as many SDH-promoting services may instead translate into financial losses for MMCOs, even as they produce positive impacts on members' health.