title: States' Influences on Medicaid Investments to Address Patients' Social Needs.
abstract: BACKGROUND
  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.
authors.affiliation: Center for Health and Community, University of California, San Francisco, San Francisco, California; Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California. Electronic address: laura.gottlieb@ucsf.edu.
authors.forename: Laura M
authors.initials: LM
authors.lastname: Gottlieb
authors.affiliation: School of Medicine, University of California, San Francisco, San Francisco, California.
authors.forename: Andrea
authors.initials: A
authors.lastname: Quiñones-Rivera
authors.affiliation: Health Begins, Studio City, California.
authors.forename: Rishi
authors.initials: R
authors.lastname: Manchanda
authors.affiliation: Center for Health and Community, University of California, San Francisco, San Francisco, California.
authors.forename: Holly
authors.initials: H
authors.lastname: Wing
authors.affiliation: Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California.
authors.forename: Sara
authors.initials: S
authors.lastname: Ackerman
mesh_terms: D006801:Humans; D008484:Medicaid / Q000191:economics*; D064890:Social Determinants of Health; D013219:State Government; D014481:United States