Q and A with Thomas J. Betlach, Medicaid Director, Arizona

Thomas J. Betlach, director of the Arizona Health Care Cost Containment System (AHCCCS), the state’s Medicaid system, is widely recognized as a national leader in Medicaid policy, program development, and management. Under his leadership, AHCCCS has been cited for its work on Medicaid Managed care oversight and behavioral health integration. Betlach was elected by his peers to be president of the National Association of Medicaid Directors, completing his term late last year. Before becoming the state’s Medicaid director in 2009, he was deputy director of AHCCCS and also worked as director of the Arizona Governor’s Office of Strategic Planning and Budgeting. He is on the Guiding Committee for the Health Care Payment Learning and Action Network established by the US Department of Health and Human Services to emphasize value over volume in Medicare payments. Betlach began attending Reforming States Group (RSG) meetings regularly in 2013 and became a member of its Steering Committee in 2016. The Fund recently asked Betlach how the RSG has helped shape his work in Arizona.

There have been many improvements in population health in Arizona. How has your team helped these along—and, as a leader, what has been your focus?

Medicaid is an interesting program due to its breadth and depth. Given its scale and scope, it is critical to develop strategies to make it viable. We have pursued better system design to reduce fragmentation of care by integrating behavioral and health services. We lead the country in the dual alignment of services for Medicaid and Medicare recipients (dual eligibles). In addition, we have worked on strategies to monetize value-based reimbursement, worked with our justice partners to improve transitions for Medicaid members, and coordinated services with area tribal members. Regardless of the issue, though, I mainly focus on sustainability to try to ensure maximum use of resources.

As you mention, Arizona is known for having integrated its behavioral health services and care for the sickest patients—and your team was responsible. What did it take to make that happen?  

Traditionally, behavioral health within AHCCCS has been the function of Regional Behavioral Health Authorities (RBHA). Among people with serious mental illness, 40% of the population is eligible for Medicare. They may have three to four different kinds of payment streams for their medical care, such as an RBHA for behavioral treatment, AHCCCS acute health plan for physical health services, Medicare and Medicare Part D for prescriptions. We have collaborated with behavioral health partners to take charge of both the physical and mental health needs of people with serious mental health, which reduces barriers to medical care. Our work with dual eligibles has resulted in a single plan for residents who are eligible for both programs, improving coordination of care. One study found that, compared to those in traditional Medicare fee-for-service plans, aligned AHCCCS duals have a 9% lower rate of emergency room use, 31% lower rate of hospitalization and 21% less hospital readmission rate.  We have had success with our integration efforts to date because we took time to listen to stakeholders and have been thoughtful in making incremental progress.

What is your biggest accomplishment?

I am most proud of the team we’ve built at AHCCCS. We are an organization that had to go through belt-tightening during the great recession, then turn around and discuss new initiatives for what I call “restoration and expansion.” Some of my staffers have taken what we’ve done in Arizona and moved on to do great and wonderful things in other states in other organizations or remain with us to continue this important work.

Many RSG participants are legislators. Has it been useful for you to connect with legislators outside your state?

I’ve served in the executive branch for 25 years, so I have a good view of government administration. Legislators have to manage a lot of different policy issues, while we in the executive branch can focus simply on health. I think it’s great to have the legislative perspective through RSG. More broadly, for someone who serves in the executive branch, RSG provides a way to engage with a variety of perspectives that help inform the debate on health care.

How has the RSG helped you?

The RSG has proven to be a good place to work amongst peers who are reforming the delivery system. I can cite many ways it has helped. The first RSG meeting I ever attended focused on dual eligibles—and this discussion helped me prioritize that set of issues in our own program. During another meeting, we heard a presentation about community paramedicine in Texas. (In the practice of community paramedicine, paramedics have expanded clinical roles.) After the RSG meeting, I asked our team in Arizona to figure out how to incentivize these innovations. Now, in Arizona, we have developed a structure where, after a 911 call, the first responder organization can treat, refer, and be paid without transporting to an emergency department. No matter what happens with financing Medicaid, the RSG will keep informing states about options that improve quality and reduce cost, such as paramedicine, value-based purchasing, and the merging of behavioral and physical medicine.

Why do you do national leadership work?

Organizations like the RSG are important to me because states have such an important role in transforming health care. At the same time, states have approached this transformation with such a wide array of initiatives. States are the laboratories for innovation and we all need to learn from one another about what works and what doesn’t. I think Arizona has an important perspective to share as part of this debate.