Tom Betlach is the former director of the Arizona Health Care Cost Containment System, the agency that administers the state’s Medicaid program. When he began his tenure at the agency working on Medicare Part D implementation — he had a finance background and was new to healthcare — the sheer complexity of the healthcare delivery system struck Betlach. “I wondered why 120,000 people in Arizona had some of their benefits delivered by one program and others delivered by another,” he says.
His mentor at the agency, Kate Aurelius, responded, “Well, if you think that’s poor system design, you should look at how behavioral health services are delivered to people with serious mental illness.” She explained that roughly half had dual plans, which were more like four plans — a Medicaid physical health plan, Medicaid behavioral health plan, Medicare, or Medicare fee for service, and a Medicare Part D plan. “That’s four different organizations involved in plan delivery,” he says.
Betlach witnessed the agency struggle with a system design involving many payers and programs. “Medicaid had to parse out who was responsible for what and try to get people to take responsibility for coordinating care and working with the member,” he highlights. “It made it incredibly challenging for the person needing services.”
Implementing Medicare Part D gave him insight into the complexities of Arizona’s healthcare delivery system — a springboard Aurelius expanded on to help Betlach better understand how services were delivered specifically for people experiencing serious mental illness.
It was 2009 and a study had just come out a few years prior highlighting that far more public mental health clients in Arizona were dying than expected (more than double). He and Aurelius were determined to develop a better care system and believed Medicaid needed to be in a leadership role to drive change.
During this period, Arizona was moving toward a comprehensive crisis system — largely due to Arnold v. Sarn, a decades-long lawsuit on behalf of people with serious mental illness that settled in 2014, and Medicaid expansion. “Even before the ACA, the state expanded Medicaid coverage to everyone under a hundred percent of the federal poverty limit,” says Betlach. He highlights that Medicaid coverage is critical for implementing and expanding a comprehensive crisis system. “Or at least helpful because it can leverage federal funding.” Both were key factors allowing for the continued maturation and growth of the crisis system in Arizona.
In 2011, the state started pursuing an integrated, single managed care plan responsible for serving people with serious mental illness in Maricopa County. It included behavioral and physical health, employment support and housing support. Developing and implementing the plan took extensive community engagement and involvement from the behavioral health and Medicaid agencies.
Betlach helped draft the procurement and expectations for the managed care organization, including crisis services. Not only was managed care responsible for comprehensive services for people with serious mental illness but also the continued evolution of crisis services. Realizing the success of the model, state leaders integrated the plan statewide.
Betlach credits Aurelius, who died in 2011 and didn’t see the plan realized, as integral to the collaboration between the behavioral health and Medicaid agencies. She had previous experience both working for a payer and as a behavioral health provider. Behavioral health leaders, points out Betlach, talk about engaging members with lived experience, treatment standards and fidelity in a way that Medicaid agencies don’t necessarily understand. Consequently, Medicaid agencies might leave those elements to their behavioral health counterparts to manage. “Kate understood behavioral health language,” he says. “She not only served as an interpreter but also gave the Medicaid agency credibility, allowing us to sit at the table.”
Even as the payer, Medicaid is often left out of critical decisions because it’s frequently without the expertise needed to leverage itself. Aurelius was a dynamic leader and communication bridge, fostering a shared vision for the two agencies. “Everyone agreed current outcomes for people with serious mental illness were unacceptable and the fragmentation indefensible,” says Betlach. (The behavioral health and Medicaid agencies eventually merged, becoming one state agency: the Arizona Health Care Cost Containment System.)
Having a single managed care organization deliver all services and for people to interface with made sense. “It also made it easier to know who was responsible,” points out Betlach. Today, a single Medicaid plan in each of Arizona’s three regions is accountable for establishing a crisis system and supporting people in crisis for the first 24 hours. In 2021, he shared with #CrisisTalk that the plan assists people through three stages of crisis care — a call to the contact center, a mobile crisis team response, and a 23-hour stay at a stabilization unit. The three providers can simply bill the health plan in their region.
Betlach often thinks of Aurelius and what she’d think of 988 and the momentum behind crisis care throughout the United States. He notes she’d be happy about the collaborative effort and engagement of policymakers, behavioral health, the community, law enforcement, Medicaid agencies, the Substance Abuse and Mental Health Services Administration, and the Centers for Medicare & Medicaid Services to align opportunities for states around developing a crisis system. “These forces have come together to advance behavioral health crisis care in a way I’ve never seen before,” he says.
He says 988, and the momentum to address behavioral health needs, is unlike anything he’s witnessed in his career and a critical opportunity for Medicaid leaders. That said, he highlights that it’s a daunting time for Medicaid. Medicaid has to do a redetermination of eligibility for all its members, a process typically done annually but put on pause during the Covid public health emergency. “Medicaid directors face a litany of issues they’re working on,” Betlach says. “However, if they’re willing to invest their time and agency resources, this is an opportunity to advance outcomes for the members they serve.”
Betlach has learned from his decade as Arizona’s Medicaid director that for crisis systems to fulfill Congress’ intent with 988, they must have viable system design, sustainable funding, metrics and data analytics, stakeholder engagement and be able to scale incrementally. “All require leadership,” he says.
As the year anniversary nears, he says it’s critical to look at how 988 is doing — what states have moved forward with crisis system redesign implementation and are funding it and which aren’t? The National Alliance on Mental Illness is mapping 988 crisis response legislation, including service fees. So far, only seven states have enacted service fees: Colorado, California, Connecticut, Minnesota, Nevada, Washington and Virginia.
The National Association of State Mental Health Program Directors Research Institute (NRI) is tracking state mental health agency initiatives, such as 988 contact centers, mobile crisis services, crisis receiving and stabilization facilities and whether the states have crisis system dashboards to track and analyze performance metrics. Some states, like Arizona, have public-facing performance dashboards.
As of April 2023, 23 states had a dashboard for parts or all of their crisis continuum — 14 had contact center dashboards, 10 had mobile crisis team dashboards, 8 had crisis receiving and stabilization facility dashboards, and 5 had a dashboard incorporating all three crisis services.
In late 2022, the National Academy for State Health Policy scanned state Medicaid managed care programs and their behavioral health performance metrics. The data includes physical and mental health service use Medicaid managed care programs measure and use in payment, such as diabetes screening and care for people with serious mental illness and mobile crisis response services that result in hospitalization for children and adolescents (only one state collects the latter measure and uses it in payment).
Betlach says an agency or office has to be accountable for the performance 988. While in most states, that’s the behavioral health office, the lead organization must regularly partner with Medicaid. “At the end of the day, Medicaid is the primary payer of these services and has levers it can use on plans and providers,” he says. In partnership with behavioral health, Medicaid can identify gaps, look at overall performance, and develop iterative ways to continue growing and expanding care.
“I don’t think you can ever declare victory,” he says. “There will always be ways to evolve and improve the system.”