Tom Betlach, one of the country’s longest-serving Medicaid directors, has been at the helm of the Arizona Health Care Cost Containment System since 2009. Under his guidance, the state has become a national leader in key areas, including physical and behavioral health integration, aligning services for dual eligible populations, and improving the delivery and efficiency of long-term care. CHCS recently spoke to Mr. Betlach, the immediate past president of the National Association of Medicaid Directors and a former fellow of CHCS’ Medicaid Leadership Institute about the significance of leadership development in his career.
Q: What are some of the earliest lessons you learned in your career regarding the value of strong leadership?
A: The first stage of my career was in the governor’s budget office. I learned very quickly the power of strong leadership and the impact it had in terms of communicating a clear path forward for initiatives across the state — whether around transportation, education or health care. “Growing up” in the budget office was a tremendous first opportunity to have a front row seat for seeing the value of leadership, how it impacts lives within a community, within a state, and sometimes more broadly.
Q: What role does leadership play in your work as a Medicaid director?
A: In Arizona, Medicaid is responsible for 1.9 million lives, $12 billion dollars, 50 percent of births, and two thirds of nursing home days. It is the state’s largest health insurer, covering 28 percent of the population. We have a tremendous ability to influence how care gets delivered, the quality of care, and the cost of care whether through delivery system transformation, value-based purchasing, system design, or other changes. Leadership is critically important in being able to prioritize issues and make sure departments have the staffing and capacity necessary to deal with complexity and change. When I think about our team and the massive amount of work that is done on a regular basis, it’s not me, it’s not my deputies — it’s the many dedicated public servants across the organization who are getting it done. Leadership is making sure those folks feel engaged and valued and have the resources they need, then getting out of the way to let them do the incredible work they do.
Leadership is also having the ability to look beyond everyday crises. You need to have processes and people in place to effectively deal with the day-to-day — so you can look ahead to address longer-term issues. We’ve been working on physical and behavioral health integration for seven years, but we’re not done yet. We’ll take another huge step forward in the next 12 months — but it has been a long, multi-year journey. Leadership is having the persistence to drive that change consistently over long periods of time.
Q: AZ’s integration effort has received much attention as a notable success story. What leadership strategies were key to the successful integration of behavioral health services within Arizona’s Medicaid agency?
A: First, we had to admit that we did not have all the answers. We had to engage stakeholders across the state — providers, plans, tribal leaders, families, and others — to determine how to best move forward. We had a broad sense of what integration could look like, but we needed to learn what integration meant to these key stakeholders and identify what resources they would need to make integration successful. Leadership was all about being patient in meeting the expectations of all stakeholders and being thoughtful about how integration would work for all involved. We also learned that in order to successfully merge with our sister agency, we needed to have different resources and different skill sets in our organization and the ability to bring everyone to the table and look at policies holistically.
Q: It sounds like there was a willingness to take risks along the way in pursuing integration — what are strategies that allowed individuals to take those kinds of risks?
A: The risk to integration becomes secondary when you look at the challenges of the existing system and the realities of people served — the individuals with serious mental illness dying 30 years younger than their peers because of a chronic condition. The 75-year-old widow who is not getting the care she needs because she is confused about navigating Medicaid and Medicare. Our rallying cry was that the status quo is not acceptable — it is not acceptable from the quality of care being delivered or from the confusion that the member has to navigate. And it is not sustainable from the public’s perspective in terms of costs of the program. In moving integration forward, we have driven a lot of change into the program — and there are plenty of risks associated with that. But I would argue that staying where we were is even more risky for the people we serve.
Q: How did your participation in the Medicaid Leadership Institute (MLI) contribute to your success and the success of Arizona’s integration approach?
A: When you compare state government to the corporate world — or even other government agencies like the Department of Defense — state government does not have any comparable leadership development infrastructure. State government promotes people because of their knowledge and their skill sets, but rarely provides leadership development training. MLI was the first formal investment made for my leadership development and it came at a critical time. I had just become Medicaid director, the state was in the deepest recession it had ever been in — we had lost a third of our general fund, our population had grown by 35 percent, and we faced a billion dollar shortfall. Medicaid was in the crosshairs in terms of the overall size of the program coupled with enhanced federal funding going away. The opportunity MLI provided to spend quality time with my peers, have a safe space to talk with them and with leadership coaches, and discuss strategies to address these challenges was invaluable. It enabled me to formulate a plan to not only emerge from the recession, but create a longer-term vision to come out as a stronger program able to pursue integration and other delivery system innovations.
Q: What advice would you give to a new Medicaid director or future Medicaid leaders?
A: For starters, I would advise folks to always feel they can reach out to peers with questions. I’ve been in Medicaid for 15 years and I still learn something new about the program on a daily basis. Second, in order to manage day-to-day challenges effectively — and find time for long-term priorities – they need to build a strong team. Third, take opportunities to meet stakeholders and build relationships — including the governor’s office, providers, manage care organizations, advocacy groups — so you have a network of individuals to tap on a regular basis. Fourth, identify the top three priorities for the long-term and figure out how to resource those multi-year initiatives. There will always be challenges that arise, but a strong leader needs to keep his or her long-term goals in sight.
And finally, so many of the former Medicaid directors I know say that being a Medicaid director was the greatest job they ever had. Those who are newly entering this position should take the time to fully enjoy this role — it’s a wonderful job to be able to impact on a daily basis all the people and the communities that we live, work and play in.