By Dominique Perkins
This month we are addressing the topic of serving Arizona’s underserved populations – a constant struggle, and a significant effort across many organizations and services. We thought it only appropriate to sit down with Dr. Sara Salek, Chief Medical Officer for the Arizona Health Care Cost Containment System (AHCCCS), to discuss State programs, resources, and issues.
The very model
AHCCCS was founded in 1982 – the first state-wide Medicaid managed care system in the nation. Structured to encourage competition and choice, AHCCCS is widely considered a top model for Medicaid programs nationwide
Since its founding, the program has operated under a federal Research and Demonstration 1115 Waiver. Salek says this set-up, “Allows for the operation of a total managed care model and provides for increased flexibility for how we run our Medicaid program.”
“AHCCCS selects contracted health plans via a highly competitive request for proposal process,” she said. “This health care model allows for member choice of health plan, management of health care networks which are monitored on quality metrics, as well as managing overall healthcare costs.”
Healthcare services include:
Acute health care services:
- Physician services, family planning, immunizations, prescriptions, surgery, hospitalizations, emergency care, and transportation.
Behavioral health services:
- Counseling, medication management, case management, peer support, residential services, and hospitalization.
Long-term care services:
- Attendant care, assisted living, and skilled nursing facility care.
According the AHCCCS website, the program includes over 60,000 health care providers, serving members living at or near the poverty level. The system covers over 1.9 million Arizonans, over 50% of the births in the state, and two-thirds of the nursing facility days, based on projections for 2017, Salek said.
AHCCCS resources reach state-wide. In fact, they are required to, Salek said.
“For example, for Maricopa and Pima Counties, contractors who provide acute care services are required to provide PCP, pharmacy, and dental services so that 90% of their membership do not need to travel more than 15 minutes or 10 miles from their residence (unless accessing those services through a Multi-Specialty Interdisciplinary Clinic),” she said.
Each network and area has carefully followed standard of care and access. Salek also said that AHCCCS is currently in the process of updating their telemedicine policy to address the ongoing needs in rural communities.
In Arizona, behavioral health has historically been a “carved out” benefit – separately managed by health plans called Regional Behavioral Health Authorities (RBHAs). Due to this structure, multiple health plans are involved in meeting mental health needs, and navigating the complex system is frequently a challenge and a barrier in obtaining care.
This can be further complicated by concerns regarding medication adherence and stigma, and in some cases these complications and fears can also result in avoiding physical health care as well as mental health care.
With the goal of creating a more streamlined system to address these issues, AHCCCS collaborated with other behavioral health partners to reduce some of these barriers. Beginning in April of 2014, approximately 17,000 members with Serious Mental Illness (SMI) were transitioned a single plan: Mercy Maricopa Integrated Care, to manage both their behavioral and physical health care needs in a “whole health” approach.
The following year, in October of 2015, this model was implemented statewide through contracts with Health Choice Integrated Care in Northern Arizona, and Cenpatico Integrated Care in Southern Arizona.
“Further health plan integration efforts are underway,” Salek said.
“Integrated Contractors responsible for both the acute physical and behavioral health care needs of adults on AHCCCS (excluding adults determined to have SMI) and children on AHCCCS (excluding foster children covered under CMDP) will begin October 1, 2018.”
While Arizona homelessness has decreased some in recent years, it is still a very real problem throughout the state. According to the Department of Housing and Urban Development’s annual report to Congress in November 2016, homelessness has dropped 30% since 2010.1
Salek described the ACHHHS approach to aiding the homeless populations in terms of overall public health:
“As homelessness is a significant social determinant of health, our health plans work with their local community partners and their contracted network to address the unique needs of this population, including addressing access to primary care and housing resources,” she said.
“Published studies demonstrate that the rate of emergency department utilization and hospitalization is higher among the homeless population compared to the non-homeless low-income population, making accessing these outpatient services and resources critical in improving overall health care outcomes and costs.”
Specific programs are available through the RBHAs to support those who have SMI and are able to live independently. Assistance may include rent subsidy, supportive and transitional housing programs, home-repairs, and eviction prevention programs.
“Independent living is supported with provider-owned or leased homes and apartment complexes that combine housing services with other covered behavioral health services,” Salek said.
Dr. Salek has been the Chief Medical Officer for AHCCCS since 2014. Salek provides clinical leadership to both the AHCCCS Division for Health Care Management, which oversees our health plans, as well as the Division of Fee for Service Management (DFSM), which includes the American Indian Health Program (AIHP).
“In my role as CMO, I oversee both medical and quality management functions, which includes addressing member access to care issues and quality of care investigations,” she said.
One a daily basis, she also oversees pharmacy services, consults on grievance and appeals, and addresses billing and coding issues.
“The current clinical initiatives my team is working on includes combating the opioid epidemic, improving the service delivery system for children and adults with autism spectrum disorder, and addressing the complex needs of children involved with the Department of Child Safety (DCS),” Salek said.
Dr. Salek is a native Arizonian, born and raised in Tucson, Arizona. Her family was a powerful influence in her education, and stressed the importance of math and science from an early age. When she was 14 years old, Salek went to work as a candy striper at Tucson Medical Center, and her decision to pursue medicine was sealed.
“Working in the hospital setting came second nature to me and I was exposed at this early age to all facets of humanity—kindness, compassion, hard work, and suffering,” she said.
She completed her undergraduate degree in Nutritional Sciences at the University of Arizona, and then went to medical school at the The University of Arizona College of Medicine – Phoenix.
Salek is board-certified in both adult and child & adolescent psychology. She completed her residency in adult psychiatry at Banner Good Samaritan Medical Center in Phoenix, Arizona, and also did a Child Fellowship through Children’s Hospital Boston, through Harvard Medical School.
After Boston, Salek returned to Arizona and practiced clinically in adult and child psychiatry for a short while, before entering a different side of medicine – administrative. She worked as the Children’s Medical Director at the Arizona Department of Health Services Division of Behavioral Health Services. When her husband got a job for Stanford University, she went back to clinical practice for a while in Palo Alto, California, where she also served as the Addiction Consultation Team Medical Director for the Palo Alto Veteran’s Administration.
Upon returning to Arizona, she began work with AHCCCS.
State resources & funding
With such an expansive, complex program, many steps are taken to ensure proper use of resources. New programs being implemented, and new needs identified mean that every bit of funding counts.
To guard against fraud, and other waste and abuse, the ACHHHS has an Office of the Inspector General (OIG), which is responsible for the integrity of the program. ACHHHS also accesses and contracts with data analytic vendors to counter fraud and other concerns, including:
- HMS: Which provides regular data matches with commercial insurance carriers to determine third party coverage that can be used for coordination of benefits.
- Work Number: Which provides real time salary data for employers that account for over one-third of the employees in the state.
- EDI Watch and Medicaid Integrity Contractors (MIC): Which analyzes Medicaid claims data to identify high-risk areas including billing irregularities.
- Medi-Medi: Which identifies potential improper billing and utilization patterns for the Dual Eligible population (Medicare/Medicaid).
- Fraud Investigations Database (FID): Which lists all federal Medicare-related investigations.
- Other government databases: Including Social Security, ADES Base Wage data, Motor Vehicle Department, and the Arizona Criminal Justice Information System.
These security measures have proven very effective, according to Salek.
“In 2016, AHCCCS realized over $1 billion in avoided and recovered costs as a result of coordination of benefits, third party recoveries, and AHCCCS OIG activities,” she said. “OIG supported the investigations of 62 successful prosecutions of either members or providers.”
To make a report of suspected fraud, waste or abuse, please contact the AHCCCS OIG at 888-ITS-NOT-OK or 888-487-6686.
Data such as this and other critical components are published on the AHCCCS website2 to ensure transparency, Salek said.
“This includes our medical policies (AHCCCS Medical Policy Manual-AMPM), our contractor policy (AHCCCS Contractor Manual-ACOM), health plan contracts, health plan performance, health plan compliance-based actions, and contractor audited financial statements,” she said.
Meeting an ever-growing need requires an ever-growing set of resources. New initiatives, partnerships, contracts, and programs make so much of this possible. Currently, ACHHHS is a $12 billion program annually.
“We are required to provide a state match of 26% in order to draw down the federal funds for our program,” Salek said. “Annually, during the state legislative session, legislators finalize the annual State budget, which includes the allocation of funding for our program.”
The 2017 legislative session has added a few services to the program, including an outpatient occupational therapy benefit for acute members, and restoration of the adult emergency dental benefit up to $1,000 annually.
In May of this year, the Department of Health & Human Services Substance Abuse and Mental Health Administration (SAMHSA) awarded Arizona a grant of a little over $24 million over a two-year period, to combat opioid use disorder (OUD) and opioid-related deaths.3
These funds will allow AHCCCS to expand their existing strategies, which include co community-based access to the overdose reversal drug, Naloxone; prescriber and patient education; opioid prescribing practices; and complex case management and care coordination.
Plans are in place to create an opioid monitoring initiative to capture, report and share opioid-related data, a comprehensive needs and capacity assessment, and a state strategic plan to address the gaps in prevention, treatment and recovery support, Salek said.
“Efforts will focus on increasing access to OUD treatment, expanding access to Medication Assisted Treatment (MAT) through stigma reduction and education, enlisting new MAT providers, ensuring 24/7 access to care points, increasing access to peer support services and increasing recovery support options,” she said.