#5 – Connecting Care Through a Clinically Integrated Network

Technology, trust and transformation — three forces reshaping the future of healthcare in North Carolina. In this episode of Pulse on Carolina Health, host Robert Shaw, co-chair of Smith Anderson’s Health Care practice group, sits down with Shaun Cox and Doug Golub of Element by Arkhe Consortium Health, two leaders driving the state’s Medicaid transformation toward integrated, value-based care. 

Shaun and Doug share how Element is helping small mental health and substance use disorder providers leverage data analytics, AI-powered insights, and clinically integrated networks to close care gaps, improve outcomes, and bring culturally sensitive mental and physical healthcare to North Carolina’s most vulnerable communities. 

From navigating the challenges of Medicaid reimbursement to embracing AI’s growing role in care coordination, this conversation explores how innovation and collaboration are transforming healthcare delivery. 

Host - Robert Shaw, Partner, Smith Anderson
Guest – Shaun Cox, Chief Executive Officer and Doug Golub, Value-Based Care and Population Health Consultant, Element by Arkhe Consortium Health

Smith Anderson is a full-service business and litigation law firm serving regional, national and global companies. Our team of experienced health care lawyers are committed to guiding medical professionals, hospitals, health care facilities and industry organizations through the attendant changes and evolving regulatory environment. We advise on health care policy, legislative advocacy, executive strategy, mergers and acquisitions, privacy and data security, litigation and the complex business requirements of organized medicine. We have been integrally involved in launching innovative health care delivery initiatives such as clinically integrated networks, joint ventures between health systems and practitioners, Community Care of North Carolina and Accountable Care Organizations (ACOs) nationwide.

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Transcript

[Speaker 3] (0:00 - 0:42)

Hello and welcome to Pulse on Carolina Health. I'm your host, Robert Shaw, co-chair of the Health Care Practice Group at Smith Anderson. I am pleased to welcome Sean Cox and Doug Golub of Element by RK Consortium. 

Sean and Doug are leaders in the value-based care transformation of the North Carolina Medicaid program towards integrated care, using the latest in data analytics and population health management, with a focus on strengthening culturally sensitive mental and physical health for our most vulnerable communities. Sean and Doug, welcome to the podcast. Thank you for having us. 

Great to have you on. Before we get started, Sean, please tell us a little bit about yourself. What's your health care background and how did you get involved in integrated care? 

[Speaker 2] (0:44 - 1:43)

Well, health care is something that I have loved to do for quite a long time. I've been in this field about 20 years. I fell in love with it, oddly, when I was on my way to law school. 

I saw my first child get better in a behavioral health day treatment setting, and I have not looked back since. 20 years of experience doing acquisitions and mergers, restructures up and down the east coast of North Carolina, South Carolina, the east coast of the United States, and also decided it was a good time to go back and get my license. So I'm also clinically trained and sound, and so I feel like I bring a unique perspective, a clinical perspective and background of some of the barriers that providers have to overcome as we try to navigate this ever-changing health care landscape and support our members. 

[Speaker 3] (1:44 - 1:56)

Mm-hmm. And that led you to begin a clinically integrated network called Element. What is Element and how is it serving the Medicaid program? 

[Speaker 2] (1:57 - 3:02)

So Element is a clinically integrated network in an ASO, and it's been for certain, Robert, a labor of love, if you would. We are dedicated to providing comprehensive education and coaching services tailored to the unique needs, as I just mentioned, of health care professionals through robust platforms like electronic health records, care management information systems, learning management information systems like Element University to include predictive analytics and dashboards and data lakes and things of that nature. And to just basically sum it up, we provide affordable technology to small providers in the state of North Carolina that would normally not have access to such robust platforms. And with that, you have to also bring education. 

So it just led me to add the education component in to also be supportive of our members and our providers to support our members throughout the state of North Carolina. 

[Speaker 3] (3:03 - 3:10)

Okay. And what kind of providers are we talking about there in your network? How many of them and where are they located? 

[Speaker 2] (3:11 - 3:30)

So throughout the state of North Carolina, we serve and are contracted with every MCO in the state of North Carolina. We have about two dozen providers that we support in each catchment area, and we have about 30,000 members or covered lives, if you would, in Elements Network currently. 

[Speaker 3] (3:31 - 3:42)

Wow, 30,000. That's a really big number. And when you MCO, let's unpack some of these words. 

What is an MCO and how they serve the Medicaid system? 

[Speaker 2] (3:44 - 4:07)

So an MCO stands for Managed Care Organization. And if you would, they are a non-profit payer, if you would think insurance company, but a non-profit insurance company or payer that manages all of the care for behavioral health, SUD services, IDD and residential services. So basically the spectrum of mental health care throughout the state of North Carolina. 

[Speaker 3] (4:09 - 4:24)

And I hear that they were at one point focused on substance use disorder and behavioral health and that we had Medicaid transformation. What does that mean to you and how did these pre-paid health plans factor into that? 

[Speaker 2] (4:25 - 5:07)

Medicaid transformation. So now we've had a lot of terms, if you would, unpacking terms. We've gone all the way through the gamut you can imagine in 20 years of providing behavioral health and SUD services in the state of North Carolina from an area mental health to an LME to an MCO and now with Medicaid transformation tailored plans. 

And basically they are providing more integrated care. And if you would, courting primary care providers and hospitals to come in to their network via Medicaid expansion has allowed that in and whatnot. So that's the. 

[Speaker 3] (5:08 - 5:29)

Yeah, Sean, you talked a little bit about bringing those, the data analytics and technology solutions to your providers through this network. Maybe it's a good opportunity to bring in Doug here. Doug, tell us a little bit about yourself. 

I hear, you know, a little bit about technology and how does that factor into what Element does? 

[Speaker 1] (5:29 - 9:00)

Thanks, Robert. Well, I started my career around 2001. I was a direct support professional working with people with disabilities and understanding some of the disparities that exist in bringing together the biopsychosocial model, right? 

It's not just healthcare. Healthcare doesn't just happen inside the walls of a hospital or of a setting, but it is the world around you. Back in 2003, I recognized that especially for home and community based providers, there weren't a lot of good options for actually documenting, recording, finding a way in a database type setting to recognize what's going on. 

Everything was on paper. So I founded an electronic records company back then because there wasn't anything else around. And over the course of the 20 plus years after that, I left for a couple of years and joined Microsoft and their health solutions group that helped me to work with some of the biggest health systems in the country, in the world, including Novant in North Carolina and understanding what the state of our technology looked like. 

This was 2007 to 2011. In 2009, 2010, after the passage of the Affordable Care Act, some of the things that we were starting to recognize were barriers to really bending the curve of improved outcomes, morbidities, mortalities, especially for complex populations. They became part of federal policy and they had been before. 

For example, looking at the social determinants of health and understanding that the concept of a health home and care coordination in a way that could be extended to complex Medicaid populations. My work changed from creating databases for providers to be able to document what they did to actually taking down some of those silos and looking at a population level of opportunities to improve those outcomes. When North Carolina started Medicaid transformation several years later, we had a public health emergency in the middle of that that probably didn't help with the trends, but this is life. 

When that started to happen and we started making available these tailored plan services and coordinating care, I recognized then some of the opportunity. And I'm no longer with the Electronic Records Company. I now work with different groups and work with Element. 

But some of those social determinants of health measures, what we capture in assessments, what we capture from our claims data, what we capture from whatever data sources that we have can help to guide and influence where resources are necessary, which people to help prioritize, what works, what doesn't work. And hopefully we'll talk about more of that today. But it's been an incredible opportunity because North Carolina really has been a leader. 

It is probably one of the more recent states to expand Medicaid, but they get to learn from what several of the other states have done and have worked in other states to understand how do we prioritize limited resources to help people live the lives they choose in the best possible environments, lowest possible costs, best outcomes, best satisfaction, the triple aim. And so working with Element really is a pleasure because not just Element, but our members, they get it. They have the lived experiences and they can build trust with the community to be able to remove that stigma wherever possible and get people the support that they want and that they need to live the lives they choose. 

[Speaker 3] (9:02 - 9:16)

We talked about a buzzword with Sean just a minute ago, clinically integrated network. So I ask the same question to you. What does that term mean to you and how is that being lived down in Element? 

[Speaker 1] (9:16 - 14:32)

It's a great question. So we have some of the best providers in North Carolina. North Carolina has some of the best providers. 

They're local. They understand the communities. They're part of communities. 

They're trusted and have been around for many years with successful outcomes. But we can't do it alone. And so having silos where all we do over here is behavioral health. 

All we do over here is primary care. All we do over here is one particular domain. That's not integrated. 

That's not effective. And for a person trying to navigate the system out there, there are a lot of different silos and you don't know what you don't know. And as a result, our costs are higher than they need to be. 

Our outcomes are probably lower than they need to be. And people are confused and frustrated. What a clinically integrated network does, and it's part of the Medicaid transformation, the way that North Carolina has created these opportunities for clinically integrated networks, they pull together these advanced medical homes. 

They pull together these case management, care management agencies so that multiple agencies working together can join an organization like Element. And there are several, but each one has its unique features that make it critical to North Carolina and the people that we serve. These clinically integrated networks, one of the key components is having technology. 

So, you know, if I'm a provider and I support 500, 600 people, I'm doing the best that I can. But suddenly I can leverage some of the data insights, some of the training best practices, some of the electronic tools, some of the advocacy that come from being part of something bigger with 30,000 people where I'm still incredibly important, haven't lost my identity at all as a provider, but I'm stronger together with other providers. And that's what these clinically integrated networks do. 

It allows us to bring on top notch consulting and, you know, top notch medical advice and top notch relationships with the leveraging the power of multiple groups working together while still being able to provide each individual with the support that they need and that they choose. These clinically integrated networks are incredibly important. And the other part of it is we have an opportunity to partner with the four local management entities, managed care organizations across the state of North Carolina, each one covering a different geography with very different landscapes when it comes to urban rural, when it comes to racial differences, income differences, health outcome differences. 

And so that kind of patchwork of being sensitive to each local community, it's not easy to do, but that's what the providers in each of the local communities are able to do. And particularly in in, in the Charlotte area and the Raleigh area, and many of those counties put together Alliance Health is the local management entity, managed care organization, LMEMCO. And they've provided, they were the first to provide some opportunities to groups like us, a clinically integrated network to be able to do something that was also part of the Affordable Care Act and part of Medicaid transformation, which is called value-based care. 

So going back over the last several decades of health in North Carolina and across the U.S., we've had a fee-for-service model that didn't necessarily incentivize being the most efficient with dollars. It incentivized many providers to do the things that you get paid for, which would be the logical conclusion anyone would end up at when you're trying to take a look at the finances, but it wasn't necessarily the best for, for outcomes and for being good stewards of public funds. What value-based care does is there's, there's, it came from, well, out of the Affordable Care Act, it was codified and we continue to work with it. 

It provides incentive payments. It's either upside or risk, but in this situation, it's, it's upside. When we're able to close different gaps for the people who are on our caseloads, who, who choose the providers that connect to, to the clinically integrated network, there are payments available. 

When a gap, a gap is closed, when someone has, you know, an annual well child visit, when someone's been hospitalized and we follow up after a hospitalization to make sure that they're not readmitted again, when it's preventable, there are several examples of this. There are actually incentive payments available because we know that in the long run, it reduces costs and improve outcomes and study after study shows that. And we're beginning to be able to show that here at Element as well, that this value-based care model is an alternative payment model to fee-for-service. 

And it makes a big difference for costs and for people's lives. And we're really proud to be able to partner with Alliance to make that happen. 

[Speaker 3] (14:33 - 14:53)

And Sean, sounds like a lot of the movement here in, in the last few years with Element and partnering with Alliance. Tell us a little bit about how you've partnered with Alliance to make these improvements in care and, and help your members achieve that digital transformation goal. 

[Speaker 2] (14:56 - 16:39)

Alliance Health has been an amazing partner to Element. I often say Element was born out of Alliance. This has been a multi-year project. 

Element definitely did not just come about. We went through a long due diligence and discovery period through the help of Sean Schreiber at Alliance. And I definitely want to always say thank you to his efforts with this. 

We definitely saw that there was a need for a clinically integrated network that specifically supported small providers throughout the changes in North Carolina, if you would. To that end, Alliance has helped us with the support of all of our data analytics through their Novolon system, through us building our system out through SIFWELL to provide data analytics and education on how to read those predictive analytics, and also to help providers implement and understand how to apply those things within their own practices. They've been supportive, of course, financially, that goes without saying, but not just financially, but through education, through the structure, helping building Element through different connections and things of that nature. 

But it's definitely been, if you would, a labor of love, I would say, not only for Doug, for myself, but for Alliance. And it shows their strength and their understanding to support small providers and make sure that they also survive this ever-changing landscape in healthcare. 

[Speaker 3] (16:40 - 17:14)

You heard Doug mention a little bit about some of the metrics and goals that help increase the quality of healthcare, lower the cost, and those kinds of objectives. From your perspective, how is Element working with Alliance to achieve those objectives? Do you think you've made progress on increasing the quality of care and controlling costs and making the provider-payer Alliance more fruitful and strengthened? 

[Speaker 1] (17:17 - 20:30)

Yeah. There are several key ways that we can help to do that. And so part of the Medicare transformation, especially in what's called the tailored plan for people that qualify because of substance use, traumatic brain injury, intellectual disability, behavioral health needs, having a care manager that's paying attention to you and your data is a big help for those people who are interested in having that. 

So some examples, and there are many, but some of the examples of what we use Cifuel Health and the dashboards to be able to provide data on is, for the first time, we're getting data as the care manager. People have consented to share data on their medications and their medication fills, on the procedures and their use of health care and other behavioral health services for engagement. So we can see some of these things. 

We think about the opioid epidemic here in North Carolina, and there are medications for opioid use disorder. They're only effective if you take them. Similarly, medications for other behavioral health needs, for schizophrenia, for example. 

And so we have measures that we take a look at. One in particular, adherence to anti-psychotic medications for individuals with schizophrenia. We can tell when a medication's been filled, when a prescription's been written, when the order's been made. 

And if it hasn't, well, then you know for sure the person's not taking those medications. Medications are not the answer to everything. However, when it comes to medications for opioid use disorder, medications for schizophrenia, if you're not taking your medications, what ends up happening from there is it's linked to relapse, it's linked to hospitalization, and then you get into factors related to your employment, to your social settings. 

So helping to support consistent medication management through coordinated care is something we can see right away on our dashboards and our care managers, our coaches, through having regular weekly rounds with the care management agencies that we work with can help to provide strategies, training, pinpoint how we can be helpful, what the studies and what our own examples tell us work and what doesn't work for a population that isn't also always open to some of these supports if the trust isn't there and if the relationships aren't there. So that's one of the other really important parts here. I've spent my entire career working on the data side of things. 

That's only half the battle. The other is the relationships and the trust. The data doesn't do anything by itself. 

And that's why the incredible team here at Element and the absolutely incredible people that we have the opportunity to work with at the different case management, care management agencies, events, medical homes, really do help provide options that otherwise would have many people falling through the cracks. And we've got plenty of success stories. There's still plenty of challenges, of course, but plenty of success stories of really moving the needle here in North Carolina. 

[Speaker 3] (20:32 - 21:22)

Yeah. When I think of value-based care, I think of at least two important things, and they're equally important. One is it's all about incentives and aligning incentives and coming up with a more meaningful relationship between the provider and the patient and the payer to align those goals. 

And then the other piece of it is culture transformation, like you said, which is how do we transform the delivery of health care and connect those goals to the culture of the communities that we serve and the culture of the providers that we work with? To me, that's a really important part of what you're doing in Medicaid transformation and value-based care transformation. 

[Speaker 1] (21:22 - 24:23)

That's a really good point. Specifically around the providers, I've been working with providers my entire career, and we're working largely with public funds. There's a lot of scrutiny, right? 

It doesn't take much to get a news story that's been something in a way that we see it all the time. And yes, there probably is some real fraud, waste, and abuse. It gets a lot more in the news than it probably, as the scale, it over-indexes a bit in the news. 

We're a very heavily regulated space, and our audits and the documentation and the requirements are ever-building. For providers, they are stretched really thin. The rates are, you know, can't always pay people what they're worth, which is not unique to our space. 

However, in that work, we understand that there is a big need to try to do all these things, all of these regulatory requirements, all the forms we're supposed to fill out, and you don't necessarily get paid for it. What value-based care does is a big departure from some of the past challenges, which is things that weren't specifically billable before, right? Some of the extra things we may do to help buy supplies for people, and Alliance and the managed care organizations do a great job of providing different options, incentives, benefits. 

These weren't necessarily paid for by anything before, you know, certain services. And what the value-based care measures do is you don't have to specifically be paid for every little thing that you do. If you can follow up with somebody and prevent a hospital, prevent readmissions to the hospital, if you can have annual well-care visits where you pick up on things in a preventative way so that years down the road, you catch something early, right? 

Like I said about the hospitalizations, improving seven-day discharge follow-ups so that when people are discharged, they have some of the instructions of what they need to do next. These weren't necessarily funded before, and now those incentive payments are available for doing the things that we know data tells us in a data-informed way makes a difference. It helps providers to be able to do the things that weren't billable before. 

Now there's an incentive. Now we're all aligned and on the same page, and it's not perfect, but it's a lot better than just sort of chasing what can I get paid for because that's not necessarily what gets people the better outcomes or gets the most out of the investment that the state of North Carolina is making, and so it's a really positive move towards value-based care for the people who are members of these organizations or who use these services, but also for all North Carolinians to raise the bar to improve healthcare and outcomes across the state. 

[Speaker 3] (24:24 - 24:41)

Mm-hmm. Sean, we heard a little bit about quality metrics there with Doug's discussing value-based care and also the reimbursement trends. What's most on your members' minds these days? 

What's concerning them, and what are they really focused on right now? 

[Speaker 2] (24:44 - 25:59)

Well, of course, the looming thing, the change with the budget cuts that will change the rates for the services that they provide. That's a huge concern and stressor with their organizations because as you know, a lot of our providers, a lot of them live reimbursement to reimbursement. That can mean for some providers, depending on their size and their arrangement of services month to month, some it can mean week to week. 

So right now, I would say that's for sure the number one stressor and how it's going to affect their organizations. With our quarterly provider meetings, we polled them and we asked them before all of the budget cuts, what was the thing that was on their mind? And the thing that they came back with was risk management. 

So we're making sure with Element University, which is in our learning management information system, and also with our coaches, that we provide strategies and training and coaching to that end to be able to help them with risk management. And then also, of course, how to help the changing landscape with these budget cuts and rate cuts for the services that they provide. So I would definitely see it say, Robert, those are the two top things right now. 

[Speaker 3] (26:00 - 26:07)

In your crystal ball, what do you see in Element's future and the Medicaid program's future over the next few years? 

[Speaker 2] (26:09 - 28:54)

Listen, again, I can't say enough how Element has been a labor of love. And this is something that I enjoy doing. Again, I have 20 years of experience building agencies up and down the East Coast, being a licensed clinical mental health counselor, supervisor, and addiction specialist as well.

 So I sat in the seat, being the butcher, the baker, and the candlestick maker, and understanding that sometimes you're facilitating the classes, you're driving the bus, you're the payroll person, you're the human resources person, you're all the things at the end of the day. We were able to effectively launch the Clinically Integrated Network. We have started to get VBC payments out to our providers.

 And we also, as you know, we have formed implementation that has been seamless to a lot of our providers. The next steps, I would say, for Element is to help them with some of the things that I just named. In Q1, we're looking forward to developing and realizing the ASO function. 

So some of those things that they have to do in the back of the house, or the organizations that stretch them thin. And this is something that I don't think a lot of people take into consideration. Some of these, if you will, these quality issues that they have, or compliance issues, if you will, that they have, they're not necessarily intentional things sometimes. 

Sometimes they're stretched too thin. If you're in the agency, and you're doing things, and let me give you a quick story of something that's enduring to my heart when we started Element. We had a provider, bless her heart, she wanted to use our platforms. 

And she also had an emergency call that the county that she was providing services in could not take. This is the owner of the organization. She got on their van that takes the emergency calls because the county could not get to the patient, if you would. 

And at the same time that our team is providing her the information for these platforms and services to help her, she's also on her way to an emergency call that the county cannot take. So if you will, these are the type of providers that we support at the end of the day. And I've been one of those providers for many years in the Carolinas. 

And I understand because I've sat in that seat. If you will, what's on the horizon for Element to make sure that we dig a little bit deeper and we realize some of these other things that we can do to support these providers and help them survive this changing landscape in the state of North Carolina. 

[Speaker 3] (28:55 - 29:12)

Oh, fantastic. Doug, I expect you probably have a crystal ball as well. And we could probably do a whole other podcast about this topic. 

What does your crystal ball tell you about digital transformation in health care over the next few years? 

[Speaker 1] (29:13 - 29:59)

Well, I think it's exciting, right? I mean, some of the rise of AI comes with some huge opportunities and plenty of problematic risks as well. But we're beginning to see more and more of that to help us with strategies to help pick up on something. 

You know, one of the, I mean, there's so many great pleasures of working with Element and with Shanshan. I mean, his story after story, having been a provider herself with people that will still call her in the middle of the night when they're in crisis. And you're not going to be able to get past the human touch there. 

But that lived experience is, well, the experience is incredibly important. The technology is getting closer and closer to being able to bridge what only people