Latest / Becker’s Payer Issues Podcast / From Reactive to Proactive: How AI Is Transforming Care Management

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From Reactive to Proactive: How AI Is Transforming Care Management · Becker’s Payer Issues Podcast

• 0:00
  Everyone. This is Lucas Voss with Becker's Healthcare.
• 0:02
  Thanks so much for tuning in to the
• 0:03
  Becker's Healthcare podcast series. It's fantastic
• 0:06
  to have you excited for today's episode
• 0:09
  from reactive to proactive
• 0:11
  AI's role in the next generation of care
• 0:14
  management. And joining me for today's discussion, very
• 0:17
  excited to have them both on, Michelle Fullerton,
• 0:19
  vice president care management and customer consulting at
• 0:21
  Blue Cross Blue Shield of Michigan, and Connie
• 0:24
  Duquesne, senior vice president strategic solutions of MindYou.
• 0:28
  Michelle and Connie, thanks so much for being
• 0:30
  here today. It's great to have you.
• 0:32
  Excited. Happy to be here. Absolutely. It's great
• 0:34
  to have you. We'll start off with introductions,
• 0:36
  for our audience here. Michelle, why don't you
• 0:39
  kick us off? Can you share a little
• 0:40
  bit about your background and your work in
• 0:42
  health care?
• 0:43
  Sure. Well, hi, everyone. I'm Michelle Fullerton. I
• 0:46
  am a nurse. I'm also a certified case
• 0:49
  manager. I have been with Blue Cross Blue
• 0:51
  Shield of Michigan
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  for twenty eight years,
• 0:55
  have worked in a variety of roles as
• 0:58
  a nurse on the phone with patients,
• 1:01
  all the way to now being the vice
• 1:03
  president of care management, but I've also worked
• 1:05
  with our group customers in population health.
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  I love care management. I think it's a
• 1:11
  wonderful profession,
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  and I think that we are the core
• 1:15
  of what a health plan can deliver to
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  help patients
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  when they're in their times of trouble.
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  Absolutely. Connie, over to you.
• 1:25
  Yeah. So thank you. So first, I wanna
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  say I agree with Michelle
• 1:28
  core of care with land with the care
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  managers.
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  My background is telephonic intervention,
• 1:36
  call centers. I'm a behavior change professional.
• 1:39
  So I have more decades than I should
• 1:42
  probably say on this,
• 1:43
  podcast
• 1:45
  experience.
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  But now I have the opportunity to bring
• 1:48
  those skills to MindYou
• 1:50
  to help
• 1:52
  payers and providers and other groups sort of
• 1:55
  think about how do we incorporate what we
• 1:57
  do here at MindYou into their current processes
• 2:00
  and sort of reimagine
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  how could they use
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  AI,
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  mind you, Eleanor,
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  in providing care to their members and patients.
• 2:11
  Absolutely. And it's a very interesting topic because
• 2:13
  it's developing so much for so many organizations,
• 2:16
  and it's constantly developing. It seems like every
• 2:18
  single day, there's something new. Right? New news,
• 2:20
  new technology. And this was an interesting stat
• 2:23
  from from McKinsey.
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  In 2024,
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  70% of US health care organizations were exploring
• 2:29
  or already using AI across clinical and administrative
• 2:32
  functions. So, really,
• 2:33
  most of the industry were already there, and
• 2:36
  we know it's a critical part of care
• 2:37
  management.
• 2:39
  Michelle, I'd love to start with you on
• 2:40
  this.
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  How are you using AI today,
• 2:44
  and what's really motivating
• 2:46
  continued investment in these technologies for you and
• 2:49
  your teams?
• 2:51
  Well, for every leader of care management,
• 2:54
  this is all about our cost to deliver
• 2:57
  and how to be more efficient
• 3:00
  and also letting nurses
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  perform
• 3:03
  all of their tasks at the top of
• 3:05
  their licensure. I think those are three
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  huge factors
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  that drive
• 3:12
  what care management is all about. We have
• 3:14
  a large organization
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  between commercial and Medicare Medicare Advantage Care Management.
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  We have over 500 employees.
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  Mhmm. That is expensive.
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  Nurses are expensive. They're an extremely
• 3:25
  important asset,
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  but we need to use them efficiently,
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  effectively,
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  and
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  also
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  at top of license.
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  So those are really three drivers that have
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  always driven us in how we create our
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  care management programs.
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  Yeah.
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  So
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  AI
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  has stepped in
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  to help us become more cost efficient.
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  Which is a a key driver, obviously, as
• 3:52
  you've mentioned for a lot of organizations. And,
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  again, we have that 70% number.
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  Connie, I'd love to hear your perspectives on
• 4:00
  this too,
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  specifically around that second part, which I think
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  is very interesting, right? Why now? Why is
• 4:06
  this happening now? Why are we seeing this
• 4:08
  great increase, the 70% number? Why are we
• 4:11
  so many organizations going that route?
• 4:14
  Well, there's always been a need to do
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  more with less.
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  Right? And that's even magnified,
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  I think,
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  more now than ever.
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  And
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  more and more people are getting comfortable
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  with the utilization of AI. Right? So so
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  organizations
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  are getting comfortable whether you they're using it
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  for stratification
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  or ambient listening, whatever the reason
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  that organizations are getting comfortable and humans are
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  getting comfortable. Right? So we are using a
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  AI more and more. I mean, it's 01:00
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  in the afternoon, and I've already used AI
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  a half a dozen times,
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  and I'm not alone. I think if we
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  all step back and looked at our lives,
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  we would say, everybody's using it. So let's
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  find more ways to bring the tools to
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  the workforce
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  so they can, you know, create more space
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  in their day to do the important work.
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  Yeah. Just as a follow-up to that, Connie,
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  really quickly, are are you feeling like leaders
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  are understanding that more and they're bringing in
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  more of that expertise to be able to
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  say, this is how we can use AI
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  better?
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  I think so. I I think there's a
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  a lot of information, podcasts like this, a
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  lot of written materials
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  that are helping people to to know more,
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  appreciate it more, and so they're leaning in.
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  So it isn't just me going out to
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  payers and saying, hey. You should check out
• 5:33
  this technology.
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  There are payers coming to us saying, we
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  wanna check out your technology.
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  Yeah. Yeah. How can we be more efficient,
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  which Michelle mentioned, right, efficiency across a large
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  employee base. And, again, I I think the
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  the top of the licensure is such a
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  big and important piece of the puzzle for
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  a lot of organizations.
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  Michelle, I'd love to come back to that
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  too in terms of the use cases that
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  you have,
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  for your organization specifically.
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  Can you expand a little bit on on
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  some of the use cases and especially what
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  outcomes you've seen? How have they
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  affected your your teams and especially the workflows,
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  etcetera? What are some of the things that
• 6:12
  you're seeing there?
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  Absolutely. I would love to talk about this
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  because I will tell you I was probably
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  one of the doubting Thomases at the very
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  beginning of AI,
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  and I would say that AI,
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  does not replace a nurse.
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  Yeah. But what I have learned is that
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  AI can aid a nurse, and it can
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  aid in our workflow. So number one, we
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  use a lot of AI in our ID
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  and stratification
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  of patients.
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  Mhmm. Then of any care management program for
• 6:42
  anyone that's listening, we all do the same
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  thing. We have to reach out to members,
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  and we have to try to engage them
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  in our programs, whatever those programs may be.
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  It may be a rising risk. It may
• 6:52
  be an ER reduction.
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  It may be a disease management program,
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  but we need to reach out to members
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  and engage them in our program with our
• 7:01
  nurse. Yeah. Well, I call that dialing for
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  dollars. If you have a 100 nurses
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  that are on a phone
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  calling patients
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  and you only get a hold of 50
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  of them and then you only gauge, you
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  know, another 30,
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  there is a lot of
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  work left on the floor, right, on on
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  the Cutting Room Floor. So
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  why do we not use AI
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  more effectively and efficiently
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  in these work processes?
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  And that's what made me
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  my ear started to listen
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  when Connie was presenting
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  what they do in an organization
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  and how their use case could help me.
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  Yeah. Absolutely.
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  Connie, this is a the the dialing for
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  dollars piece is a is a great transition
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  for me
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  because I think that's where it gets sort
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  of the rubber meets the road to bring
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  in another cliche. Right? Is how do we
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  evaluate this? I'm spending money, but I wanna
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  make sure this actually works.
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  When in your conversations with leaders,
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  when it comes to evaluating ROI,
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  what are some of the metrics or outcomes
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  that you're specifically looking for
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  that leaders should prioritize?
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  Yeah. So
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  it's a good question. So
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  it often starts with a conversation about ROI,
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  but then when we keep talking, it's really
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  about value. What value are you gonna bring?
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  And so there's three categories. There's the efficiency
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  component,
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  there's a quality component, and then there's an
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  economics component.
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  So depending on the program will determine
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  what does value look like. So, for example,
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  Michelle referenced some of these already. Let's say
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  it's about
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  supporting a person who was
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  recently discharged from the emergency department.
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  We can measure the value
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  of
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  the patient
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  selecting the right type of care,
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  potentially PCP or urgent care
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  as compared to an ED. We can quantify
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  that.
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  Others are harder to quantify.
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  For example, if we call 50,000
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  patients whose provider went out of network
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  and we want to help them get connected
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  with a new provider,
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  that's harder to quantify. It's important, but it's
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  not as easy to measure. And then there
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  are those that are sort of in the
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  middle. And this one, Michelle has referenced a
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  couple of times. It's helping
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  the
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  care managers, the nurses
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  work top of license
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  by taking
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  low skilled tasks
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  off their workload. That's measurable.
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  But what's not measurable is what does that
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  do to the quality of their work life?
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  Right? How do we measure that? So some
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  are very concrete and some are softer, but
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  there are a lot of different ways of
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  measuring value.
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  And those that I'm talking to are looking
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  at all three of those buckets,
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  efficiencies,
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  quality, and economics.
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  Yeah. And those are the primary ones that
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  that organizations should be looking at, leaders should
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  be looking at.
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  When we measure this this ROI piece, taking
• 10:09
  a step back here really quickly,
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  can you touch on some of the use
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  cases that you've seen where this IUI is
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  ROI is, like, clearly showing, okay, this makes
• 10:17
  the most sense,
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  how it's affecting teams, etcetera. You've mentioned the
• 10:22
  the work life balance piece, right, that's hard
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  to measure, etcetera. Can you touch on those
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  use cases, and and which ones are important
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  to you, and which ones are are have
• 10:31
  you seen make the biggest difference?
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  I certainly can start, and I'll let Connie
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  finish. But,
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  let's just take
• 10:39
  avoidable
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  ER visits or
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  talking to every patient who's been in the
• 10:45
  emergency room.
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  So we can identify people that we wanna
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  reach out to who we feel
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  maybe they shouldn't have been in the ER.
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  They're paying a high co pay when they
• 10:55
  go to an ER when they could have
• 10:57
  done telehealth or they could have gone to
• 10:59
  an urgent care. And number two is when
• 11:02
  they get home, are they okay?
• 11:05
  Did did their issue
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  get resolved, or do they need to follow-up
• 11:09
  with their primary care physician? If they don't
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  have a primary care physician, how do we
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  get them one? So there are many scenarios
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  just with ER. Now in our program today,
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  I may only be able to reach out
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  with the capacity that I have with my
• 11:23
  nursing staff. I may only be able to
• 11:26
  reach out to, let's say, 200 members a
• 11:29
  day. But in our book of business,
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  maybe we had 500 members that went to
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  the ER
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  yesterday.
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  We wanna reach out to all 500.
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  We can do that
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  with
• 11:43
  Eleanor. Right? Eleanor can make those calls.
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  So then
• 11:48
  Eleanor can make those calls, and if the
• 11:50
  member wants to talk to a human,
• 11:53
  we let them come through to talk to
• 11:55
  a nurse.
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  But many times, surprisingly,
• 11:59
  the patient is just happy to talk to
• 12:01
  Eleanor,
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  and Eleanor can call the patient back. They
• 12:05
  monitor the patient. How are you doing today?
• 12:07
  Can I call you back next week?
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  So all of that work, all of that
• 12:12
  phone work has now been taken over by
• 12:16
  Eleanor,
• 12:17
  but, also,
• 12:18
  it allows the nurses to get the cases
• 12:20
  that a member wants to talk to a
• 12:22
  nurse. Right? But, also, that patient has now
• 12:26
  been reached we've reached 500 of them versus
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  200.
• 12:29
  That's powerful.
• 12:31
  Right? And what you've mentioned, it's that tandem
• 12:33
  work of provider and AI working together. Right?
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  It's not the the we're not eliminating one
• 12:39
  or the other.
• 12:40
  It's that that working together that really makes
• 12:43
  a difference. Connie, feel free to weigh in
• 12:45
  here too and on on your thoughts.
• 12:47
  Yeah. So always, it's about augmenting
• 12:50
  the clinical staff. Right? So we're the clinical
• 12:53
  staff's plus one.
• 12:55
  But there's a lot of work we can
• 12:56
  do
• 12:57
  where the majority of it, 85, 90% does
• 13:00
  not require a human. So, potentially, it's making
• 13:03
  outreach calls for vaccinations in the fall and
• 13:06
  to help people see the value of getting
• 13:08
  vaccinated. It's calling patients that are newly diagnosed
• 13:12
  with diabetes
• 13:13
  and educating them and then tracking with them
• 13:15
  and only sending them to a nurse when
• 13:18
  there's a need for a nurse. Right?
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  And so,
• 13:22
  Michelle made a comment that people are happy
• 13:25
  to talk to Eleanor, and that is a
• 13:26
  true statement. We have people who have talked
• 13:29
  with her
• 13:30
  for months. Right? And then we have some
• 13:32
  outliers that we will say have maybe done
• 13:34
  it for years. Right? So people
• 13:37
  feel safe and cared for
• 13:39
  when an empathetic
• 13:41
  voice
• 13:42
  is outreaching. So I I you know, just
• 13:45
  to be very specific about this is Eleanor
• 13:47
  calls patients directly,
• 13:49
  and she's talking to them about what's going
• 13:51
  on in their world and then transferring when
• 13:53
  needed. So there's a whole host of use
• 13:55
  cases where
• 13:57
  the patient wins,
• 13:58
  the provider wins, everybody wins because the patient
• 14:03
  member feels heard.
• 14:05
  We're not losing the human touch even though
• 14:07
  we have an AI piece in Eleanor that
• 14:10
  takes care of an automated task piece, which
• 14:13
  is important. We're we're feeding volume, which is
• 14:15
  very important.
• 14:16
  And then your
• 14:18
  use cases become limitless.
• 14:20
  How do you integrate this into your program?
• 14:24
  So to anyone else that's running a program,
• 14:26
  you know,
• 14:27
  ER is just one use case, but there
• 14:29
  are so many different use cases.
• 14:33
  And that is the fun part of AI
• 14:36
  is
• 14:37
  just the creativity
• 14:39
  of how you integrate this. But you do
• 14:41
  so for all of those listening, you do
• 14:43
  need to integrate it into your
• 14:46
  processes. That's the work. Integrating it into your
• 14:49
  workflows,
• 14:50
  training your staff all about AI. Those are
• 14:53
  two very important things.
• 14:55
  But then
• 14:57
  the potential is seen by everybody. And so
• 14:59
  we have our nurses
• 15:01
  creating new workflows and asking, why don't we
• 15:03
  use AI for this? Yeah. So it is
• 15:06
  exciting.
• 15:07
  Once you get your hands in there and
• 15:09
  start to use it, you can see a
• 15:11
  lot of different potential
• 15:14
  use cases
• 15:15
  for other things that you do.
• 15:17
  Yeah. And and we've touched on this earlier,
• 15:20
  in the conversation as well. Right? This is
• 15:22
  a a complex space. There's a lot happening.
• 15:25
  It can be intimidating. There's a lot of
• 15:27
  questions. A lot of folks don't necessarily know
• 15:29
  how everything works.
• 15:31
  Michelle, I'd love to stay with you on
• 15:32
  this. You've touched on it just a little
• 15:34
  bit here in your answer.
• 15:35
  But what's the the one piece of advice
• 15:38
  that you have that you want to offer
• 15:40
  peers that are looking to integrate more AI
• 15:43
  into care management programs?
• 15:45
  Where should they start,
• 15:47
  and what should they try to avoid?
• 15:49
  Sure.
• 15:50
  AI is not gonna solve the entire world,
• 15:52
  which some people promise. That is not true.
• 15:56
  AI is not going to replace
• 15:58
  nurses' jobs.
• 16:00
  Those are two big things.
• 16:02
  Then number three is don't be intimidated
• 16:06
  by AI.
• 16:08
  Every leader in care management
• 16:10
  knows that we must constantly change.
• 16:13
  Adaptation and change
• 16:15
  is in our DNA as a case manager,
• 16:19
  and this is just
• 16:20
  a new technology
• 16:22
  that helps nurses
• 16:24
  work at top of licensure.
• 16:26
  And don't be afraid
• 16:28
  to test it. So go small. Test one
• 16:32
  small thing
• 16:33
  and become comfortable with it. Let your teams
• 16:36
  become comfortable with it. And
• 16:39
  then you know
• 16:41
  that as people become more comfortable, they will
• 16:43
  see the potential,
• 16:45
  and the use cases will grow. So start
• 16:47
  small. Don't be intimidated
• 16:49
  and start small.
• 16:51
  Dave mentioned the workflow integration piece, which is
• 16:53
  so important to let teams explore how it's
• 16:56
  working within their own workflows
• 16:58
  so they feel like they're still in charge.
• 17:00
  Right? It's not taking Absolutely. What they're doing,
• 17:02
  which is so important. Connie, same question for
• 17:04
  you. What are the some of the things
• 17:06
  that you're talking about in terms of, hey.
• 17:08
  This is what folks should pay attention to.
• 17:10
  This is what they should they avoid.
• 17:12
  What are your thoughts?
• 17:13
  Yeah. So so one of the things that
• 17:16
  we encourage people to do is ask
• 17:19
  solution partners hard questions.
• 17:22
  Ask about how are you training the models
• 17:25
  that you are using.
• 17:27
  How do you prevent
• 17:28
  hallucinations?
• 17:30
  How are you going to attend to a
• 17:32
  critical issue? If
• 17:34
  technology if in our case, Eleanor is talking
• 17:37
  to a person
• 17:39
  and a person is expressing
• 17:41
  suicidal ideation,
• 17:43
  what are you gonna do? So ask the
• 17:45
  hard question.
• 17:46
  Right? And,
• 17:48
  solutions that have been in practice
• 17:51
  for a while will have protocols for those
• 17:53
  things,
• 17:55
  and you will get the answers. One of
• 17:57
  the things that we've created is a list
• 17:59
  of questions that the people we're working with,
• 18:03
  payers, providers, whoever, here's a list of questions
• 18:06
  that you will wanna consider asking anyone who
• 18:10
  is going to be speaking with your patients
• 18:12
  and members.
• 18:13
  Yeah.
• 18:14
  Right? So you can feel confident to Michelle's
• 18:18
  point that
• 18:19
  the solution isn't overpromising,
• 18:22
  but that they are gonna deliver
• 18:24
  or overdeliver.
• 18:26
  Right? So good questions make a big difference.
• 18:29
  Can I possibly end with a wonderful case?
• 18:33
  I find giving people real life cases
• 18:36
  helps people understand how this works. Sure. So
• 18:39
  we're calling patients who have been to the
• 18:42
  emergency room, checking in on them, making sure
• 18:44
  they're okay.
• 18:45
  First of all, for all of those that
• 18:47
  are listening, we have a 72%
• 18:50
  answer rate. So 72% of the people we're
• 18:53
  calling are answering the phone and talking to
• 18:55
  Eleanor.
• 18:56
  In this situation,
• 18:58
  Eleanor talked to a patient
• 19:00
  who asked to be transferred
• 19:03
  to a nurse case manager
• 19:05
  because she was having palpitations,
• 19:08
  and she couldn't get an appointment with her
• 19:10
  cardiologist
• 19:12
  within the next week.
• 19:14
  And she was nervous. She didn't know what
• 19:16
  to do. This is exactly the patient that
• 19:18
  will go back to the ER, right, because
• 19:20
  she can't get in to see the cardiologist.
• 19:23
  Call was transferred from Eleanor
• 19:26
  into our care advocate program.
• 19:28
  Advocate
• 19:30
  picked up the call, talked to the patient,
• 19:32
  turned around,
• 19:33
  called the doctor's office,
• 19:35
  and got the person in the next day
• 19:38
  with their specialist.
• 19:40
  That is advocating for the member,
• 19:43
  and
• 19:44
  we avoided a future ER visit.
• 19:47
  That's where she would have gone.
• 19:48
  So isn't that a wonderful story?
• 19:51
  Yeah. Absolutely. Again, it it illustrates partnership. It
• 19:53
  illustrates
• 19:54
  understanding it, what it can actually do. So
• 19:56
  I appreciate you sharing that because, again, I
• 19:57
  agree. Use cases are very important for folks
• 20:00
  to understand how this actually works.
• 20:02
  Michelle and Connie, thank you so much for
• 20:04
  taking the time today. This was a fantastic
• 20:06
  conversation. So many great insights. Thanks so much
• 20:08
  for being here.
• 20:10
  Appreciate the help of you today. Yes. Absolutely.
• 20:12
  And we also want to thank our podcast
• 20:14
  sponsor. Mind you, you can tune in to
• 20:16
  more podcasts from Becker's Healthcare by visiting our
• 20:18
  podcast page at beckershospitalreview.com.