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