A message from Dr. Heather Stamat, medical director, Clinical Partnerships
Using predictive analytics to transform health care

From artificial intelligence to platforms such as TikTok and Pinterest, predictive analytics is becoming part of our daily lives. Predictive analytics can also be a powerful tool for transforming health care.

By using predictive analytics, we not only can identify at-risk patients and develop a plan to improve patient outcomes, but we can make the job of health care workers easier by improving operational efficiency. In short, predictive analytics may well become the cornerstone of health care in the future.

At Blue Cross Blue Shield of Michigan, we’ve already been hard at work integrating predictive analytics into physician practices. In 2023, we launched two clinical pilot programs:

• Serious Illness Predictive Model Pilot — For patients who would benefit from advance care planning and discussions about care goals due to serious illness. Many times, it’s a hospital admission that triggers providers to start these kinds of discussions with a patient, but we want to be more proactive, encouraging those conversations earlier to help avoid unnecessary hospitalization and ensure that medical care is aligned with patient goals.
• Chronic Kidney Disease Predictive Model Pilot — For patients who are at risk of having undiagnosed, under-diagnosed or developing chronic kidney disease.  We want to identify patients with CKD earlier to limit disease progression and improve outcomes.

The Serious Illness pilot was conducted from January through June 2023 and included seven physician organizations, while the CKD pilot took place from April through September 2023 and included four physician organizations. We’re currently in the process of analyzing the results of the pilots.

Each of the pilot participants was provided with a predictive list (list of at-risk patients), a toolkit and a Key Performance Indicator report monthly. We also met with each of the physician organizations monthly to obtain feedback about the lists, toolkits and how they were implementing the processes and working with primary care offices.

About CKD
According to the Centers for Disease Control and Prevention, an estimated 35.5 million individuals in the U.S. have chronic kidney disease but 90% are unaware of it. Risk factors include diabetes, hypertension, heart disease, obesity, family history of kidney failure, acute kidney injury and tobacco use. CKD screening tests of at-risk individuals can lead to earlier diagnosis, initiation of treatments to help slow disease progression and a delay in dialysis treatment.

About serious illness
When a patient is seriously ill, the medical care they receive isn’t always aligned with the patient’s goals. And outcomes aren’t always improved with increased utilization. But with earlier advance planning, we can better align patient wishes with the treatment plan and improve the patient and provider experience.

Now that we’ve completed our pilots, we’re preparing to roll them out to our provider network. Key components of this larger program will include:

• A predictive list of at-risk patients will be delivered monthly to POs.

• The toolkit will be posted on the Provider-Delivered Care Management section of the PO Collaboration site.

• Additional provider training and resources will be available through the Michigan Institute for Care Management and Transformation website.*

We’ve also developed a PGIP incentive program for POs and primary care physicians for 2024. Additional information is available on the PO collaboration site.

The Chronic Kidney Disease Toolkit will include:

• Appropriate screening labs
• Classification of a patient’s CKD stage
• Timing for a nephrology referral
• Best practice CKD interventions

The Serious Illness Care Toolkit will:

• Provide tools on how to have a goals-of-care discussion.
• Define goals of advance care planning and provide resources for end-of-life discussions with patients and family members.
• Review what an advance directive is and the requirements in Michigan.
• Outline the Michigan Physician Order for Scope of Treatment document to be used as a physician order for patients in the last year of life.

Going forward, we’ll be shifting the focus of care to a proactive approach as part of our overall goals to improve population health and patient outcomes, increase provider and patient satisfaction and reduce the cost of care.

*Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.