Meet the Team – Case Management

Melody Bautista, Director Clinical Data Analytics

From new product launches to partnerships with 2nd.MD and the National Hemophilia Foundation, there’s a lot going on in our Large Claim Solutions vertical. Director of Clinical Data Analytics, Melody Bautista, shares what she’s been working on, and is the perfect example that no two days are the same here at BCS!

Q: Describe your/your team’s role at BCS. 

A: I am the Director of Clinical Data Analytics and work mostly on BCS’s large claim solutions products and services.  My role/responsibility includes data analytics, clinical claims review, risk/cost management, and R&D. We are using an integrated data approach to bring together relevant clinical and claims data in a form that supports a variety of tools and analytics that we can leverage to improve outcomes, quality, and cost for our Blue Plan partners and payers. We identify high cost claimants (HiCCs) using predictive analytics tools and trigger reporting (diagnosis, specialty drugs, Gene Therapy/CAR-T) to identify members that are most likely to incur at least $250,000 in claims spend, then perform clinical claims review and identify BCS Risk Navigator solutions for our customers to contain costs and help their members achieve quality outcomes.

Q: What does a typical day look like for you at BCS?

A: Every day brings plenty of variety.  In a single work day I can work on press release and webinar content with marketing, on development of our HiCC database with Data and IT, conduct clinical claims review from trigger reporting, have meetings with our Blue Plan partners, review a specialty vendor Master Service Agreements with legal, work with account management and sales on an XOL Operations deliverables, assist coordination of SFTP set up with the Data and IT teams, work with our business analyst on clinical data analysis, research Specialty Pharmacies for a limited distribution drug, work on diversity and inclusion initiatives with our Culture Team, and work on process improvement activities with my Six Sigma team. Unlike Phil from Groundhog Day, I can honestly say that I have never had the same day twice and every day is an unknown adventure waiting to unfold.

Q: What trends are you watching in the healthcare industry right now?

A: There are many healthcare trends to watch right now from COVID-19 impact, to changes in healthcare delivery systems, and factors contributing to rising healthcare costs and premiums, but my main focus is always on HiCCs.  That includes paying attention to trends in million-dollar claims, emerging high cost therapies (Gene Therapies, CAR-T, immunotherapy cancer treatments) and specialty drugs, Stop Loss data trends, payment financing models (VBAs/OBAs), and more.  We use the knowledge of these healthcare trends and combine that with our claims/clinical data analytics information to develop highly relevant HiCC solutions to help our customers mitigate risks and improve outcomes.

For example, our actuary department provides us with an annual reports of the highest cost claims conditions and we combine that information with national healthcare information and our data analytics tools, predictive analytics outputs, and clinical claims review reports to identify what conditions we need to target for specialized solutions.  Out of that comprehensive data collection process and analysis, we determined we needed to find the best solutions to address members with oncology conditions like lymphoma and leukemia that persistently sits at the top of the highest cost conditions categories for the healthcare system nationally. That is why we partnered with 2nd.MD to provide top-tier medical navigation, expert consultation, and personalized second opinion services.  With this partnership, BCS can help members get the appropriate care they need, connecting them with board-certified, elite specialists from top medical institutions, and reducing their costs along the way.  In many cases, the second opinion can change the treatment trajectory – 85% of 2nd.MD’s consultations result in improved treatment plans, 35% lead to alternative diagnoses, and nearly 30% of surgery consults result in surgery cancellation.

Using this data, we developed two other customized solutions to support the approximately 20,000 individuals with hemophilia.  With the average annual cost for a patient with hemophilia topping $350,000 – $500,000 a year, we made it our priority to bring to market a solution set for health plans and their members to improve the quality and cost of care for members with hemophilia.  We partnered with the National Hemophilia Foundation (NHF), a trusted advocacy organization aligned with our focus on assisting with quality and cost of care. In addition, we also partnered with Audaire Health to provide hemophilia treatment management that improves patient adherence for high-cost therapies through real time tracking and pharmacy notifications.

We are looking to expand our customized specialty solutions to target more conditions, including Hereditary Angioedema/Defects in the Complement System, Cystic Fibrosis, Multiple Sclerosis, etc.  There is great interest and excitement for these customized solutions and we are currently working with our partners on implementation.  We are also excited to have recently joined our partners at the NHF, who are working on a collaborative with a mission to connect payers and patient advocacy groups to improve access to high quality care and address issues surrounding high-cost claimants through open dialog and shared solutions. I must say, I am truly proud to work for a company that strives to mitigate risks with cost containment solutions and improves quality of care outcomes for members.

Q: What are the most important skills you bring to your role?

A: The most important skills for this role are; flexibility/agility, a collaborative spirit, a strong interest in R&D/innovation, analysis, problem solving, and a having very curious mind.  Anyone who knows me knows how much I love solving puzzles and my keen interest in analysis is a great fit for this position because I enjoy recognizing patterns, looking for outliers or anomalies that help identify opportunities, and using data analytics to help guide better business decision making.  It also helps to be resilient and to view setbacks not as “failures” but as challenges or an opportunity for improvement.

Q: You have quite the commute. Pre-pandemic, what are your favorite ways to pass the travel time?

A: I have always had a long commute even when I used to live in the suburbs and took the train to the city but with this reverse commute, I actually use my commute time for prayer. Oddly enough, it is a good way to stay nice and calm during my long commute from the city. It’s tough to get upset with bad drivers when I’m thinking about the people in my life that I am grateful for.