1. CRMS & PREDICTIVE MODELING AT BCBSLA Blue Cross Blue Shield of Louisiana Felix J. Bradbury, RN, MHA, ScD*, CHE Director, Medical Management & Reporting Department September, 2003

3. What is a Predictive Model? A software application which generates a prospective index of risk and a probability of admission from a combination of medical, pharmacy and laboratory claims data. This data allows us to compare the expected future health status of an individual member, or the aggregate health status of a group, product or LOB.

5. Introduction and Overview Forces driving strategic change in the health insurance industry

7. Why Do we Have Predictive Model, Cont’d Overview of Member Risk Stratification

21. Example of Employer Group Disease-Specific Approach

26. Example of the Low-to-High and Moderate-to-High Cost Transition Approach This slide is an example of the list of high-risk members referred to case management on a monthly basis .

27. The BCBSLA Predictive Model Referral Schema, June 2003

28. Predictive Model Referral Schema, Cont’d

32. Question and Answer Session