We believe data is essential to providing quality care for our members. Using Texas Health Resources’ extensive network of hospitals and care facilities, we have access to members’ clinical data to understand their health history and be able to offer care options tailored to their needs. Additionally, we can also analyze insurance claims they’ve made to understand pain points better and work to mitigate those.
With this integrated clinical and claims data, we enable better patient outcomes by coordinating real-time and ongoing data exchange between all health facilities the member may need in their healthcare journey. Our systems are integrated across facilities, so patients don’t have to worry about their data not reassigning between admissions, discharges or transfers throughout the care experience. This allows physicians, regardless of the care management stage where they interact with the member, to have their entire medical history and related background information. Additionally, our care management teams receive real-time notifications if one of our members enters the hospital or is admitted to the emergency room. This allows the team to personally guide them throughout the process and ensure they are receiving the highest quality of care.
Holistic care approach
The top 5% of members in an employer health plan typically generate more than 50% of the costs. Many factors combine to affect the health and related healthcare costs of individuals and communities. Recent studies have shown a broad range of social, economic and environmental factors shape individuals’ engagement in healthy behaviors, with more than 60% of health outcomes driven primarily by these social determinants.
At Texas Health Aetna, we take a holistic approach in targeting these members and providing care management closer to where members live. Our locally-based care team includes a dedicated medical director, pharmacist, nurses, social workers and diabetic educators who support members and their families with their complex needs face to face. This high-touch case management is integrated with the rest of our provider partners and is personally tailored to include home visits, accompanying members to doctor visits, as well as caregiver education and training.
Because we carefully assign higher risk members to our care providers who live in or close to their neighborhoods, our place-based care management approach can successfully connect members to community-based providers and social support resources. We want to improve the overall health of the North Texas population and to do so we cannot simply focus on traditional medical conditions, but all aspects of healthy living.
Local care network
When we say the word “network,” we don’t simply mean the approved list of physicians and facilities members can access. We are more than a network, but a connected community of health professionals who are ready and willing to help our members. The Texas Health Aetna network includes:
- 1,700+ primary care doctors
- 1,300+ behavioral health providers
- 4,100+ specialists
- 50+ behavioral health facilities
- 50 hospitals
- 3,000+ care nurses, pharmacy nurses, social workers, nutritionists and physical therapy coaches
By providing both clinical and non-clinical in-network options for members, we are creating a holistic care model and providing care management programs that go beyond traditional insurance plans.
As the industry moves away from fee-for-service to a value-based care model, we believe true partnerships between the insurance companies and local health systems are the future. Through this approach, we can provide care that is significantly more personalized, convenient, easy to navigate, localized and higher quality as both parties of the healthcare journey are working in unison. Today, we are transforming the way consumers and employers think about healthcare and removing those pain points from the healthcare journey to provide better experiences and ultimately better outcomes to ensure a healthier North Texas.
Genevieve Caruncho-Simpson is the chief operating officer of Texas Health Aetna, the jointly owned health plan focused on improving quality, affordability and overall member experience between Texas Health and Aetna. The company represents two leading healthcare organizations coming together to fundamentally transform the healthcare experience for members through technology-enabled, data-driven analytics and enhanced local care management.