Genevieve Caruncho-Simpson

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 predicts the cost of healthcare will rise by 6.5%, meaning the spending continues to outpace the economy. In Texas specifically, healthcare costs increase approximately 6% each year, according to 

	Unfortunately, these rising costs do not equate to a higher of quality care, with many people across the country complaining about our nation’s healthcare industry. In fact, North Texas ranks significantly low on many healthcare quality, outcome and satisfaction measures. This problem stems from uncoordinated efforts and unaligned incentives between insurance companies, providers, pharmacies, labs and most other health facilities.

	To diminish and eventually eliminate these issues, Texas Health Resources and Aetna came together to create the first joint venture of its kind in the North Texas market-Texas Health Aetna. Our goal is to transform the healthcare experience for employers, providers and members, removing the roadblocks and streamlining processes to create a better experience. We are working to break the traditional care model by offering our members four differentiating values.

	Did you know the average physician appointment wait time is 15 days or more? In today’s fast-paced world, this is simply unacceptable. If your child comes down with the flu, the options currently available are to visit an urgent care center or the emergency room, as there is a good chance the pediatrician will not be able to see them immediately. Texas Health Aetna members are offered next day or same day appointments with primary care physicians who have opted into our plan and provide high-quality care and an improved, simplified experience.

	Additionally, physician office and emergency department visits have increased by 18% and 21% respectively. Sometimes a trip to the doctor isn’t necessary, but we still want an expert’s opinion. Therefore, we created the 

 app to give members 24/7 virtual care access at their fingertips for nonemergency situations. If a member has a question about a rash or a cough, they can consult a board-certified ER physician to determine next steps. This allows members to have peace-of-mind knowing they have a physician available to answer questions, free of charge, any time of the day or night.

	Healthcare is personal and the level of care members receive should also be personal. Each member who signs up receives a customized onboarding and welcome packet and access to a navigation center where they can speak with local nurses and customer service representatives. No longer do they have to talk with someone who doesn’t understand the market landscape of North Texas, but instead can talk to a neighbor down the street.

	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.

	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. 

 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.

	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:

		     1,300+ behavioral health providers

		     50+ behavioral health facilities

		     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 

 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.  

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