Insurance & Benefits

Texas Health Aetna Takes Its Network Nationwide

Genevieve Caruncho-SImpson
Genevieve Caruncho-Simpson (Courtesy of: Texas Health Aetna)

Texas Health Aetna’s President and Chief Operating Officer Genevieve Caruncho-Simpson says the joint venture between insurer and provider is a total cost of care solution for the region utilizing virtual care, national coverage, and other innovations to bring down healthcare costs for North Texans.

The organization covers 110,000 lives, and is working to reduce the pain points that plague the medical industry. Texas Health Aetna is making significant progress against the physician shortage, an over-reliance on emergency care care, and a significant population with chronic conditions, Caruncho-Simpson says.

Embracing technology has been a key to the success. THA’s Anytime-MD has been a successful virtual care platform with four times the utilization compared to industry standard, and provides patients a video, phone, or chat option 24 hours a day. The digital first experience at THA has helped their utilization rates soar, Caruncho-Simpson says.

The text-based platform at Anytime-MD is meant to provide free access to emergency physicians in a minute or less for acute and urgent care issues that may have meant a trip to the emergency room without it. Since implementing the platform, ER visits have been reduced by 25 percent across all members, and around half of the members from a large school district in North Texas had used the app, resolving three-fourths of cases in one patient population in a recent month, saving $667,000 in avoided ER visits.

“We are able to serve more members in their homes and outside traditional healthcare,”Caruncho-Simpson says. “It is the tip of the spear for our home-based, virtual care.”

That school district, which included 4200 teachers and staff across 40 campuses, took a long-term view of their healthcare spending, focusing on education, developing a clinic for the district that resulted in a single digit rate increase after years of double digit bumps.

The network for THA has also enabled low cost options for members no matter where they live. It includes UT Southwestern, Methodist, Cook Children’s, Children’s Health, and around 2800 primary care doctors, 17,000 specialists and 66 total hospitals. The network also includes CVS Minute Clinics, allowing those traveling nationally to access care at little or no cost wherever a Minute Clinic exists. CVS and Aetna just won antitrust approval from a federal judge this year, combining the insurance and pharmacy giants in a $70 billion merger.

Caruncho-Simpson sees further growth for how THA can further partner with CVS. She sees the organization continuing to add convenience, dealing with every day healthcare issues and engaging with patients in real time while integrating service with primary care providers.

While consolidation may be good for decreasing conflicts, it has historically increased prices. Insurers are at times locked in public disputes with providers over reimbursement rates, with threats to take business elsewhere included in the posturing. But competition between providers and networks should in theory be good for patients. The Texas Health Aetna plan will not include Medical City and Baylor Scott and White facilities, two of Texas Health’s main rivals in North Texas. The alignment of health plan and provider means less competition between providers for health plan members.

But the typical market forces don’t always apply to the medical industry, as negotiated discounts between providers and insurance companies are often meaningless, because rarely does any insured person pay full price for a procedure. So a higher price could just mean a better discount that insurers can sell to their members. “Traditional solutions have not given relief,” to prices, Caruncho-Simpson says.

North Texas is no stranger to deals between insurer and provider, but it is also already one of the most expensive places to receive healthcare despite Dallas County being only the 54th healthiest county in the state. Blue Cross Blue Shield of Texas opened its first of several clinics in the region, and UnitedHealthcare-owned Optum Medical Group has long been a presence here. While Texas Health Aetna’s joint venture is not structured the same way, it is another example of providers teaming up with insurers.

But Caruncho-Simpson says that at Texas Health Aetna, overall margin is shared by both provider and insurance, meaning the organization works together to avoid unnecessary costs. It also removes the battleground between insurer and provider, which can leave the patient in the middle and without a convenient place to go if a provider leaves the network.

“For us, we think about making sure we are focused on making sure our healthcare services are easy, engaging, and effective. If it doesn’t meet all three, it is not worth doing,” Caruncho-Simpson says.


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