In the wake of ongoing negotiations between Duke Health and Aetna, the North Carolina State Health Plan Board of Trustees on Friday approved procuring a transition services vendor to help plan members find new health care providers if an agreement can’t be reached by an Oct. 20 deadline.
Duke Health says that unless Aetna raises its reimbursement rates, many patients will lose in-network coverage to Duke’s doctors, hospitals, clinics, and services, including over 750,000 state employees covered under the State Health Plan.
Aetna is administrator of the SHP, which is the company’s largest customer in the state and is responsible for half of its member base in North Carolina.
About 22,000 members have Duke as their primary care provider, and approximately 40,000 members have filed a claim through Duke this year.
State Treasurer Brad Briner, whose office oversees the health plan, said it would be entering into uncharted waters as the plan had never taken such action before.
“If we end up out of network, Duke is the one who made that choice,” the treasurer said during a special session. “They will have made that choice that their financial goals are more important than their mission to serve. Not only did Duke initiate this negotiation, they also decided to adopt very aggressive tactics with the intent of scaring our members.”
Briner alluded to multiple letters sent to members and multiple radio ads that have been running as a “public pressure campaign.”
“It is not what we should expect from one of the state’s pre-eminent nonprofit hospitals,” he added. “I honestly think this behavior is beneath Duke, and I hope that the new leadership there will agree that we come to a mutually beneficial agreement, and to be very clear, a mutually beneficial agreement remains our goal and is achievable.”
Briner said while the health plan doesn’t have a seat at the negotiating table, Aetna has kept his office informed. At this point, it doesn’t look like the two sides are close to an agreement.
Thomas Friedman, executive administrator for the State Health Plan, said it is working with other providers throughout the community in putting plans in place to ensure that members have continued access to care.
Transition of care forms have been sent to those first in priority situations, like people being treated for cancer and pregnant women. About 2,800 members fall under that category. People who are scheduled for things like surgery would be next on the list. Other members may receive a phone call.
Members who don’t receive a letter will need to request the transition of care form. The member and their doctor must complete the form and return it to the SHP.
Those who don’t receive a form can call Aetna Health Concierge at 833-690-1037 (TTY: 711).
Friedman added that the plan has been developing a preferred provider program, which has enhanced co-pay reductions for people using certain primary care and specialty care providers. Many of them, he said, are in the Clear Pricing Project, so there would be a co-pay reduction to go with those providers as well.
Board member Brian Miller, who is also a physician, said that he found it concerning that while everyone worked together to close a half-billion-dollar gap in the State Health Plan, including members paying a higher premium and the General Assembly giving the plan $100 million, Duke Health is choosing not to be a good partner.
“I took a look at Duke’s financials, and from their audited financials, they are not in distress, and that they have $4.3 billion —with a ‘b’ — in investments,” he said. “I also saw that they had $566 million in positive cash flows from operating activities and a $202 million annual operating income. This does not sound like a health system that is in financial distress.”
Miller said he was sincerely disappointed that Duke is choosing to behave this way.
“Duke is choosing to prioritize its investment portfolio instead of the health of local citizens who work as custodians, help take care of parks, and local teachers, and they would rather pad their investment portfolio off the backs of these workers,” he said. “I find that a fundamental moral failure.”