For the past year, Buncombe County teacher Shanna Peele has driven two hours each way for her appointments at Atrium Health Rheumatology in Charlotte. The commute isn’t convenient, but the care she’s received from Atrium has been well worth it, Peele told Carolina Public Press. However, a public feud between Atrium and the State Treasurer has made it difficult for Peele to know whether she can keep her care at Atrium at the same rates going forward under the State Health Plan.
That’s because next year, the State Health Plan, which offers health insurance to 750,000 teachers and state employees, is switching to a new tiered provider system in a bid to save money. Over the past four months, Atrium has gone back and forth with the state over how much it will cost for plan members to receive care at its facilities.
In July, the State Health Plan announced that Atrium would be a “nonpreferred” provider, meaning that members would have to pay more for services there starting in 2027.
Atrium countered with its own savings scheme for State Health Plan members, but it was met by a lawsuit from State Treasurer Brad Briner, who argued that Atrium’s move risked bankrupting the State Health Plan. A week later, the state removed Atrium from its network entirely.
The two parties eventually worked out their differences, and on Oct. 27 they announced that Atrium would rejoin the network as an “access” tier provider, keeping members’ copays and benefits steady in 2027.
The problem, however, is that much of that drama happened in the middle of this year’s open enrollment period, which began on Oct. 12. That left Atrium patients like Peele confused about their options.
“To be honest, I haven’t really been able to keep up with all the news,” Peele told CPP.
Amid its spat with Atrium, the State Health Plan extended its enrollment deadline from Oct. 30 to Nov. 6. Peele took advantage of that extra time, as she still hasn’t made a decision on what plan she intends to select for 2027.
Ultimately, she said, her choice will come down to what will allow her to keep seeing her doctors for the least cost.
Looming fiscal crisis drives overhaul
The State Health Plan is facing down a financial crisis which drove it to develop the new tier system in the first place.
As Briner tells it, he inherited the problem following years of medical costs outpacing revenue. His solution was to negotiate directly with health systems to lower their prices. In return, the State Health Plan would push members towards those providers.
This summer, the State Health Plan unveiled its tiers, which placed hospitals in one of three categories: preferred, access or nonpreferred. Preferred providers would have the least expensive copays, while nonpreferred providers would cost more to use.
Affiliates of UNC Health, Novant Health and Iredell Health are preferred providers, while hospitals associated with WakeMed and Duke Lifepoint are nonpreferred. Most other hospitals are “access,” meaning prices there would neither increase or decrease for plan members.
The plan also includes carve-outs for certain situations. For example, prices for emergency room services, behavioral health and therapies will remain the same regardless of the provider tier.
Patients who are receiving cancer treatment or maternity services at a nonpreferred provider may also continue to see their doctors without a change in rates. The same applies to people undergoing an organ transplant or who have a child in the NICU.
The Treasurer’s office estimated that the new system would save the State Health Plan hundreds of millions of dollars, although it still forecasts a $58 million shortfall in 2027. Last week, trustees approved a measure to take more cash from the Retiree Health Benefit Fund to keep the State Health Plan afloat through the end of the year.
State Health Plan whiplash
The State Health Plan isn’t alone in worrying about its finances.
Joanna Loftis, a multi-lingual teacher for Charlotte Mecklenburg Schools, said veteran educators like her are feeling the pinch of high prices, from gasoline to groceries.
“Everything is just piling up,” she said.
Rising healthcare prices are one of those economic stressors, and Loftis, whose family receives their care at Atrium Health, felt stuck waiting to see what would happen with Atrium’s tier designation.
“It’s been very frustrating … the complete changing from one day to another, not knowing what’s going on,” Loftis said.
She and her husband considered switching providers, but decided it was best to stick with their specialists at Atrium.
“We decided we were just going to bite the bullet and hope it doesn’t send us into extreme medical debt this year, because to re-establish a medical relationship, it’s not something that you really want to play with,” Loftis said.
With Atrium now in the access tier, Loftis’ copays shouldn’t go up next year. But she felt that the State Health Plan’s communication during the whole ordeal was “extremely confusing.”
Outside of her day job, Loftis serves as president of the North Carolina chapter of the American Federation of Teachers.
She helped craft a letter on behalf of the organization to both Atrium and the State Health Plan, urging them to “provide immediate, clear, consistent, and written guidance” to members during open enrollment. Neither recipient offered a response to the letter, Loftis said.
WakeMed left out of Atrium deal
Although the State Health Plan upgraded Atrium to the access tier, it did not do the same for another closely linked system in WakeMed.
Atrium is currently pursuing a combination with WakeMed, which operates three acute care hospitals in Raleigh and Cary. Wake County commissioners greenlit the deal in September, but it is still awaiting regulatory approval before being finalized
Atrium entered into a similar arrangement with Wake Forest Baptist in 2020, which operates six hospitals across the Piedmont. Those hospitals were originally nonpreferred but were upgraded to the access tier along with the other Atrium facilities.
In the Research Triangle, the State Health Plan favored WakeMed competitors UNC Health and Duke Health.
“WakeMed has not been given the opportunity to negotiate our continued service to (State Health Plan) members as an access-level provider,” the system wrote in a statement on its website.
“We remain proactive in our efforts to engage SHP leadership to better understand the evaluation process and any remaining opportunities for consideration as it is certainly in the best interest of SHP members.”
Alex Wall, who teaches at an elementary school in Raleigh, told CPP he’s in the process of switching his cardiologist at WakeMed to one at UNC Health. His gastroenterologist is with UNC Health, but works out of two locations — one preferred and one access.
Wall said he’s had to show some of his colleagues how to search their doctors to see whether they are preferred providers.
“There’s a cloud of confusion, and people don’t know how complicated this is until they try and do it.” Wall said.
“There’s going to be a lot of people who find themselves in a difficult place because their specialist is now nonpreferred.”
Open enrollment for the State Health Plan will continue through Nov. 6.
Loretta Boniti, a spokeswoman for the Treasurer’s Office, told CPP that there would be no further extension of the open enrollment period, despite the recent developments with Atrium.
As of Oct. 30, 115,879 State Health Plan members had taken action on their insurance plans. The plan was not aware of any members holding out due to Atrium’s or WakeMed’s network status, Boniti said.
Wall, for his part, was not a holdout. But he’s certainly not happy about being compelled to change doctors.
“We shouldn’t have to bargain shop for our doctors,” he said.
This article first appeared on Carolina Public Press and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License. ![""]("https://i0.wp.com/carolinapublicpress.org/wp-content/uploads/2020/07/cropped-cropped-CPPlogo_icon_RGB.png?fit=150%2C150&ssl=1"){kind=icon}
Source: carolinapublicpress.org
