Faculty question care plan

Law professor Paul Haagen spent two days trying to make a doctor's appointment for his child as a new member of the Duke Managed Care plan. But, Haagen said, "When I got a doctor, he was lovely," and the problem was solved.

Like many employees dealing with managed care for the first time, Haagen said, "My experience has been marginal and mixed." His difficulty in getting through to a doctor seems to be representative of the difficulty with health care under the new plan: Quality health care preceded by slow administrative procedures and lots of red tape.

Most of the University's approximately 33,500 eligible employees and dependents are enrolled in one of two plans: the health maintenance organization Kaiser Permanente, and the newly developed Duke Managed Care plan, administered by Sanus-New York Life, which replaced the Duke Comprehensive Plan last July as a means of cutting rising health-care costs.

Under Duke Managed Care, patients choose a primary-care physician from a network of Medical Center faculty and affiliated community doctors, who administer general health care and refer patients to specialists for problems outside of routine practice. Kaiser offers similar services at other local health-care facilities.

In light of concerns about the plan's efficiency, several faculty have said that the current health care offerings are too limited and do not allow for necessary competition between health-care providers.

"People just don't feel there's a lot of options," said Jim Siedow, professor of botany and chair of the Academic Council. "The only other option they've got is Kaiser."

The issue has been further complicated by Kaiser's recent move from Durham Regional Hospital to the University of North Carolina at Chapel Hill's hospitals, Siedow said. "When the only alternative is Kaiser, and they leave town, it becomes a problem."

University administrators will be examining options for health care services this spring. Two additional health maintenance organizations, Healthsource and PHP, have indicated that they may make proposals to the University to offer health care to employees. The Healthsource plan, currently being pursued by the Academic Council, would offer a fee-for-service option currently not available at the University, Siedow said.

Because the University's financial contribution to the plans depend on the number of employees enrolled, Kahr said, an additional plan will not necessarily cost the University more money. If a large number of employees leave the Duke Managed Care plan, however, the loss of business could hurt the Medical Center, said Joe Lipscomb, associate professor of public policy.

The University has a responsibility to provide reasonably priced choices for its employees, but providing the Medical Center with a great deal of competition could hurt the University as a whole, Lipscomb said.

But Larry Evans, chair of the physics department, said that the University, regardless of other interests, "has no right to restrict us to the Duke health plan."

An additional plan may not be necessary, Kahr said. The Kaiser option currently enrolls less than five percent of University employees and dependents, while some plans offered in the past did not have enough enrollment to stay afloat. "There's a good question as to whether or not there's sufficient interest," he said.

All employees were made aware of the changes before last spring's open enrollment period, said Jane Walbrun, health plan manager. The change, however, had a negligible effect on Kaiser enrollment, calling into question the significance of the change.

In addition, Kaiser's local services have not been changed as drastically as it may seem, Walbrun said. While Kaiser is withdrawing its services from Durham hospitals, its own two primary medical centers, one of which is located next to Durham Regional and the other which is located closer to Chapel Hill, will not be affected.

Kahr also suggested that the University may eventually follow in Durham's footsteps by dropping Kaiser.

If the University chooses to add Healthsource as a fee-for-service plan, it is likely to be more expensive than the managed-care plan. Under fee-for-service plans, consumers pay a premium and then pay a percentage of the cost of their health care, while consumers under managed care pay a premium and a fixed dollar amount of their health care costs, said Chris Connover, an associate in research at the Center for Health Policy Research and Education.

Fee-for-service plans do not "steer" consumers as much as managed-care plans because patients can go directly to a specialist rather than receive health care first through a PCP and then, if deemed necessary, a specialist, Connover said.

"Some people will put their money where their mouth is and pay for the choice," he said.

While the University is concerned with providing equal coverage to all its employees, some of them are saying that they have a right to pay for additional choices. "I think [managed care] kind of impinges on one's personal freedom to pay [for the services they want]," said Dr. Rose-Mary Boustany, associate professor in the Division of Pediatric Neurology.

Some say that paying for a fee-for-service plan will reduce what some consider to be difficulty in accessing health care. Like Haagen, many employees praise the health care itself while criticizing the red tape involved.

Kahr acknowledged that familiarizing a large number of employees with their personal-care physicians for the first time proved to be a problem.

"Everyone tried to get through the turnstile at the same time," he said. While employees were asked to wait to set up appointments to meet their PCPs, "most [employees] tried to set up earlier appointments and it did cause a bulge in the system." As a result, employees had difficulty getting through to their PCPs by phone, and waiting lists for appointments were long.

These delays, which Kahr said are typical of a large-scale switch to managed care, are expected to end soon.

Others say, however, that the quality of care is not what it should be. Evans, who says he has been collecting stories about the health care plan, said that "some of them are fairly disturbing stories [about things from] unnecessary delays to things [for which] I would think one could win a malpractice suit."

"If that's any indication of what's going on, it's off to a pretty rocky start," said Evans, who switched to Kaiser this year.

Inaccessibility to health-care services significantly reduces their effectiveness, Boustany said. "It's not as easy to get health care as before the plan. There's no two ways about it."

As a doctor, she said that she feels doctor-patient relationships were destroyed with the advent of PCPs. While specialists were told they could become PCPs under the new plan, certain stipulations have made this infeasible for many physicians. The result of this is that "the loser is the user," she said.

As a patient, she said the plan is "not easy and it's a disappointment. It's not user-friendly."

Walbrun and Kahr, however, maintain that the plan has had very few official complaints.

"You could argue that the managed-care system has a built-in incentive to underserve," Connover said. But, he said, "trying to hash this out using anecdotes to me isn't terribly effective." Other forms of health care can be equally problematic, he added.

Many cite the disparity between the Duke Comprehensive Plan, which had covered almost all employee medical expenses incurred at Duke Medical Center for the past decade through Blue Cross/Blue Shield of North Carolina, and the new plan as the source of much employee concern.

"We had access to literally world class health care at no cost to us," Connover said.

But those involved in developing the new plan emphasize that changes had to be made to stop the spiraling costs of health care at the University. "The fact was that the plan was bleeding to death," said Ed Shaughnessy, professor of mechanical engineering and materials science.

Under the old plan, premium costs were skyrocketing and would begin to hurt the lowest-income employees significantly, Haagen said. "We were... facing a situation in which either you put increasingly large amounts of dollars into medical care or you come up with ways of controlling those costs," he said.

Many also note that the changes are reflective of a general nationwide trend toward managed care. "The whole world is moving toward managed care, whether we like it or not," said Alison Ashton, associate professor in the Fuqua School of Business.