SHP, Duke Health reach access provider agreement

The North Carolina State Health Plan (SHP) and Duke Health announced an agreement Wednesday that will make Duke Health an access provider under the plan’s new provider tier system across the state, with a primary emphasis on the Triangle in the central part of the state.

Access providers will maintain the same level of service next year, at the same cost as members are currently paying. 

“Serving State Health Plan members is both a privilege and a responsibility for Duke Health,” David Zaas, MD, chief executive officer of Duke Health, said in a press release. “Our priority is making sure State Health Plan members and their families can continue turning to Duke Health. We’re grateful to Treasurer Brad Briner and his team for working with us to reach an agreement that preserves access to Duke Health for the people who serve our state every day.”

According to the release, as an access provider, Duke Health will continue offering State Health Plan members access to its statewide network of hospitals, physician practices, and ambulatory locations across North Carolina, connecting patients to the full range of primary care, specialty care, and highly specialized treatments available through Duke Health. In 2025, State Health Plan members received care through Duke Health more than 253,000 times.

“To see this kind of dedication from a world class organization like Duke Health shows just how important our members, and their families, are,” State Treasurer Brad Briner, who chairs the SHP Board of Trustees said in a press release. “The extensive network of doctors, facilities and expertise they bring to our members is just the type of partnership we have been looking for.” 

wakemed will be classified as non-preferred for most services

The State Health Plan, which has nearly 750,000 members, had been in negotiations with both Duke and WakeMed as an access provider.

According to an emailed statement from Loretta Boniti, director of strategic communications and media relations for Briner, a majority of WakeMed’s services will be non-preferred.

She said, however, that current individual primary care providers associated with WakeMed will remain preferred, and as a Tier 1 trauma center, WakeMed’s emergency room will remain as an access provider. 

“Given that many Duke Ob-Gyns also deliver at WakeMed, we will figure out a path to ensure those members have a seamless experience,” Boniti said. 

Tom Friedman, executive administrator for the SHP, said in an emailed statement that Duke Health reached out following the June board meeting, where the treasurer said that although they were in a good position with assembling the different provider tiers, they were still open for negotiation.

“Given the substantial number of patients who utilize Duke Health, their excellent quality and many complex services they offer for our sickest members, and a significant discount off current rates, we felt this partnership aligned perfectly with our commitment to quality, access, and affordability while minimizing patient disruption,” Friedman stated in the email. “It is rare a partnership can check all of those budgets and address so many member concerns. Duke’s outreach and bold plan caught the Plan by surprise given the previous CEO’s very public push for rate increases for SHP members, but we believe it is a clear demonstration that competition brings out the best of us and when we align our interests, we get the best deal for all stakeholders.”

He said that WakeMed is an excellent facility and they continue to value their services, such as their emergency department and their OB platform (which they currently partner with Duke Health on). 

“But given the saving to the Plan and the human impact, we believe Duke Health is the right access partner for the State Health Plan,” Friedman added.

Briner echoed that sentiment to Carolina Journal’s editor-in-chief, Donna King, who was filling in for Pete Kaliner on The Pete Kaliner Show on WBT Radio Wednesday afternoon.

He told King that the SHP has partnered more closely with health systems who really want to serve state employees and the way they are doing that is with providers that have provided substantial capacity at a reduced price for the plan. In turn, they are passing on those savings to members to encourage them to see those providers.

Briner said non-preferred providers, for their own business reasons, really don’t want to work with the plan and as result, there will be higher costs for the SHP to pay for members to go there, and members themselves will be paying a higher cost.

“So, we’re hoping members vote with their wallets and find a provider who is preferred or at least access and shop for your services that way,” he told King.  

The announcement comes less than a week after the SHP Board of Trustees voted on the new provider tier system including preferred, access, non-preferred, and out-of-network providers.

UNC Health and Novant Health made the cut for the preferred tier, joining Iredell Health System. Atrium Health, Granville Health, and some Duke LifePoint Healthcare facilities fall in the non-preferred category.

The goal of the tier structure is to have as many members as possible to use preferred providers, which will save the SHP and the member the most money, with an estimated savings of one-third of out-of-pocket (OOP) costs. Members who use access providers, which are mainly in rural areas, will basically have the same co-pays and deductible as they do now.

The new tiers structure will take effect on Jan. 1, 2027.

“This is monumental,” he said at the SHP board meeting on July 10. “It’s thousands of dollars to the average member of the State Health Plan if they participate in the Preferred Provider program. Our members know that those thousands of dollars are much more important than the $2 to $4 premium increase we will be talking about.”

As was mentioned at last month’s board meeting, ER coverage will be the same cost across all tiers and there will be a very robust transition-of-care plan in place for those using maternity/NICU services, cancer, and transplant treatments. The timeframe, according to Friedman, is indefinite. Current PCP and behavioral health coverage will not change and will still be under the preferred status.

Overall, members will see a 5% increase in premiums for 2027. On average, an employee paying $50 per month whose salary increased by 5% would see their monthly premium rise to $52.50.

A further breakdown shows that active employees would pay anywhere from $1.76 to $8.04 for an individual monthly premium or $21.12 to $96.48 annually.

The SHP board also awarded the third-party administrator (TPA) and pharmacy benefit manager (PBM) contracts to Blue Cross Blue Shield of North Carolina (BCBSNC), effective January 2028. This will bring BCBSNC back as the TPA after a three-year hiatus. CVS Caremark is the current PBM for the SHP. 

“SHP, Duke Health reach access provider agreement” was originally published on www.carolinajournal.com.