While Vineyarders await a legislative vote needed to make the Island Health Plan (IHP) a reality, some Island health officials are already worrying about the impact of the new affordable insurance program on existing Island medical services.

"There are some concerns, and they are well-founded. There is very important work that remains to be done here on the Island to make this work," said Tad Crawford, chairman of the Dukes County Health Council, a group of Vineyard health professionals and users who meet to discuss the Island's health care needs. The health council conceived of this Island-based affordable health insurance program in 1998.

The Island Health Plan, a grassroots initiative to help link many of the Island's 3,000 uninsured residents with comprehensive coverage, has been under development for several years. The legislative vote is expected any day, and IHP executive director Cynthia Mitchell hopes to roll out the program this spring. Mrs. Mitchell, along with two other health agencies, is also spearheading efforts to open a rural health clinic - a practitioner-driven clinic intended to alleviate the primary care shortage by offering care to about 3,000 patients each year. The clinic is also scheduled to open this spring.

Some health officials are bracing for what they fear could be a shakeup in the delivery of medical care on the Island. Questions dominating discussions among health professionals these days range from the type of care chronically mentally ill patients will receive under IHP to what kind of competition the program will stimulate in the Island's closed health care system.

Health officials also say they know little more about Neighborhood Health Plan (NHP) - the Boston-based managed care company contracting with the Island Health Plan.

The finished product - a managed care company - looks sharply different from the homegrown insurance program Island health officials imagined more than five years ago. The plan, as first envisioned, focused on prevention, education and alternative medicine.

Mrs. Mitchell admits this version does not emphasize these prevention and education components, but the Island Health Plan, she said, will eventually incorporate such features.

"There's no way to avoid a managed care system initially. The first goal is to get people some insurance coverage. We'll start with a very good product, albeit a managed care product. But we'll build on that. NHP has their own prevention programs, but we'll add on to that. We're really only beginning," Mrs. Mitchell said.

Managed care companies, some officials say, face constant pressure to control costs. Officials wonder who would shoulder the expenses left unmet by the new program.

"The concern is that when you deal with an HMO, there are likely to be fewer benefits to the clients. But the need for services does not change. The way a managed care company makes their money is to manage care, by delivering less of it," said Ned Robinson-Lynch, executive director of Martha's Vineyard Community Services.

Mr. Robinson-Lynch is most concerned about the effects of this plan on his chronic population receiving mental health counseling through Medicaid. Neighborhood Health Plan, which already handles most of the state's Medicaid patients, would pick up all of the Island's 1,700 Medicaid clients who do not request otherwise. But mental health benefits under the Neighborhood Health Plan restrict visits to six per year without preauthorization. That limit could harm the population of about 100 chronic patients who receive counseling care at Community Services.

"I don't know what the safety net would be for that population," said Mr. Robinson-Lynch, noting that they currently receive limitless care through their Medicaid benefits.

If these patients switch to NHP and run out of preauthorized visits, they will likely go to Community Services or the hospital for treatment. The cost of that unfunded care could fall on the shoulders of those agencies.

Mrs. Mitchell said she will work to help inform Medicaid patients about the services they will receive if they switch to NHP in order to help them make the best choice. Mr. Robinson-Lynch said he will write letters to these patients as well.

Mr. Robinson-Lynch and Mrs. Mitchell met for the first time in many months last week to discuss these patients and a working relationship between their two agencies.

"I have no reason to think that outstanding issues will not be able to be addressed to mutual satisfaction," Mrs. Mitchell said yesterday.

But the question weighing most heavily on medical professionals these days is: Will the Island Health Plan and the new rural health clinic bring a level of competition that is detrimental to the Island? In any closed health care system, one department inevitably subsidizes others, explained Timothy Walsh, chief executive officer of the Martha's Vineyard Hospital. In the hospital's case, the emergency department, with its booming summer business, offsets losses in less busy departments such as obstetrics. To the extent that the rural health clinic would divert business from the emergency department, the hospital could feel a financial effect.

While all health officials know there is a primary care shortage on the Island, some have doubts about how many extra providers are needed to plug the hole.

"I get nervous. If there's one thing worse than not having enough primary care providers, it's having too many. You'd rock the boat the other way. The Island is already very hard on doctors," said Mr. Walsh. The hospital brought on a new primary care physician two years ago, and another has been recently hired. The hospital is also recruiting a replacement for Dennis Hoak, who recently retired.

"Once we hire this doctor, we need to stop and watch what's going on," Mr. Walsh said.

Mrs. Mitchell said that thousands of Islanders are still in need of a primary care provider, not to mention summer residents and visitors.

"It is quite clear there is a huge need for both - the affordable insurance plan and a primary care source. We have been told to expect a deluge when we open the clinic," Mrs. Mitchell said.

Over the last year, Island Health Plan leaders have been lobbying state legislators to pass a bill that would provide the millions of dollars in state subsidies needed to lower premiums for employers and employees. Many of the final details of the insurance plan hinged on these state approvals, so Mrs. Mitchell said she put many discussions with Island providers on hold until she had more information.

"Until the legislation was clearly going to pass, the hospital had other priorities to focus on. They didn't need to invest their resources in this until we knew is was going to be a reality," said Mrs. Mitchell.

The hospital received contract proposals in early February and is currently reviewing the plans. Physicians and mental health counselors, including Martha's Vineyard Community Services, will receive theirs shortly, Mrs. Mitchell said. No one will be excluded, she added.

"The Island Health Plan will not radically alter and it does not seek to alter referral patterns. If anything, there will be an incentive to seek health care on the Island," said Mrs. Mitchell, explaining how Island doctors have preliminarily accepted a sliding-scale copay system. A user's copay will be determined based on his income.

But health professionals are still uneasy and will continue to be so until they have more information.

"I'm not panicking yet, but there's a delicate balance in health care. We're disrupting it without a lot of face-to-face conversation," said Mr. Walsh.

"These are longstanding, and frankly legitimate, concerns. But none of them can't be addressed," said Mrs. Mitchell.