UPMC-Highmark tiff getting messy

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Six months before the possible/​apparent/​certain (take your pick) end of the Highmark-UPMC contract, the pending dissolution of the relationship between Pittsburgh’s health care giants is starting to look more messy and entangled than you might expect.

“There will be hundreds of complications, small and large, that people have not even thought about,” said Stephen Foreman, associate professor of economics and health administration at Robert Morris University. “These medical entities are so intertwined that, in unwinding them, things will happen that no one can foresee.”

Health care provider UPMC insists the unwinding will take place once its contract with insurer Highmark expires Dec. 31 now that Highmark has built a competing provider network. But many questions remain about how that disengagement will go.

Possible complications include:

• Patients whose primary care physician may be attached to Allegheny Health Network hospitals but have been seeing a UPMC specialist for a chronic condition. If they need to find a different doctor, how will that be handled? How long will it take to have medical records transferred if hundreds of requests come in at once?

• University of Pittsburgh students whose families have Highmark Community Blue insurance who, as sophomore Alaina Smith learned when she broke her ankle in April, will be turned away for follow-up, nonemergency care at UPMC hospitals and physician offices that border the Pitt campus.

• UPMC workers who have Highmark insurance, either because they’re part time or because they’re covered through a plan offered by their spouse’s employer. “There are quite a few of us,” wrote one reader, a part-time UPMC clinical staff member insured through her husband’s work who asked that her name not be used. “Soon this group won’t be able to receive care at the facilities they work at … crazy but true.”

And the possible complications include employers who must decide, within weeks, whether to continue offering Highmark exclusively, offer alternatives or just go with one of the national insurers or the UPMC Health Plan.

“Frankly, it’s too late already in a lot of ways,” said Jessica Brooks, executive director of the Pittsburgh Business Group on Health, a coalition comprised of major local employers.

Typically, employers have decided by May what plans they will offer for the next year, she said. This year, only 8 percent of the business group’s 70 members had locked in by then. Another 39 percent said they will decide in July, and 22 percent will wait until August.

State regulators have told Highmark to submit a plan by July 31 detailing the transition to a post-UPMC contract world, but Mrs. Brooks said employers need to know sooner. On Tuesday, the group sent letters to top state officials including Gov. Tom Corbett urging them to expedite the transition plans.

“We need clarity about who is truly in-network, physicians and facilities,” Mrs. Brooks said, “and what is the out-of-network impact cost-wise.”

UPMC officials estimate that perhaps 95 percent of the region’s residents will at least have the option of going with an insurer that will offer in-network access to UPMC after this year, and they predict most will go that route. Highmark, on the other hand, says its retention rate is nearly 90 percent.

Highmark says 68 percent of UPMC physicians will be in-network, in part because some treat patients at community hospitals that contract with Highmark. UPMC says that percentage is too high.

With the two sides disagreeing about such details, the chances for a smooth transition seem doubtful.

“What our clients want to know is who’s in and who’s out of network. They’re getting different messages and they don’t know what to believe,” said Tom Tomczyk, head of the health and productivity division with Buck Consultants, Downtown. “That’s been the most frustrating part of this thing because they just can’t plan.”

Mr. Tomczyk works with local employers. Some on the front lines already see confusion.

Independent obstetrician/​gynecologist Dean Pollack has seen patients for 28 years at his UPMC Shadyside Hospital office. He’s had patients lament that they won’t be able to continue seeing him after Dec. 31 because of the Highmark-UPMC split which, he quickly points out, is not true. As an independent practitioner, he accepts all insurance.

Other questions are also likely to come up. Given the nature of medical billing, people may not learn for weeks after they leave a hospital how much they owe. When people arrive at a hospital, will they know if all of their tests and procedures will be in-network?

“By the middle of next year,” predicted Mr. Foreman at Robert Morris, “everyone in town is going to hate their health insurance.”

Meanwhile, Mr. Tomczyk — perhaps echoing the sentiments of his employer clients — said simply, “At this point, I don’t really care if they have a contract or not. Just tell me and let’s move on.”

Steve Twedt: stwedt@post-gazette.com or 412-263-1963.

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