Key disagreements between UPMC and Highmark persist after the unveiling of Highmark’s transition plan earlier this month, a plan meant to clarify questions regarding insurance subscribers’ access to UPMC health services after the Dec. 31 expiration of the contract between the two.
UPMC maintains Highmark is grossly exaggerating what access its members will have, in what UPMC spokesman Paul Wood described as “an attempt to bait and switch unsuspecting consumers.”
A top Highmark executive contends UPMC is deliberately muddying the waters to create uncertainty and push Highmark members to other insurers. “I think they are trying to cause confusion, and unfortunately it creates some concern for individuals in the community,” said Deborah Rice-Johnson, Highmark Health Plan president.
The disagreements include some fundamental questions.
How many UPMC doctors will remain in Highmark’s network once the two parties’ contract ends? Highmark says it’s 80 percent of UPMC’s near-3,600 employed physicians; UPMC says it’s no more than 56 percent, at best, and within Allegheny County could be as low as 25 percent.
Then there’s emergency care. Highmark maintains the two sides agreed that the insurer’s members needing care at a UPMC emergency room will remain in-network at that hospital until the patient is ready to go home. UPMC says in-network rates last only until a patient is stable enough to be transferred somewhere else, a contention that seems to be backed up in a letter Insurance Commissioner Michael Consedine sent to a legislator in July.
These and other questions were supposed to be addressed, if not settled, in the transition plan Highmark submitted to the Pennsylvania Insurance Department on July 30. State insurance officials reviewed it and released the plan publicly Sept. 2.That plan was supposed to refine and clarify consent decrees signed by both parties in June.
Mr. Consedine said his department continues to evaluate the plan. “Where either we or the community still have outstanding questions of how the plan meets the terms of the consent decrees, then we’re going to push Highmark to provide additional information or clarification.”
He said there will be more steps coming as the fall progresses, including an outreach and education plan from the Corbett administration. “We’ve made tremendous progress in addressing the big questions that the community was asking two months ago,” Mr. Consedine said in a statement. “But we certainly recognize that there is more work to do, and we’re committed to doing it.”
At stake are the hearts, minds and insurance premiums of many of Highmark’s regional subscribers, most of whom get coverage through an employer who often decides which plans to offer based on a broker’s recommendation.
“Employers continue to be left in limbo, not really knowing if the recommendations they are receiving from their brokers are in their best interests,” said Jessica Brooks, executive director for the Pittsburgh Business Group on Health, a coalition representing more than 90 local employers.
On the other hand, she noted, “Brokers are in an equally difficult position.”
The debate continues as a crucial period for local consumers begins. Annual open enrollment is set to begin Oct. 1.
Challenging the lists
UPMC’s spokesman is eager to lay bare what he sees as a misrepresentation by Highmark on access to the health system’s doctors.
The previously agreed exceptions include physicians treating patients at UPMC emergency rooms, Children’s Hospital and Western Psychiatric Institute and Clinic as well as outlying facilities such as UPMC Bedford and UPMC Altoona.
“The reality for people who are trying to find a doctor they want to go to in the eight UPMC hospitals in Allegheny County, is that it’s probably at best 25 percent,” Mr. Wood said.
He said UPMC’s in-house contracting staff identified some 1,250 UPMC physicians who were “miscoded” on Highmark’s YourNetwork2015.com website where members are supposed to be able to find out if a particular physician will be in Highmark’s network after Dec. 31.
Mr. Wood pointed to some noteworthy physicians he said are erroneously listed as in-network, such as UPMC pulmonologist Steven Shapiro. Dr. Shapiro is UPMC’s chief medical and science officer whose administrative duties limit how many patients he sees. Those patients he does treat are at either UPMC Presbyterian or UPMC Shadyside, hospitals that will be out of Highmark’s network beginning Jan. 1.
Ms. Rice-Johnson countered that UPMC had not asked to cancel Dr. Shapiro’s in-network listing, although Highmark has now removed it from the YourNetwork2015.com website.
Another example cited by Mr. Wood is independent private practice orthopedic surgeon Anthony DiGioia, who sees patients at UPMC Magee-Womens but is listed on the Highmark site as in-network with an affiliation with West Penn Hospital in Bloomfield, “a place where he resigned his staff privileges more than six years ago,” said Mr. Wood.
Highmark spokesman Aaron Billger acknowledged Dr. DiGioia does not currently have admitting privileges at West Penn, but said Highmark is regularly updating the website as information from UPMC comes in.
Mr. Wood further takes issue with physicians listed as “in-network” who may work one day a week, or once a month, at an in-network community hospital but are out of network the rest of the time.
He described the 80 percent as a misleading figure that “may happen one day out of the year if all UPMC Oakland-based doctors are off-site and if the planets are exactly aligned. It will never be a 365-day occurrence. Adding an asterisk to a website is not helpful.”
By his calculations, among UPMC-employed physicians, about 1,200 are pediatricians, psychiatrists and emergency doctors who will remain in Highmark’s network. Another 400 physicians practice outside the local five-county region also will be in-network for Highmark subscribers.
“That leaves 2,000 employed med-surg physicians practicing primarily at our facilities in Allegheny County where the vast majority of care is provided and will be out-of-network for Highmark subscribers,” Mr. Wood said.
“At best, only 400 of the 2,000 docs in Allegheny County that practice at Mercy could be considered in-network — but then for only another year until that contract expires.”
Responded Ms. Rice-Johnson: “That’s not what they agreed to at all.”
Rebutting the charges
Ms. Rice-Johnson provided the Post-Gazette with an internal Highmark document showing that as of Sept. 12, UPMC employed 3,565 physicians. Of those, the document states that 1,719 will still be in-network after Jan. 1 and another 1,126 will be in-network when seeing patients at facilities contracting with Highmark.
The two combined represent 80 percent of the total, Ms. Rice-Johnson said, while another 720 will always be out-of-network for Highmark members.
Each of those numbers, she said, was validated by both UPMC and Highmark officials, and she added that the two sides co-authored footnotes for the website explaining the partial in-network status for those doctors.
She also said UPMC officials David Farner, chief of staff for president Jeffrey Romoff, and Joseph Chuba, vice president for contract services, agreed that Highmark members seen in a UPMC emergency room would remain in-network through in-patient discharge. Highmark agreed, she noted, even though it would benefit Highmark financially to transfer a patient once he or she was stable.
“We even went as far as talking about what happens if someone is discharged and needed follow-up care,” she said. In that circumstance, they decided the patient would need to be seen at a facility contracting with Highmark to be in-network “but it was always ‘after discharge.’ ”
She added that state officials believed this was an important safeguard as well. “The regulators wanted to make sure that these patients were not disrupted — not financially and not from a safety perspective,” she said.
But in a July 30 letter to Rep. Tony DeLuca, D-Penn Hills, Mr. Consedine stated that while emergency patients will be transferred to a hospital in their network “once stabilized.” The question then becomes medical, but it also carries legal and liability implications: How readily will an emergency physician pronounce a seriously ill patient stable enough to transfer?
Not about the consumer
Benefits consultant James McTiernan of Triad USA, Downtown, a division of Arthur J. Gallagher & Co., said the consent decrees signed in June and now the transition plan do bring significant clarity to what will happen in 2015.
The current disagreements between Highmark and UPMC may come down to “just trying to put themselves in the best light they can, and I think that’s a fairly natural thing to do,” he said.
“How does any of this help the consumers? From day one, this hasn’t been about the consumer.”
Mrs. Brooks has lobbied to include employers, such as her business group members, in the state-level negotiations to insist on greater clarity. To her frustration, that has not happened.
“No matter how Highmark interprets access and coordination of care, UPMC will communicate its interpretation, which will lead to confusion in the market,” she said.
“It’s a failure of [Gov. Tom Corbett’s Patients First team of top agency officials] and both Highmark and UPMC to not be at the table together on behalf of their members and customers to create a consistent message.”
First Published: September 24, 2014, 4:00 a.m.
