A University of Pittsburgh sophomore’s broken ankle has exposed a new twist in the ongoing Highmark-UPMC contract dispute — beginning Jan. 1, likely thousands of Pitt students with Highmark insurance could have limited or no access to non-emergency care at the health system affiliated with the university they attend.
For biology major Alaina Smith, that future is now.
Ms. Smith, 20, from a small town south of Harrisburg, was longboarding down Neville Street in Oakland on her way to the library March 29 when she hit a patch of gravel, sending the board forward and her body backward, ending with an awkward landing on her right ankle.
A friend drove her to UPMC Presbyterian’s emergency department where an X-ray confirmed she had a broken fibula. The medical staff fitted her for a brace and told her to call UPMC’s orthopedics office Monday morning, once the swelling receded, for a follow-up appointment to get a cast.
“I was in and out in an hour,” said Ms. Smith. “It was really efficient. They were really, really nice to me.”
She said she got a different reception Monday morning when a woman answered her call to the orthopedics office.
“She said, ‘Our records say you have Community Blue [insurance], so we can’t take care of you. You’ve got to find another doctor,’” Ms. Smith recalled. “She was kind of condescending.”
In January 2013, Highmark launched Community Blue, a low-cost plan that excludes most UPMC physicians and hospitals from its “in-network” roster. A few months after that, UPMC responded by dropping all Community Blue members, declining to see even those who offered to pay cash.
That episode represented another chapter in the three-year dispute between UPMC, the region’s largest health care provider, and Highmark, the region’s largest insurer, over Highmark’s move to establish its own provider network, the Allegheny Health Network.
After being turned away at UPMC, Ms. Smith phoned her mother, Denise, a Highmark employee based in Camp Hill, who “did the Mom thing” and assured her she would fix this. That involved arranging an appointment at an Allegheny Health Network outpatient clinic in Bethel Park for a cast fitting two days later, then arranging a follow up appointment at Allegheny General Hospital on North Side two weeks after that.
Ms. Smith got a new set of X-rays at each stop, three in all.
“I understand what’s going on. I don’t understand why it’s going on,” said Ms. Smith’s father, Wayne, who has spent most of his career in insurance.
Although aware of the Highmark-UPMC battle, he said he thought it should have been resolved by now.
“She’s a student at their university and it’s their health system. How many other people are out there who have Highmark insurance and may be denied access to care when they are right down the street from it?”
UPMC spokesman Paul Wood acknowledged that Pitt students with Community Blue insurance will not receive non-emergent care at its Oakland facilities other than Western Psychiatric Institute and Clinic — but he blames Highmark.
“Highmark designed Community Blue specifically to steer patients away from the care they would prefer to receive at UPMC,” he said. “It’s unfortunate that Highmark’s marketing misrepresentations of the product have confused even its own employees.”
Highmark spokesman Doug Braunsdorf countered that "Highmark never intended for Community Blue members not to use their insurance at UPMC facilities. But UPMC has made a business decision to cut off access to Community Blue patients."
He added that "UPMC's refusal to treat patients solely on the source of payment is unprecedented in the health care industry."
Pitt does offer students what it describes as “a comprehensive affordable health insurance plan” with UPMC Health Plan, which provides access to UPMC facilities and physicians for $179 a month with no deductible, and a $75 copayment for an emergency room visit like Ms. Smith’s.
Students are not required to buy the insurance, however, and many, like Ms. Smith, have insurance through their parents’ coverage, particularly now that the Affordable Care Act allows young adults to stay on their parents’ plan until age 26.
Of the 35,330 students at Pitt, only 4,100 have purchased UPMC Health Plan insurance, according to Pitt spokesman Ken Service. It is not known how many of the remaining have Highmark insurance.
A few block east on Forbes Avenue, meanwhile, about 7,000 Carnegie Mellon University students have subscribed to its student insurance plan — which is offered through Highmark and also will be out of UPMC's network in 2015 if there is no contract. Both universities have student health clinics to take care of minor illnesses and injuries.
Because UPMC now considers Highmark a competitor — even though UPMC has its own health insurance arm that competes with Highmark — UPMC says it will not renew or extend its current contract with Highmark past the Dec. 31 expiration. After Dec. 31, anyone with Highmark insurance — not just Community Blue members — likely will face paying higher, out-of-network rates to receive care from UPMC physicians and facilities.
That dissolution may be particularly bewildering to Highmark-insured Pitt students given the proximity of UPMC hospitals to the Pitt campus.
Instead of walking across the street for a doctor’s appointment or taking a quick bus ride down Fifth Avenue, they may find out they have to navigate their way to the North Side or Bloomfield or one of the suburban hospitals.
Ms. Smith predicts many will have a reaction similar to her own.
“I was like, ‘What do I do now?’ UPMC is all I see every day. I was ignorant that there was even another hospital around here.”
Steve Twedt: email@example.com or 412-263-1963.