Pregnant moms navigate confusion created by UPMC-Highmark split
January 18, 2015 12:00 AM
Deena Blumenfeld says students at her Shining Light Prenatal Yoga Studio in Lawrenceville have questions about how the Highmark-UPMC split affects them.
Deena Blumenfeld teaches prenatal yoga Thursday at Shining Light Prenatal Yoga Studio in Lawrenceville.
By Steve Twedt / Pittsburgh Post-Gazette
With a new obstetrics unit at Jefferson Hospital and expansion plans at West Penn Hospital, the choices for expectant parents are increasing in the region — but so are the questions about how to navigate the insurance and provider maze created by a post-UPMC-Highmark world.
“There’s been confusion. I think that’s the biggest problem,” said Deena Blumenfeld, who runs Shining Light Prenatal Education in Lawrenceville. “All the marketing they’ve done really hasn’t cleared things up.”
That point was underscored late last week when Highmark notified independent obstetricians that they could not deliver the babies of already-pregnant women at UPMC Magee because it is now out of network.
Confusion and frustration were already in play well before that, though. Ms. Blumenfeld sees 200 to 300 expectant or new mothers monthly at her Butler Street storefront who come for classes in prenatal yoga, Lamaze, breastfeeding and childbirth education. And, in the months leading up to the Jan. 1 expiration of the Highmark-UPMC contract, she says they also came with questions.
“The concern is for people trying to get pregnant with their second child,” Ms. Blumenfeld said. “They often can’t have the same care provider because they were with a UPMC doctor for the first baby and they delivered at Magee, and now their doctor is out of network because they have Highmark insurance.”
The two Pittsburgh health giants are still unable to agree on what constitutes “continuity of care” that would allow Highmark insurance members to keep seeing their UPMC physician at in-network rates, meaning patients across the spectrum may get caught in the middle in coming months.
But new and expecting parents — a sizable group since there are 13,000 new births annually in Allegheny County — may be hit the most and hit the hardest.
“I don’t think all the dust has settled in terms of what people want to do or need to do,” said Karen Schogel, a primary care physician with the independent Genesis Medical group in Ross. “But I think in the first quarter is when things might start to shake out in terms of patients saying, ‘Oh, gee, I wonder if I have to change my doctor?’”
That is not an easy decision, Ms. Blumenfeld said. “It’s a very personal choice who you choose to have your baby with. If you have a relationship with your doctor or your midwife, and you had a good experience, you want to stay with that person.”
First-time parents are concerned, too, she added. Women with Highmark insurance who knew before Jan. 1 that they were pregnant last month should be able to continue with a UPMC physician, but some mothers are wondering how long that in-network relationship will continue after the birth.
Expectant parents are asking her, “What happens after the six-week post-partum visit if I have another issue? Is that still covered? My answer to them is, ‘I really don’t know.’”
A hospital birth for someone with insurance can cost several hundred dollars. A delivery out-of-network, however, can approach $10,000 for an uncomplicated vaginal delivery and $15,000 or more for an uncomplicated cesarean section, according to the Webmd.com website.
“The cost differential for most people is insurmountable,” said Ms. Blumenfeld.
State health and insurance officials have set up a website, www.stayinformed.pa.gov, to answer questions, but the advice boils down to this: You should ask your provider and your insurance company.
It also says physicians employed by either UPMC or Highmark’s Allegheny Health Network cannot refuse to refer a patient to the other’s network. That doesn’t mean cross-network referrals will be common, as network-employed physicians may feel pressured to keep patients in-house.
“The network doctors are trying to play it to their network’s advantage,” said Dr. Schogel, “and we as independents are going to be able to take a step back and hopefully make good judgments about whether people really need to continue with one particular doctor and what needs to be changed.”
Ms. Blumenfeld acknowledged that, unlike some remote rural areas, “It is a luxury that we have the ability to choose care providers.”
She said, “I have people who love [UPMC] Magee and I have people who love [AHN’s] West Penn.”
But she sees trouble ahead when preferences no longer match the insurance plan.
“Most people don’t have a choice because the employer has offered one insurance plan,” she said. “Or, when we had open enrollment, they picked a plan, then find out later they are pregnant, and it wasn’t something they were thinking about at the time.
“I don’t want to see parents making medical decisions based on financial considerations only.”
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