Highmark's 'Community Blue' patients rejected by UPMC

Community Blue subscribers who want to pay out of pocket can't see their doctors

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When Marie Acquafondata retired after 40 years at what is now UPMC Shadyside, she and her husband, John, had to switch health insurance plans. They left her UPMC Health Plan and signed up with Highmark's new Community Blue plan, offered by his employer.

Community Blue is a low-cost "select-network" plan, which means it doesn't include most UPMC doctors and facilities in its directory of preferred, "in-network" physicians. And as the Bloomfield couple -- and hundreds more -- are now finding out, UPMC is scrubbing Community Blue subscribers from its rosters of active patients as UPMC and Highmark fight for local health care supremacy.

The Community Blue insurance plan launched Jan. 1, and those who joined on day one were given two months by UPMC to find new doctors. On Saturday, they were cut loose.

For Mrs. Acquafondata, a breast cancer survivor who worked in histology research, that means she'll be losing nearly all of her doctors -- primary care, endocrinology, oncology and more. The couple were willing to pay out of their own pockets to keep her doctors, said Mr. Acquafondata, a courier for West Penn Allegheny Health System, the would-be acquisition target of Highmark Inc.

"Anything and everything she had was a UPMC physician," Mr. Acquafondata said.

Though paying out-of-pocket may be an option for other would-be UPMC patients, not so for Community Blue customers. And that's a point of contention between the two squabbling Pittsburgh health care giants: UPMC says this is what happens when customers subscribe to a Highmark product that intentionally excludes UPMC; Highmark calls the "firing" of longtime UPMC patients "unacceptable and unethical."

When Mrs. Acquafondata began receiving certified letters from UPMC clinics and physicians last month, telling her that "you will no longer be an active patient," she felt "betrayed and angry ... I don't think that's right," she said.

As a longtime UPMC employee, she has great respect for the system, its physicians and her former colleagues, but she said she blames UPMC, not Highmark, for this lockout.

And because of her long tenure with the health system, she is also familiar with UPMC's "Patient Bill of Rights," particularly item No. 13, which says, in part, that "a patient has the right to medical and nursing services without discrimination based [upon] source of payment."

Cash is usually an accepted form of payment -- but not when it comes to Community Blue customers.

"We have decided that a Community Blue subscriber's willingness to self-pay or ability to self-pay is not one of the approved exceptions" that would allow them access to UPMC's provider network, said UPMC spokesman Paul Wood.

The Acquafondatas had looked into other options before choosing Community Blue, particularly the purchase of extended UPMC Health Plan coverage through COBRA, a federal law that allows retirees, spouses, dependent children and others to continue with their former health plans. But coverage purchased through that program for former employees is far more expensive than what current employees pay. For the Acquafondatas, the UPMC Health Plan coverage would have been five times more expensive than the Community Blue premiums.

"It was a no-brainer," Mr. Acquafondata said. They went with his Highmark plan, made available to him because he is a WPAHS employee; Highmark and West Penn Allegheny employees are, essentially, the canaries in the coal mine during the early, test-drive months of this UPMC-free product.

Alicia Marney of Monroeville likewise was willing to pay out-of-pocket to continue to see her UPMC doctor. She, too, is a breast cancer survivor. Because of the rarity of her form of cancer, she has been treated through a special clinical trial being conducted by Shannon Puhalla, a medical oncologist and hematologist at UPMC Cancer Center at Magee-Womens Hospital of UPMC.

Until this year, that is.

Ms. Marney, a secretary at Forbes Regional Hospital, now has coverage through Community Blue. When she met with Dr. Puhalla last month to discuss her treatment, she was told that she could not return.

Both Ms. Marney and her fiance, Rocco Vitalone, said Dr. Puhalla is a wonderful physician who was apologetic about the marching orders. "This is not my decision," they remember her saying. But that doesn't ease the sting, said Ms. Marney.

"I work in a hospital. I understand billing and insurance," she said. "I have no understanding of why this could not be a self-pay [situation]."

For a routine office checkup, Ms. Marney figures she would have had to pay an extra $70 on top of what she paid with her old coverage, based on her understanding of the cost of her visits to Magee.

Even though Community Blue considers UPMC out of network, because of the special nature of her clinical trial, Ms. Marney had received an "exception letter," sometimes known as a waiver letter, from Highmark. A waiver allows the patient to seek care out of the provider network, at in-network costs.

But to date, UPMC has declined to continue treatment, she said.

Mr. Wood, the UPMC spokesman, said that there might be case-by-case exceptions to UPMC's policy, including patients receiving "unique treatments."

But he stressed that the blame lies not with UPMC for the lockout, but with Highmark for not adequately communicating to its Community Blue customers that they would lose UPMC access. That's evident, he said, in the phone calls fielded by UPMC customer service reps from Community Blue customers. (In one such call, a woman said "we would have never picked this plan" had she known she would lose her doctors.)

The loss of UPMC access is why so few companies, other than Highmark and WPAHS, have signed on with Community Blue, Mr. Wood said, adding that UPMC had sent out "hundreds" of the notification letters.

"So it's a pretty small number of people that are, unfortunately, being caught in this situation," he said.

One UPMC employee, who did not want to be identified, said: "We all feel horribly about this ... we have been leaned on by UPMC" to refuse treatment for Community Blue members, even those with exception letters. "It's not the [doctors], it's the administrative powers."

Generally, health care providers can treat whomever they wish, and can cut patients loose as well. If a patient has a history of skipping appointments, for example, he or she can be dismissed from a practice.

However, it's common for doctors -- especially primary care physicians -- to see patients who are considered out-of-network.

In those cases, depending on the arrangement with their insurer, patients are usually responsible for a higher co-payment and the remaining balance of the physician-billed charges after the insurer picks up part of the tab. Sometimes, a patient will dispense with insurance altogether and just pay in cash.

In other words, just because a health insurer considers a doctor "out-of-network," and leaves him or her off the insurer's list of preferred providers, doesn't necessarily mean that doctor is off limits. It just means the insurance coverage won't work there.

For Ms. Marney, there's an extra layer of irony at play -- her fiance, Mr. Vitalone, has health insurance through Blue Cross Blue Shield of Illinois. His insurance plan does not include UPMC among its in-network providers, yet he is still able to see the health system's doctors on an out-of-network, extra-cost basis.

That means UPMC doesn't exclude all out-of-network payment arrangements, or even all out-of-network Blue Cross Blue Shield-affiliated patients.

"Bottom line," Mr. Vitalone said in a letter sent to UPMC and the Post-Gazette, "I could not be more disappointed with [UPMC] ... It is disheartening and honestly it feels criminal."

"It's disappointing," Ms. Marney said, "that we, the patients going through a serious illness, have to be part of the so-called war."

Community Blue is the revived version of a popular Highmark insurance product that was eliminated in 2002 when UPMC and Highmark agreed to a 10-year contract allowing the insurer's customers to be treated at UPMC facilities. When the two parties agreed last year to a contract extension running through the end of 2014, part of that agreement allowed Highmark to offer insurance products in which UPMC hospitals were out-of-network.

Under the new Community Blue plan, Children's Hospital of Pittsburgh, UPMC Northwest, UPMC Bedford and Western Psychiatric Institute and Clinic are considered "in-network," and the rest of UPMC's hospitals are out-of-network.

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Bill Toland: btoland@post-gazette.com or 412-263-2625.


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