UPMC vs. Highmark: In a feud about access, real patients fear the future

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First of three parts.

Karen Engbarth of Shaler is battling two demons, a 2010 diagnosis of stage four ovarian cancer and a 2011 decision by UPMC to part company with Highmark insurance in the middle of next year.

Her Highmark policy, which she buys as an individual for $491 a month, has covered excellent treatment, she said -- a six-hour surgery, months of chemotherapy and a gantlet of diagnostic tests, by UPMC staff at UPMC hospitals. But her battle against cancer is compounded by anxiety over how long she can rely on UPMC for care.

"This is unfair because I already have a major health situation. To have this insurance thing on top of it is just not right. It's a seesaw of emotions. It makes me feel like I don't mean anything to anybody," said Karen, who is 60. "At least my doctors don't feel that way."

She's not alone. More than 3 million Highmark customers will face the same loss of in-network, affordable access beginning June 30 to UPMC physicians and then, a year later, to most of its hospitals. It's a corporate decision with personal consequences throughout Western Pennsylvania, and for the next three days, Post-Gazette editorials will tell the stories of some of the real people behind the statistics.

UPMC says it must sever its long-standing relationship with Highmark because the region's dominant insurer is investing heavily to prop up a UPMC competitor, the smaller and financially struggling West Penn Allegheny Health System. UPMC says Highmark's new partnership puts it in both the insurance and hospital business. Yet UPMC, a 20-hospital network, has had its own insurance subsidiary for more than a decade while not refusing Highmark's dollars.

For Karen and Highmark customers like her, it's not "Life Changing Medicine," as UPMC calls it, but "Life Rearranging Medicine."

The corporation's marketers are clever, though. They've launched a special website called keepyourdoc.com, which tries to strike comforting notes for the people who are threatened by UPMC's business strategy to curtail Highmark access. On a page called Continuity of Care for Patients Undergoing Treatment and another titled Care for Patients with Chronic Diseases, UPMC notes that its contracts with Highmark "provide for cooperation" on patients who are being treated and that UPMC is "prepared to work with Highmark" to identify such patients. "Provide for" and "prepared to" -- hardly a guarantee to treat.

With a faux concern that is lawyerly worded, the Web pages then pose questions to Highmark on the need to work out the details, as if the insurer is to blame for the cutoff that UPMC promises next year.

Karen continues to receive good care, although her life is a jumble of medical acronyms. She gets periodic CAT scans and recently had a PET scan and an MRI. "My blood markers are going up in a hurry," she said, an adverse sign in cancer patients. This month she resumed chemotherapy.

"I go to the oncologist's office and ask what's going to happen on the insurance. They say, just wait and see. But how long do I have to wait and see? What happens when it's May or June? This is the last thing I want to have to worry about."

Although she was in the high school class a year behind Shaler's favorite son, Gov. Tom Corbett, she hasn't thought about calling his office regarding UPMC-Highmark. She's heard the advice of UPMC CEO Jeffrey Romoff, who said earlier this year that Highmark customers who want to stay with UPMC should just change insurance carriers. Said Karen, "Who's going to take me if I switch plans? Who would want to insure me? Besides, I'm sure I'd be paying much more."

Karen and Chuck, her husband of 40 years, have three adult children and a grandson. They've lived in the same tidy house for 38 years and the couple plan to stay there a lot longer. "I try to stay positive, but I'm realistic at the same time," she said.

She is willing to keep up her fight against cancer and endure more time on the receiving end of needles, scalpels and bad news. But she doesn't need the additional pain, dumped on her by UPMC's corporate strategists and board of directors, of a threat to pull the plug on her continuum of care.

First Published December 18, 2011 5:00 AM


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