Blue swamp: Patients get stuck when health care networks feud

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A group of Highmark insurance subscribers feel like they're being fired by their doctors, but it's more accurate -- though no less disturbing -- to say that they're caught in the crossfire of a corporate battle for customers. They are collateral damage, and they don't deserve to be.

Customers of Highmark's new Community Blue coverage should have known from the start that most UPMC doctors and facilities were not included as in-network providers under the plan. What many didn't realize until recently is that they would not be able to access those physicians and hospitals even if they wanted to pay higher rates to do so.

The question is, why not? The answer is complex, and some of it depends on who is supplying the explanation.

Here's how Highmark says Community Blue was supposed to work: Most UPMC facilities are not considered in-network for subscribers. However, instead of being considered out-of-network -- which would mean the patients would have to pay full price and then negotiate some reimbursement from Highmark -- participants in the Community Blue plan would be a sort of hybrid. UPMC would accept the agreed-upon rates provided under a contract with Highmark, but the patient would pay a larger share -- for example, a 40 percent co-pay instead of 20 percent.

UPMC disagrees. It says its negotiated rate was intended to apply to the four UPMC hospitals that were exceptions under the agreement -- Children's Hospital of Pittsburgh, UPMC Northwest, UPMC Bedford and Western Psychiatric Institute and Clinic, plus some specialized cancer treatments. In addition, the rate would apply when a Community Blue subscriber had a medical emergency and received treatment at a UPMC facility.

UPMC says the deal never was meant to apply in situations where a Community Blue member simply chose to see a UPMC doctor or go to one of its hospitals. If that were the case, UPMC asks, what would have been the point of excluding its facilities as in-network providers in the first place?

So, even as UPMC allows individuals who have no health insurance to use its doctors and hospitals if they're willing to pay full price, the system won't accommodate Community Blue subscribers.

How did it ever come to this? The answer is this is what cutthroat competition looks like.

Highmark wants to drive more patients to seek treatment at its West Penn Allegheny Health System, rather than at UPMC. With Community Blue, the insurer created a low-cost coverage plan that cut out most of the access to UPMC, and it sold the product with the promise of reduced costs for employers who signed up for it. Highmark maintains patients could keep seeing UPMC doctors by paying higher rates.

For its part, UPMC wants patients to use its doctors and hospitals, and it would like more customers to start buying UPMC health insurance plans, too. It wants to be sure that Highmark customers know what they'll be missing if they sign up for certain Highmark insurance plans.

The region's largest health insurance provider (Highmark) and its largest health care provider (UPMC) are both saying the same thing: It's just business. It's not personal.

But health care couldn't be more personal, and that's the problem with using aggressive strategies like high-pressure sales tactics and customer raiding in an industry that is supposed to be about serving the health needs of a community.

And all that is rather sickening.



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