The “new” end-of-contract transition plan between Highmark Health and UPMC looks a lot like the separation agreement that has been discussed all along, but there are some key improvements that should make the split more tolerable for Pittsburgh-area customers who stick with their Highmark insurance.
The consent decrees, which were finalized by the two Pittsburgh health care giants Tuesday and brokered in recent days by Gov. Tom Corbett’s office and other state officials, clarify some of the lingering continuity-of-care issues for Highmark commercial subscribers who currently use UPMC doctors, or may need to in the future.
Highmark commercial policyholders — non-Medicare, Medicaid and CHIP customers — may continue to see certain UPMC oncology specialists, including those at community hospitals, according to a source familiar with the agreements. Highmark customers may also use all UPMC emergency rooms at in-network rates, which removes the the risk that a surprise visit to the ER could lead to big out-of-network charges.
Highmark customers with chronic conditions or ongoing care issues also will be able to keep their doctors, under certain circumstances, for as long as a year, in what’s being called a “safe harbor” provision, a source said.
The consent decrees, barring revision or a new contract, will remain in effect for five years, and should a conflict ever arise between the two organizations over the enforcement of the agreements, an arbitration process will settle them.
Seven of UPMC’s 16 major hospitals will be in-network for Highmark customers starting Jan. 1: Children’s Hospital, UPMC Bedford Memorial, UPMC Northwest, UPMC Altoona, UPMC Hamot, UPMC Horizon and Western Psychiatric Institute and Clinic. Many UPMC-affiliated doctors who have admitting privileges at other hospitals also could remain in-network for Highmark customers.
But UPMC’s urban and flagship hospitals — Mercy, Magee-Womens, Montefiore, Passavant, Presbyterian, Shadyside, St. Margaret, McKeesport and UPMC East — will remain out of network if and when the divorce goes through.
Neither Highmark nor UPMC would comment on the nature of the agreement on Wednesday, and Mr. Corbett’s office will describe the substance of the agreement in greater detail today. As it stands, those Highmark customers who had hoped for in-network access to UPMC’s East End hospitals won’t get it.
That’s a bitter pill for those who were hoping UPMC would capitulate in the face of ongoing pressure from patients, politicians, business groups and Highmark itself.
It’s not a surprising outcome, given that the governor, in announcing that he and his “Patients First” leadership team would be wading into the fray, said he was interested only in transition-of-care issues and wasn’t seeking to broker a larger contract extension between Highmark and UPMC.
Still, some were hoping for a bit of election-year strong-arming.
“I am quite disappointed that our region’s health care giants could not come to a mutually beneficial agreement,” said state Rep. Tony DeLuca, D-Penn Hills, his party’s ranking member on the House Insurance Committee. In a statement, he also said that he is “disappointed that the governor could not broker a contract extension and that [Republicans] refused to run any bipartisan legislation” that might have forced all UPMC facilities to accept Highmark patients at in-network rates.
Those Highmark patients likewise also were hoping for more. On Wednesday, about 50 of them gathered outside of Mr. Corbett’s Downtown offices for a previously scheduled protest, armed with the Wednesday morning news of an updated separation agreement.
Casey Swartz of Swissvale, one of the speakers at the rally, carried a poster-sized Highmark card with “DENIED” stamped in bold red ink. Another speaker, Joanna Bouldin of Dormont, said she would lose half of the doctors who now treat her back condition if the UPMC-Highmark contract isn’t extended.
“We are fighting for access to the network hospitals we helped to fund and we helped to build,” said Gabe Kramer, a Squirrel Hill resident and organizer for One Pittsburgh, a coalition of liberal activists and local labor groups, including the Service Employees International Union, which through its health care division is seeking to organize UPMC employees.
Several protesters accused UPMC of bullying the region’s patients into signing up with insurance carriers of UPMC’s choosing.
“The ideal outcome would be for UPMC to act like a human being instead of treating everything like a game, with market domination as the end goal,” said Tassi Bisers of Westfield.
Ms. Swartz, Mr. Kramer and a couple other attendees were turned away from the lobby of Gov. Corbett’s office when they attempted to pass along a letter to his staff. The march continued toward Attorney General Kathleen Kane’s office on Forbes Avenue, where a representative met them in the lobby and accepted a letter detailing their concerns.
Doctors, on the other hand, hope their concerns will be satisfied in the agreement’s granular details.
“From the beginning, physicians were most concerned about continuity of care for their patients,” said Kevin Garrett, president of the Allegheny County Medical Society, in a statement.
Despite having a separation agreement in place, the possibility still exists for a new partnership down the road, said Jim McTiernan, a benefits consultant at Pittsburgh-based Triad USA, a division of Arthur J. Gallagher & Co.
Mr. McTiernan, who long has believed the two health giants would eventually renew or extend their contract, said Wednesday that “I’m probably in the 50-50 range now. I was much more confident [there would be a contract] 2-3 months ago.”
Still, the intervention by Mr. Corbett and state regulators could simply be a contingency plan in the event the current contract expires Dec. 31, “but that does not necessarily rule out that they could come to an agreement” before then, he said.
Even if the contract expires at the end of 2014, Highmark and UPMC might decide to reunite in a year or two, once they’ve assessed the financial impact of the separation on their bottom lines, he added. For example, UPMC had denied full network access to Aetna for a decade, before inviting Aetna back into the UPMC fold in 2011.
Highmark’s separation agreement with UPMC is independent from the post-UPMC transition plan that Highmark must file with state regulators by the end of July.
Bill Toland: email@example.com or 412-263-2625. Yanan Wang: firstname.lastname@example.org or 412-263-1949. Steve Twedt contributed. First Published June 25, 2014 11:37 PM