UPMC, Highmark feud over network physicians

Number remaining with insurer disputed

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A sharp disagreement has flared up between Highmark and UPMC about how many UPMC physicians will remain in Highmark's insurance network if the contract between the two Pittsburgh health companies expires Dec. 31.

The dispute emerged last week at a Pittsburgh Business Group on Health forum held at a Downtown hotel when Deborah Rice-Johnson, president of Highmark health plans, told the employer group that nearly 70 percent of UPMC-employed physicians would remain in Highmark's network next year based on a methodology that both sides had agreed upon.

In a presentation immediately following, UPMC officials took issue with Ms. Rice-Johnson's numbers.

"They said that was a lie, that they hadn't even talked to Highmark at all and they didn't agree to that," said Jessica Brooks, executive director of the business group comprised of some of the region's largest employers, a point reiterated Wednesday by UPMC spokesman Paul Wood.

"There are no agreements for UPMC physicians to be in-network for Highmark subscribers, except for services provided at sites specified" in an agreement mediated by Gov. Tom Corbett two years ago, Mr. Wood said.

But Tom Fitzpatrick, Highmark's vice president of provider contracting and relations, said Wednesday he has been meeting weekly with his UPMC counterpart since last summer, and every other week for the year prior to that.

He said the meetings have been held to work out details of the mediated agreement that extended the Highmark-UPMC contract through Dec. 31, including discussing rates and access to so-called "exception hospitals" that will continue to be in-network after this year -- UPMC hospitals such as Children's, Western Psychiatric Institute and Clinic, and some outlying hospitals such as UPMC Altoona, UPMC Bedford and UPMC Northwest that would continue to be in-network for Highmark members.

Mr. Fitzpatrick said many issues remain unresolved. But, he said, the two sides did have verbal agreement that UPMC-employed physicians who see patients at the exception hospitals -- or have clinical privileges at an independent hospital that is part of Highmark's network -- would still be considered in-network for people insured by Highmark.

So, for example, he said a Highmark member could be treated at the independent St. Clair Hospital in Mt. Lebanon by a UPMC physician and be considered in-network.

By Mr. Fitzpatrick's count, 68 percent or 2,397 of UPMC's 3,510 employed physicians would fall into that category, including 416 of its 828 primary care physicians, 77 of its 166 obstetrician-gynecologists and 86 of its 102 medical oncologists.

Mr. Wood's response: "We have no idea what Highmark is talking about or how they dreamed up that number. We have reached no agreement other than all UPMC-employed docs will be out of network except for services provided at sites specified in the mediated agreement."

"Even if we counted in the convoluted way Highmark would like to count, in no way could anyone come close to the 68 percent simply because the vast, vast majority of our physicians primarily practice at soon-to-be 'out-of-network' hospitals and seldom cross over to the exception hospitals."

This is just the latest battle in the ongoing war between the two health care giants, which, between them, dominate the regional insurance and provider markets. The ultimate outcome will likely determine for thousands of local residents which doctors they see and which hospitals they go to.

Based on UPMC officials' comments at the business forum, the Pittsburgh Business Times reported Wednesday that Highmark's Ms. Rice-Johnson had sent a letter to Mrs. Brooks of the Pittsburgh Business Group on Health saying UPMC seemed to be backing away from the agreed-upon methodology. In the letter, she also noted, "We believe that there will be government intervention surrounding this issue," without specifying what that intervention might be.

Mr. Wood on Wednesday insisted, "UPMC has never 'backed away' from anything," calling the figures cited at the Pittsburgh Business Group on Health meeting "just another example of Highmark's continued bait-and-switch dishonesty with employers and brokers. It's also further evidence Highmark is only trying to throw up obstacles, to, rather than embracing, a smooth transition."

In-network status, which means lower rates for patients, depends on where services are provided, Mr. Wood said.

"Maybe Highmark should stop selling its insurance plans based on the clinical excellence of UPMC and instead start focusing on the capabilities of [Highmark's Allegheny Health Network] since that's where its subscribers will be going," he said.

UPMC has consistently said it will not renew its contract with Highmark since the insurer is building its own health care provider network to compete with UPMC.

While the issue of in-network physician access has obvious importance for Highmark members after this year, there are more immediate implications. State regulators have said Highmark must submit its plan for transitioning to a post-UPMC world by July 31.

"We certainly are going to need them to confirm this number [of in-network physicians] in order for us to submit and have the state approve our transition plan," said Mr. Fitzpatrick.

The uncertainty also puts employers in a quandary at a time when they're trying to make decisions on which insurance plans to offer their workers, Mrs. Brooks said.

"Highmark is giving them this message of hope and UPMC is being very definite that there is not going to be a contract. For an employer, whose word do you take?"

READ about Highmark’s change at the top.

Steve Twedt: stwedt@post-gazette.com or 412-263-1963.

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