Business struggling on health insurance

UPMC-Highmark uncertainties persist

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It’s a help, but not enough of one.

That’s the sentiment many local employers are voicing now that they’ve had time to digest and analyze a state-brokered agreement between Pittsburgh health giants Highmark and UPMC.

To be fair, the consent decrees announced by Gov. Tom Corbett and Attorney General Kathleen Kane on June 27 were presented simply as “a framework for the transition plan” that Highmark must file by July 31 to set out what happens when the insurer’s in-network contract with health provider UPMC expires Dec. 31.

But employers are making decisions now about which health plans to offer their workers in 2015, and they say a framework doesn’t provide the information they need.

“It has not helped them make their decision any better,” said Jessica Brooks, executive director of the Pittsburgh Business Group on Health, a coalition of major local employers.

“They do recognize that they have put in an adjustment period for the most vulnerable positions and that is a help, but as far as expediting their decision-making, [the agreement] is not doing that for us.”

Preliminary results of a survey by the business group bear her out — 47 percent said they either “disagree” or “highly disagree” that the agreement brings “clarity and stability to the local health insurance market,” while 21 percent said it does. No one responded that they “highly agree” the agreement brings clarity. The remaining 32 percent were neutral.

In some respects, the consent decrees may complicate the situation further, said one local health expert.

“If I were an employer, this whole situation would seem more uncertain now,” said Stephen Foreman, associate professor of economics and health administration at Robert Morris University. “Some of the employers I've spoken to were planning for two scenarios: Agreement or no agreement. Now they've got this third path.”

There is some certainty: Highmark’s Medicare patients won’t have to worry about access to UPMC physicians and facilities, and the consent decree offers protections for the seriously ill. Also, Highmark members who are seeing a UPMC physician this year can continue to do so at in-network rates through 2015 if they can’t find another doctor.

But fissures in other areas are already evident.

After Highmark ran newspaper ads that said its subscribers “will have in-network access to all UPMC services for oncology care, including the Hillman Cancer Center,” UPMC spokesman Paul Wood accused the insurer of making “disingenuous promises” regarding in-network access.

“The only way Highmark has a chance to prevent their expected enormous defection of subscribers to other insurers … is for Highmark to ‘flash’ the availability of the world-class care at Hillman, then steer patients to Allegheny Health Network. This is what Highmark has already been telling area physicians they will do and, more importantly, this is what Highmark must do in order to preserve AHN,” Mr. Wood said.

Mr. Wood believes Highmark Health’s Allegheny Network’s new collaboration with the Johns Hopkins’ cancer center in Baltimore is one strong indication that AHN will do what it can to keep Highmark members in its own network.

In response, AHN spokesman Dan Laurent said Highmark members may be able to participate in Hopkins-led clinical trials from here. He said it will be comparatively rare for Pittsburgh-area patients to need to travel to Baltimore.

“It’s also important to remember that AHN alone is a formidable academic cancer program, with a complete spectrum of advanced oncology services, 150 oncologists in the region and more than 200 active cancer trials,” he said. “There are very few clinical cancer capabilities at Hillman that cannot be found at AHN.”

For the record, the agreement states that Highmark members will have in-network access at Hillman if their physician determines they should be treated by a UPMC oncologist there and the patient agrees.

Cancer care is just one area of contention, and others may be lurking; there is still no agreement on rates for outlying UPMC hospitals, for example. And as each new dispute gets settled, employers have to recalibrate.

Should they offer additional plans? Stick with Highmark? How will they communicate the options and changes to their employees? It could be an administrative headache that lasts well beyond next year.

Mr. Foreman did praise state officials for brokering the agreement and particularly for including binding arbitration provisions that will force the two sides to settle disputes.

“The good thing is that [Highmark and UPMC] actually agreed to something,” he said, but, “There’s still a lot that’s up in the air.”

The UPMC and Highmark consent decrees may be viewed online on Pennsylvania Attorney General Kathleen Kane’s website,

Steve Twedt: or 412-263-1963.

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