The UPMC-Highmark dispute is bigger than either institution, writes UPMC physician DENNIS GABOS
May 4, 2014 12:00 AM
By Dennis Gabos
In June of 2013. the board of “nonprofit” UPMC, assumed to be community conscious and independent thinking, unanimously reaffirmed its plan not to contract with Highmark, the area’s largest insurer.
Prominent local leaders such as Paul O’Neill and Jim Roddey, and a long list of physicians, lawyers, business executives and citizens have articulated compelling opposition to UPMC’s intentions. The vast majority of health care professionals and all patients and citizens that I encounter also disagree with UPMC’s arbitrary and unprecedented policy to restrict access to our hospitals. But many of my professional colleagues fear openly defying UPMC by defending the rights of patients to access UPMC hospitals and doctors.
What is UPMC?
The reality is that there are two UPMCs: “UPMC-Corporate” comprised of CEO Jeffrey Romoff, his million-dollar executives and his board of directors; and “UPMC-Real Health Care” comprised of patients, physicians, nurses and others. UPMC’s health care professionals yearn to foster enduring relationships with their patients without barriers like those imposed by UPMC-Corporate.
What are hospitals?
They are shelters where we seek refuge from the storms of illness. Hospitals are not private or corporate property. They are no one’s yet everyone’s. They are community assets sustained by citizens — via health insurance and cash payments, taxes that support state and federal grants, Medicare and Medicaid, philanthropy and volunteerism, as well as the privilege of nonprofit status.
Nonprofit UPMC is obligated to be a responsible steward of our hospitals, honoring the needs of all citizens, not just the ones they choose. Highmark, the Allegheny Health Network, the Pennsylvania Insurance Department and the state Legislature likewise should not permit the creation of prohibitive barriers to health care access.
UPMC claims that to have a truly competitive “market” it must not contract with Highmark to provide “in-network” insurance coverage at UPMC facilities. This effectively will close the doors of most UPMC hospitals to many citizens, severing longstanding relationships with their doctors and creating medically risky conditions in which health care services will be further fragmented. Patients having emergency care in one hospital will be forced to have follow up or elective care elsewhere. Similar consequences will occur when employers change plans.
UPMC claims that Highmark would steer away 41,000 hypothetical patients (the estimate given to the state insurance department), which could collapse two UPMC hospitals. Yet how much more likely would such a collapse occur if UPMC turns away most Highmark patients? Historically there have been more than 45,000 Highmark admissions to UPMC hospitals annually, not to mention the tens of thousands of outpatient visits, most of which would vanish without a contract. (Do the math!)
UPMC’s passionate sensitivity to having patients steered away from health care facilities conflicts with its actions. UPMC built a new hospital very near to Forbes Hospital in Monroeville and plans office space close to Highmark offices north of Pittsburgh.
Ironically, in Erie, where UPMC has less market control, UPMC-Hamot is willing to contract with Highmark in hopes of enticing patients away from nearby St. Vincent’s Hospital, part of Highmark’s new Allegheny Health Network. Why the double standard?
Some legislators hesitate to interfere with the market, but there is no free market in health care. We have an employer-based system in which employers buy and own nonportable health insurance of their choosing with employees’ hard-earned dollars rather than empowering employees to buy their own health insurance that they can take from job to job. The lack of a true free market results in inflated charges that have little to do with the real cost of services. Highmark patients will have to pay especially exorbitant prices for UPMC services in the absence of a contract.
Our state legislators’ inaction has emboldened UPMC and already harmed patient access. In 2013 we witnessed something unprecedented in my 26 years of medical practice. In violation of its own code of conduct, UPMC-Corporate locked out Highmark’s Community Blue patients, refusing to see them even when they desperately offered to pay cash for services.
What is health insurance?
Health insurance is the financial doorway to access our hospitals and doctors. Thus, UPMC’s refusal to deal with Highmark is much bigger than either institution. The real conflict is between UPMC-Corporate and the citizens it proposes to lock out so that it can maintain its market dominance.
These actions are a flagrant violation of at least the spirit of nonprofit law and make our hospitals instruments of exploitation, leaving employers facing this ultimatum: Keep your Highmark insurance and lose most of your UPMC doctors and hospitals, or cave in to extortion and keep them by abandoning Highmark.
What has also become apparent is that not only are there two UPMCs, there also are two factions of Pennsylvania legislators. There is “Harrisburg for Corporate Medicine” — those faint-hearted lawmakers who refuse to protect citizens against UPMC-Corporate. They’re OK with “might is right” and with seeing patients’ relationships to their hospitals and doctors subjugated to aggressive corporate power.
And there is “Harrisburg for Real Health Care”— those legislators willing to put themselves at risk to act ethically on behalf of their constituents’ health care rights. Among these are Sens. Randy Vulakovich, R-Shaler, and Jay Costa, D-Forest Hills; and Reps. Jim Christiana, R-Beaver, and Dan Frankel, D-Squirrel Hill, who have introduced patient-empowering legislation: House bills 1621 and 1622 and Senate bills 1247 and 1248.
We should support this legislation if we honor the relationships we have with our doctors and want access to the hospitals we citizens make possible.
Dennis Gabos is a cardiologist who practices in the UPMC system and lives in McCandless.
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