UPMC-Highmark accord falls far short of what's needed

Employers remain in the dark about how our health system is going to work

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The recent announcement by Gov. Tom Corbett claiming progress in the protracted Highmark vs. UPMC health-insurance battle missed the mark when it comes to putting patients first.

While the governor’s efforts are admirable, the consent decrees he hammered out did little to clear things up — in fact, they may be creating more confusion — about how employers are supposed to deal with the Highmark-UPMC divorce on behalf of their employees.

That’s why the Pittsburgh Business Group on Health recently launched its Priority Initiative to expedite discussion between Highmark and UPMC and ensure that the business community has a seat at the table. After all, commercial policyholders — the majority being employers — are the ones being most tussled over, yet they are the ones being least considered in this dispute.

Along with cost, patient access to health-care services is a top consideration for employers. Employers do not, however, want to be in the business of making physician choices for their employees.

As things stand, employers continue to lack the support they need to accurately communicate to their employees the impact that new regional health-care arrangements might have on their families, choices, costs, transparency of information or what kind of upheaval patients should anticipate during the transition.

A survey conducted this month among members of the Pittsburgh Business Group on Health, which represents more than 70 regionally headquartered employers, found that not a single employer highly agreed and only 20 percent agreed that the UPMC-Highmark consent decree brought “clarity and stability” to the local health-care market. Conversely, 32 percent disagreed and 16 percent highly disagreed. When asked what additional information they needed to choose a health-insurance carrier, local employers considered clarity of cost as most important.

All that said, there is a much bigger picture to consider, especially when it comes to keeping down costs for both employers and employees: We need competition among both insurers and health-care providers.

We are seeing more competition in health insurance with the influx of national carriers into the market. But at the provider level, there is continuing consolidation by two big systems — UPMC and the Allegheny Health Network — and the possibility of only one gaining a virtual monopoly. This threatens to result in even higher premiums, deductibles and out-of-network fees, and a lowering of average quality. Patients and employers would have even less influence.

The ideal system would give individuals maximum choice among insurers as providers compete on both cost and quality. This would require total transparency in patient outcomes, cost and prices.

Any willing insurer should have access to all providers at similar rates — rates that are publicly known. Instead of relying on secret deals with individual insurers to make money, providers should have to rely on innovation and their ability to raise the quality of their care while keeping costs in check.

In Pittsburgh, UPMC, Allegheny Health Network and community facilities would compete and accept reimbursement from all willing insurers — Highmark, Aetna, United Healthcare, UPMC Health Plan, etc. This is very different from what we face now: a region served by two dominant integrated financing and delivery systems, a potentially stifling competitive model.

The Pittsburgh Business Group on Health is committed to empowering employers to make value-based health-care purchasing decisions. PBGH is trying to help employers and their employees make decisions based on cost and quality. Fortunately, there remain numerous choices for high quality care in our region — within the UPMC and Allegheny Health Network systems but also among community hospitals, many of which produce better outcomes at lower costs.

Highmark says it is maintaining its grip on the insurance market, while UPMC says that by next year many customers — including employers and employees given a choice of plans — will switch to other carriers when the open-enrollment period begins this fall. If everything breaks the way UPMC hopes, 92 percent of the commercial market will, at the very least, have a non-Highmark option that includes full UPMC access.

In the meantime, the consent decrees meant to clarify the terms of divorce leave many questions unanswered. Among the concerns of PBGH employer members is the “safety net,” which is supposed to allow Highmark members to continue seeing UPMC physicians with in-network coverage through 2015 if they cannot find another doctor they like. Highmark and UPMC disagree about how many Highmark subscribers this would apply to.

Highmark and UPMC also disagree about conditions for Highmark subscribers to continue seeing UPMC oncologists for cancer care or how long they could pay in-network rates for emergency care. What happens to a Highmark subscriber on a list to receive a transplant at a UPMC hospital? How will referrals work between physicians affiliated with different health-care systems?

Administratively, how will Highmark and UPMC processing systems handle exceptions and medical-record management? UPMC has an integrated electronic medical-records system that does not share information with Allegheny Health Network. Errors and confusion could abound.

Despite all this, progress has been made and the sky is not falling. But significant work remains to be done and many answers must be addressed — now.

Employers’ decisions over the next couple of months will have great impact on our health-care delivery and financing systems, not just in 2015 but for years to come. Therefore, we need Highmark and UPMC to get on the same page as to who will be in-network, who will be out-of-network and who will pay how much so that employers can make informed decisions. Employers needed this information yesterday.

The best solution would be a comprehensive agreement that allows all willing insurers to cover all health care providers on an in-network basis. The next best would be a consent decree that makes clear how a Highmark-UPMC divorce would work.

The consent decrees recently announced were a step in the right direction, but they did not tell consumers and businesses across southwestern Pennsylvania what they need to know, leaving them hanging — again.

Jessica Brooks is executive director of the Pittsburgh Business Group on Health (www.pbghpa.com). The group is hosting its annual Health Care & Benefits Symposium Sept. 4 at Pittsburgh Marriott City Center.

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