The transition: UPMC and Highmark make promises for the future

Any praise and self-congratulation on the two consent decrees announced Friday in Harrisburg between UPMC and Highmark should be put on hold until the accord gets a reality check, say, a year or so from now. You don’t have to be a card-carrying Highmark customer to know the devil’s in the details.

What was laid out in the Capitol media room by Gov. Tom Corbett, state Attorney General Kathleen Kane, the insurance commissioner, the health secretary and one executive apiece from UPMC and Highmark may have seemed long on clarity, but for many Western Pennsylvanians it is still short on comfort. The transition agreement on exactly how UPMC, the region’s largest health network, will divorce from Highmark, the region’s largest health insurer, remakes the health care landscape largely according to the designs of UPMC.

The plan provides no contract after Jan. 1 that will give all Highmark insurance customers in-network access to all UPMC facilities and physicians. These so-called “vulnerable populations” will still have total access, however: Highmark subscribers enrolled in Medicare, Medicare Advantage, Medigap health plans, Medicaid and the Children’s Health Insurance Program.

For all Highmark customers, half of UPMC’s 16 hospitals will stay in-network: Children’s, Mercy (through mid-2016), Western Psychiatric Institute and Clinic, Bedford, Venango, Altoona, Hamot and Horizon. But most of UPMC’s major, centrally located hospitals — Magee-Womens, Montefiore, Presbyterian, Shadyside, St. Margaret, Passavant, McKeesport and UPMC East — will be out of network, affecting the most densely populated part of the region.

In addition, Highmark and UPMC have pledged to negotiate an agreement to give Highmark customers in-network access to UPMC emergency and trauma facilities; Highmark subscribers will continue to have in-network status with UPMC facilities and physicians for cancer care, including the Hillman Cancer Center and Magee; and Highmark and UPMC have agreed that Highmark customers will have in-network access at in-network rates to maintain continuity of care for as long as the doctor and the patient decide is necessary.

These are more assurances than Highmark customers had before, but certainly not as many as they would like.

Mr. Corbett said, “This agreement puts the needs of patients and consumers first.” Ms. Kane said her top priority since taking office has been “ensuring greater access to care and transparency for Western Pennsylvania.” Their continued oversight and involvement on the way forward for UPMC and Highmark will be necessary if these protections are to unfold as promised.

Although UPMC and Highmark are now fully engaged in both the health care and health insurance businesses, there is no reason for their dealings to take patients or subscribers hostage. For this pact to meet customers’ needs and allay their concerns, the health-care giants will have to act more as the charitable nonprofits they say they are than as the corporate competitors they have lately become.