After surviving what they charitably termed a "challenging" 2009, local insurers and providers Tuesday offered their own ideas for reforming health care, ranging from better management of chronic diseases to addressing the state's dwindling pool of primary care physicians.

Insurers faced a double dose of uncertainty last year, as many lost subscribers from plant closures and layoffs. Combined with the unknowns surrounding health-care reform, "it caused us to take a hard look at ourselves," said Dan O'Malley, market president of the western region at Highmark Blue Cross Blue Shield.

Mr. O'Malley was part of a panel discussion at the Pittsburgh Business Group on Health's annual executive leadership forum, Downtown.

The region's largest insurer provides coverage for a quarter of a million people. But, after a failed merger attempt with Independence Blue Cross, Highmark "will continue to pursue opportunities for growth," he said. After losing 120,000 subscribers, "we have to try to support our investment. We need to grow our base."

At the same time, "we have to get costs under control," and Highmark is considering outsourcing and off-shoring. But, he added, "before we ever take jobs out of this country, we will look at every other alternative."

Diane Holder, president and CEO of UPMC Health Plan, stressed the importance of managing chronic diseases such as diabetes and asthma. Treatment for ongoing conditions accounts for 75 cents of every health-care dollar, she said, so it is critical that it be managed well. One UPMC Health Plan program for diabetics, she said, pushed compliance from 10 percent to 60 percent, which can reduce the risk of complications.

"That's a phenomenal outcome," she said.

Norman Mitry, president and CEO of Heritage Valley Health System with hospitals in Beaver and Sewickley, said the system has set up clinics in Wal-Mart stores so people have a place to seek treatment for minor ailments if they can't get in to see their primary care physician.

Otherwise, those patients may end up making unnecessary and expensive trips to the emergency room. "We want to get that ER piece out of there."

But the best reforms may not help without addressing problems with health-care delivery, specifically the exodus of physicians, said Dr. John F. Delaney Jr., chair of the psychiatry department at West Penn Hospital and new president of the Allegheny County Medical Society. With half of the state's doctors older than 50, and 4 percent under 35, "we're having a net loss of physicians," he said.

Between daunting medical malpractice premiums, and the prospects for big medical school loan debts, fewer doctors may be entering primary care because other specialties pay more.

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