Why are UPMC and Highmark separating?
Ever since Highmark announced its plans to purchase West Penn Allegheny Health System in 2011, UPMC has refused to negotiate a new contract that would give patients with Highmark insurance access to UPMC doctors and hospitals.
What is the current status of the split between UPMC and Highmark?
When a short-term extension of UPMC’s contract with Highmark expired in 2014, most Highmark customers in Allegheny County lost in-network access to UPMC doctors and hospitals. However, agreements negotiated by state officials kept emergency, trauma, and cancer services in-network, and limited the amount that Highmark and UPMC could charge out-of-network patients. The consent decrees also allowed patients in the middle of treatment and those enrolled in Medicaid, CHIP, and Medicare Advantage to remain in-network. Those consent decrees are set to expire on June 30.
When will Highmark patients lose access to UPMC doctors and hospitals?
In Allegheny County, patients who have been protected by the consent decrees will lose in-network access to most UPMC facilities on June 30, 2019. However, Highmark customers still have access to some facilities under other short-term agreements:
- Access to UPMC Children’s Hospital expires in 2022;
- Access to Western Psychiatric Institute and Clinic, UPMC Center for Assistive Technology, the UPMC Center for Excellence for treatment of Cystic Fibrosis, and specialized organ transplant services expires in 2024.
- Two UPMC cancer centers in Allegheny County are still in-network for now (one in Sewickley and one at St. Clair Hospital in Mt. Lebanon); access to those expires in 2021.
UPMC has said that “the wind down of the UPMC-Highmark relationship has greatly benefitted western Pennsylvania.” Is that true?
UPMC says that as a result of the split, the health insurance market has become more competitive and insurance costs are now lower in this region than anywhere else in Pennsylvania. However, premiums for employer-sponsored insurance were also lower here before the UPMC/Highmark split, and research shows that more competitive insurance markets actually lead to higher prices for hospital care. For people who purchase their own plans on the ACA marketplace, the lower premiums in this region are unsustainable: in an effort to gain market share, both Highmark and UPMC have priced their plans below cost. Highmark lost $1 billion on its ACA plans before raising premiums. UPMC is still losing money on its ACA plans and will eventually have to raise premiums as well. Meanwhile, hundreds of thousands of Western Pennsylvania residents, including seniors and cancer patients, have lost (or are about to lose) access to their long time caregivers as a result of this “wind down.”
How many seniors will lose access to providers when the consent decree expires?
There are currently 163,000 seniors with Medicare Advantage in Allegheny County alone, and over 100,000 are covered by Highmark or UPMC. Some have already lost access, as not all plans currently include both health systems: Highmark estimates that 50,000 enrollees will lose access to UPMC in the Pittsburgh and Erie markets when the consent decrees expire.
Is there anything seniors can do now to access both UPMC and Highmark doctors and hospitals?
Seniors have until March 31 to switch to a different Medicare Advantage plan or enroll in traditional Medicare. Traditional Medicare provides access to all providers (but it doesn’t have a cap on out-of-pocket spending, so most people also purchase a supplemental Medigap plan). Some of the Medicare Advantage plans offered by national carriers have access to both UPMC and Highmark, as well. However, for many seniors, cost is a major barrier to switching. The combined cost of traditional Medicare, drug coverage, and Medigap premiums can be significantly more expensive than Medicare Advantage. And many seniors in the region get health coverage as a retirement benefit from an employer who might not offer plans from other carriers. [If you need help navigating Medicare options, the Pa. Department of Aging’s APPRISE program (412-661-1438) offers free insurance counselling.]
What can our elected officials do?
- State legislators could pass legislation that would require health systems like UPMC and Highmark’s Allegheny Health Network to contract with other insurers through a binding arbitration process.
- The state attorney general could sue to revoke the “purely public charity” status of these healthcare giants or sue them under antitrust statutes if they refuse to come to an agreement.
Why haven’t lawmakers taken action before now?
In the past, local lawmakers have introduced bills in the state legislature to address the UPMC/Highmark split, but they were never voted on. Unfortunately, this issue is seen by many in the state legislature as only affecting the Pittsburgh region. Outside of Pittsburgh and Erie, the consent decrees protected access to UPMC hospitals for all Highmark patients, not just certain groups. With the consent decree about to expire state officials have helped facilitate new deals preserving access to UPMC in other parts of the state– even as the protections for our most vulnerable residents in Western Pa. expire.
What can residents do?
You can sign our petition and share your story at HealthCarePGH.com. You can also call or write your elected officials encouraging them to take action to protect access to care for all Pa. residents.