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Highmark, UPMC uncertainty adds to patients' woes

| Sunday, Oct. 9, 2011

Highmark Inc. tells members its health insurance is accepted everywhere.

UPMC says that won't be true for UPMC-affiliated doctors after June 30, and encourages people to switch insurers.

The only certainty in this monthslong dispute is the contracts between Highmark and UPMC expire in less than nine months. What's unclear to many Western Pennsylvanians who are sick and have trouble affording their limited health insurance coverage is what will happen on July 1.

Negotiations over a reimbursement contract between the state's largest health insurer and Pittsburgh's dominant medical provider broke down in June when UPMC learned that Highmark was poised to acquire financially struggling West Penn Allegheny Health System, UPMC's chief rival. Although Highmark maintains that it wants a contract, UPMC says it won't offer favorable rates to a competitor.

While the warring health care titans continue to offer mixed messages and avoid direct talks, people with Highmark insurance who visit UPMC doctors increasingly are concerned that a difficult-to-navigate health care landscape soon will have a lot more obstacles.

"I don't understand why they can't see the problems they're creating," said Nick Balandiat, 50, an unemployed Baldwin resident.

Balandiat is one of tens of thousands of people in the Pittsburgh region who because of pre-existing conditions and employment status buy health insurance directly from Highmark. It is their only choice, because the five other health insurance providers that offer policies here either don't cover individuals or cover only healthy individuals.

"The whole situation is really nightmarish for working people," said Erin Gill-Ninehouser, a spokeswoman for the Pennsylvania Health Access Network, a statewide group that advocates for people without health insurance. "There really aren't a lot of choices out there, especially if you have pre-existing conditions."

UPMC's "Keep your doctor. Check your plan" advertising lists five insurance companies to call if Highmark subscribers want to continue seeing UPMC physicians: UPMC Health Plan, Aetna, United Healthcare, Cigna and HealthAmerica.

UPMC Health Plan and Cigna currently don't offer insurance products to individuals in Pittsburgh.

UPMC Health Plan will begin offering an individual plan Jan. 1, pending state approval, said spokesman Paul Wood. But coverage will depend on medical history — like the individual plans that Aetna, United Healthcare and HealthAmerica offer — meaning someone with an existing medical condition wouldn't qualify for coverage.

The federal Affordable Care and Patient Protection Act promised to prevent insurance companies from denying coverage because of pre-existing conditions. State-based insurance exchanges, another part of the law, are expected to make it easier and cheaper for people to buy their own insurance. But neither provision kicks in until 2014.

People with health coverage through the government's Medicare or Medical Assistance programs aren't affected when Highmark's contracts with UPMC end. Healthy individuals easily could switch insurance providers to maintain access to UPMC doctors and hospitals. Employers that offer coverage might give workers a choice of providers.

But the 136,000 people in Western Pennsylvania covered by one of the Highmark's individual health plans — including 50,000 with pre-existing conditions — could be forced to switch doctors, pay full price for a doctor's visit or go without treatment.

"This could potentially be a huge problem that's not being talked about," said Dr. Leo McCafferty, president of the Allegheny County Medical Society and a Shadyside plastic surgeon. "There are a lot of UPMC doctors who are afraid of losing their patient relationships."

When people change doctors, they're more likely to experience a medical error, McCafferty said.

"That disruption in the patient-doctor relationship really bothers the medical society," he said. "This sickens me, the potential for patients and doctors losing each other."

Many people buy directly from Highmark because they don't get insurance from their employers and are working part time or not working at all, Gill-Ninehouser said. Their budgets are stretched by premium payments, so paying to see their doctors isn't possible.

"It's really a kick in the teeth," she said. "I would assume they're just going to stop going (to doctors)."

Cindy Rombold, 55, a breast cancer survivor from Wampum, said she barely makes her $162 monthly SpecialCare premium payments to Highmark. The plan replaced the state-subsidized AdultBasic plan for working people who made too much to qualify for Medical Assistance, didn't get coverage through an employer and couldn't get private insurance because of pre-existing conditions. State officials this year cancelled AdultBasic, which cost $36 a month.

"I might as well go with no health insurance," Rombold said. She works two part-time jobs — as a school bus driver and office administrator for a small company — and neither offers health coverage.

Adding to the struggle, she worries about whether she will be able to continue treatment with her primary care physician and her cancer doctor, both of whom are affiliated withUPMC.

"I went into a panic mode. These doctors are my lifeline," Rombold said, after learning the contract negotiations ended.

UPMC, which employs more than 2,800 doctors and controls about 60 percent of the region's health care market, has said that people receiving ongoing medical treatment from its doctors could continue that treatment at in-network rates after the contract terminates. CEO Jeffrey Romoff told the Tribune-Review last month that even though he won't negotiate a reimbursement contract with Highmark, he is willing to work out a deal to help Highmark subscribers with pre-existing conditions.

That's one of more than 30 issues that UPMC last week said it wants to work out with Highmark as part of what it calls an orderly divorce. But, spokesman Wood said Highmark is denying the reality of the situation and misleading its members by refusing to talk.

Highmark counters that it won't discuss those issues because it is committed to renewing a contract with UPMC.

"UPMC is again misleading consumers into believing that the only thing left to discuss is end of contract issues," spokesman Michael Weinstein said. "That is false and UPMC should listen to the doctors, patients, community leaders, elected officials, employers and business leaders that are calling for them to come to the table to negotiate a new contract with Highmark."

UPMC's hospital contracts with Highmark, unlike the contracts with doctors, include a one-year run-out provision that allow Highmark members to continue paying in-network rates at most UPMC hospitals until June 30, 2013. Children's Hospital of Pittsburgh, UPMC Mercy and UPMC Hamot in Erie have separate contracts with Highmark that expire in 2022, 2015 and 2013, respectively.

Highmark argues the one-year run-out applies to physician contracts because doctors are "an integral part of the full continuum of medical services" provided by UPMC facilities, Weinstein said.

"Highmark intends to require UPMC hospitals and physicians to fulfill these obligations under the hospital contracts," Weinstein said.

UPMC says the contracts contain no language specifying a run-out for UPMC physicians.

The state Insurance Department can intervene in the hospital contract but has no authority over the physician contracts, Commissioner Michael Consedine has said. State lawmakers held hearings about the dispute and plan to introduce bills, even though it appears the legislators can do little to force a contract.

State Sen. Don White, R-Indiana, said during a committee hearing last month that he doubted government can play much of a role in the dispute. "I'm inclined to think our role in this is even more limited" than previously thought, he said.

Without a consensus or obvious solution, Christine Gallo said she feels helpless and frustrated. Gallo, 61, of Bethel Park buys Highmark insurance and consults UPMC doctors. She doesn't understand why the two nonprofit organizations act more like for-profit corporations.

"It's an impossible situation," she said. "I'm worried no one is going to do anything about it."

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