Chelsa Wagner launches site to show impact of UPMC-Highmark split
Judy Hays credits her oncologist and team of health care workers at UPMC Hillman Cancer Center with saving her life.
Hays, 75, of Crescent Township has spent the past nine years battling chronic lymphocytic leukemia. After undergoing four types of chemotherapy and several new drug treatments, she’s finally found a medication that seems to be making her feel healthy again.
“But after June, I have to look elsewhere for my care,” said Hays, whose cancer is not in remission and who must get blood tests every two weeks.
With the exception of her oncologist, all of the doctors and specialists seen by Hays and her husband, who has muscular sclerosis, belong to Allegheny Health Network, so they stuck to a Highmark Health Medicare Advantage plan for 2019, which means that, they will lose in-network access to most UPMC facilities, including Hillman.
“It is the anxiety of fighting the disease, and then the anxiety on top of it about health care and who I get to see,” Hays said. “To have this doctor who has been through you through thick and thin, it’s a very difficult situation. I hope that something can be done, and I hope that people listen.”
Hays was the first patient to share her story on a new website, HealthcarePGH.com, that Allegheny County Controller Chelsa Wagner launched Thursday to ramp up pressure on state officials to intervene in the looming network split of Western Pennsylvania nonprofit health systems Highmark and UPMC.
“It’s to give our residents a platform to make their voices heard, to tell their stories and ensure that our lawmakers in Harrisburg are hearing the real impact and the real facts of how this is playing out and how it’s harming our residents,” Wagner, who is running for re-election this year, said during a news conference at the Allegheny County Courthouse in Downtown Pittsburgh. “We are in the eleventh hour, and we can and must find a resolution.”
Starting in July, Highmark-insured Medicare Advantage patients no longer will be able to receive nonemergency treatment from most UPMC doctors and hospitals unless they obtain a cost estimate, schedule an appointment using a centralized system and pay for treatment in full in advance. UPMC will not accept partial payments nor arrangement plans; it will bill patients directly for any additional costs that arise during treatment.
“If I had to pay up front for my two-week stay at (UPMC) Shadyside (last year), I’d be looking at around $200,000, and I’m a retiree on a fixed income. That would be impossible,” Hays said.
Despite the strict prepay rule, Highmark has pledged to pick up the out-of-network costs for two of its Medicare Advantage plans. The insurer says it will work with patients to reimburse them as quickly as possible. Highmark officials asked UPMC to reconsider the rule, but UPMC says it is legal and permissible within federal regulations that govern Medicare Advantage plans.
Wagner called on state lawmakers and Attorney General Josh Shapiro explore possible remedies, which she said could include legislation, mediation and possibly going after UPMC and Highmark for anti-trust violations or consider revoking their tax-exempt status. She said the “final divorce” of two “so-called charities” threatens to hamper the region through an “anti-competitive duopoly which thwarts competition and denies choice.”
In a statement on Thursday, Highmark spokesman Aaron Billger said that the board in 2013 “reaffirmed its belief that every patient has a fundamental right to seek and receive treatment from the physicians and hospitals of the patient’s choice, and that every charitable, tax-exempt organization has as fundamental obligation to ensure that the community has open access to assets that the community has funded and supported.”
UPMC spokesman Paul Wood released the following statement:
“The wind down of the UPMC-Highmark relationship has greatly benefitted western Pennsylvania. Over the past five-plus years, the health insurance market has transformed from one of the nation’s most highly concentrated and least competitive to one of the most competitive and pro-consumer markets in the nation. Businesses and consumers now enjoy insurance costs lower than anywhere else in Pennsylvania and access to UPMC’s world-class physicians and hospitals is easily attainable through a multitude of insurance plans widely available.”
Tens of thousands of patients have slammed state help lines in recent months as they reluctantly considered switching plans and carriers during the most competitive Medicare enrollment period in decades.
“They were confused, frustrated, angry and scared,” said Bill McKendree, which offers free guidance to seniors seeking insurance plan information via Allegheny County’s APPRISE program.
More than 160,000 people enroll in Medicare Advantage plans in the region. MA plan enrollees will have a chance to swap plans through March 31.
“This is a big deal within our community, and it’s likely to remain a big deal as we progress through June 30,” McKendree said.
Natasha Lindstrom is a Tribune-Review staff writer. You can contact Natasha at 412-380-8514, email@example.com or via Twitter @NewsNatasha.
Natasha Lindstrom is a Tribune-Review staff writer. You can contact Natasha at 412-380-8514, firstname.lastname@example.org or via Twitter .