The UPMC-Highmark split and how it will affect Pittsburgh families

Nationwide, it’s common for a family’s health insurance policy to dictate the doctors or hospitals they can utilize in-network. On the contrary, here in Pittsburgh we’ve become accustomed to many choices for our hospitals, physicians and specialists. That could soon change. As of  January 1, UPMC facilities and providers are no longer accepting patients with Highmark insurance in-network…or are they?

Summer Arrigo-Nelson, a professor at California University of Pennsylvania, finds the details of the breakup confusing. She’s not alone. Arrigo-Nelson currently has Highmark insurance. Leading up to this healthcare separation, she was offered a choice from her employer between a UPMC health insurance plan or a Highmark one. She had just a few weeks to make her decision before open enrollment ended and says, “I spent a lot of my personal time on the phone trying to ask questions about this situation. I went through the fact sheets from each plan line by line. Not everyone has the luxury of doing that.”

Consent Decree

Earlier this year, UPMC and Highmark reached a separation agreement called the Consent Decree. The Consent Decree details how everything (from emergency room visits to physicals) will be handled. Unfortunately, the text of the document can be confusing–especially for those not familiar with the terminology. In order to help Pittsburgh families make informed choices about their healthcare needs, this article translates the Consent Decree as it pertains to pediatrics, obstetrics, emergency medicine and family medicine.

Children’s Hospital of Pittsburgh of UPMC and Pediatricians

Children’s Hospital of Pittsburgh of UPMC represents the biggest area of concern for many parents in our region, as it’s technically a UPMC facility staffed by UPMC physicians with no similar counterpart in our area. For Arrigo-Nelson, access to Children’s Hospital of Pittsburgh of UPMC is an absolute deal-breaker.

She says, “My son was a pretty healthy baby, but we wound up at Children’s because he had torticollis. We’ve had to get a few other things checked out, too–normal concerns that come up even with healthy, typical kids. I want access to pediatric specialists both in the emergency department and who practice within Children’s Hospital.”

Courtney McCrimmon, manager of media relations for UPMC, reassures parents that yes, families can still utilize Children’s Hospital of Pittsburgh of UPMC in-network, regardless of their insurance provider.

Aaron Bilger, media relations representative for Highmark, elaborates, explaining that Children’s Hospital of Pittsburgh of UPMC was never part of the contract dispute between Highmark and UPMC. He says, “pediatricians and Children’s Hospital will remain in-network until 2022.”

Bilger reiterates that pediatricians (including all specialists in Children’s Hospital of Pittsburgh of UPMC, even psychiatrists) will remain in-network until 2022.

Obstetrical Care

Related to families’ concerns about where their children can receive care, Pittsburgh parents worry about where they will bring these babies Earthside. Women who hold Highmark health insurance policies worry about whether they will have to change prenatal care providers or if they’ll have continued access to the same facilities where they birthed previous children.

McCrimmon explains: “Women with pregnancies that began in 2014 will be able to deliver in-network at Magee-Women’s Hospital of UPMC and UPMC Mercy.” According to the Consent Decree’s “safety net” provision, patients can remain with a provider for one year if they are “unable to find alternative physicians and services in their locality.”

So, even if a woman with Highmark insurance becomes pregnant in 2015, McCrimmon says she can remain with a UPMC provider “as long as both doctor and patient agree that her care at UPMC should be continued.”

Bilger notes that UPMC Mercy, another hospital choice for delivering babies, will remain in-network for Highmark members until June of 2016.

The Midwife Center

The Midwife Center for Birth and Women’s Health (TMC) is a freestanding birth center, an independent facility that accepts all health insurance plans. Women visit TMC during their pregnancies for prenatal care and generally plan to deliver their babies in one of the three birthing suites. However, in labor and delivery, things don’t always go as planned.

Women like Arrigo-Nelson, who used TMC but required a cesarean delivery for her first son due to breech presentation, will automatically have to labor in a hospital setting for subsequent pregnancies. The midwives from TMC currently have admitting privileges with UPMC Mercy, so if a laboring mother requires hospital transfer, she has a seamless experience. Her midwives come along with her and collaborate with physicians in the hospital.

Christine Haas, executive director of TMC, says the facility is committed to being accessible to as many women as possible. While UPMC Mercy continues to be in-network for Highmark patients until June of 2016, UPMC Mercy does not accept Highmark Community Blue plans. Haas says, “We are pleased to confirm that if a client with Community Blue needs hospital care, TMC has a transfer agreement with West Penn Hospital.”

Emergency Department Use

Bilger also says, “Emergency room care was one of the key elements of the state-mediated consent decrees that were agreed to by Highmark and UPMC.” The result? “Families with Highmark health insurance can be seen at emergency departments in the Allegheny Health Network, UPMC and many community hospitals, despite the fact that 6 UPMC hospitals in the immediate Pittsburgh area will be considered out-of-network for Highmark members.”

Even if a patient requires admission to the hospital following an emergency department visit, Bilger explains patients can be admitted in-network via the emergency room and remain in-network for the duration of their treatment through discharge. However, McCrimmon says a patient may be may be transferred to another facility after he or she is stabilized, depending on the type of insurance he or she carries.

Medicare for Seniors

Many young parents find themselves sandwiched between caring for young children and helping to care for aging relatives. Such families can rest assured that Medicare is, for now, exempt from the contract separation. According to the Pennsylvania Insurance Department (PID), the state organization that administers the laws of the commonwealth as they pertain to the insurance industry, “Highmark has agreed it will hold off on terminating the contracts of about 700 UPMC doctors, ensuring that consumers who visit these physicians can continue to have the same access to care. In addition, UPMC has agreed to continue seeing Highmark members who have Medicare Advantage coverage on an in-network basis.”

The exception to this would be members who have Highmark Community Blue Medicare Advantage coverage, which is a limited-network product. These patients are limited to the physicians and facilities listed as in-network for their specific plan.

Family Physicians

The waters of the separation agreement become a bit murky when it comes to adults seeking care from family physicians or other existing doctors. Bilger says families will not have to necessarily change family physicians based on their insurance if they meet the consent decree requirements.

There is a section of the Consent Decree called “Continuity of Care,” which says that, “Highmark and UPMC mutually agree that the continuation of care of a Highmark member in the midst of a course of treatment at UPMC shall be on an In-Network basis at In-Network rates.”

So, even if a family physician is not listed among the in-network doctors for the Highmark network, it’s still sometimes possible to receive treatment at in-network rates. It’s up to the doctor and the insurance company to determine what “in the midst of a course of treatment” means in each case. If, according to the Consent Decree, Highmark “disputes the opinion of the treating physician that a continuation of care is medically appropriate, the DOH or its designated representative will review the matter.”

Both UPMC and Highmark have released information guides for patients trying to make sense of the healthcare situation in Pittsburgh (Click here for information from Highmark and click here for information from UPMC). Even if the questions seem simple–can I keep seeing my family doctor?–the language of the agreement can feel confusing for the average Pittsburgher.

Anyone who has specific questions can turn to stayinformed.pa.gov for additional information from the PID, who advises patients to ask both the provider and the insurer about costs before seeking or accepting treatment.

For help with “continuing care concerns” in an ongoing course of treatment, patients can contact the PA Department of Health Bureau of Managed care via email at ra-dhwpatranqst@pa.gov or phone: 717-787-5193.

Featured Photo: Highmark and US Steel Building, Photo by Dave DiCello