04 September 2014

Pittsburgh Health Care Giants Take Fight To Each Other's Turf & UPMC and Highmark, A Confusing Truce 19AUG & 1JUL14

UPMC and Highmark may have resolved their differences in Pittsburgh but there is a health care crisis in the works in rural NW Pennsylvania. Warren General Hospital in Warren, PA is now affiliated with UPMC, and as of 1 JAN 15 if you aren't in the UPMC health care network your doctor can't treat you at Warren Gen Hospital. Private practice doctors not part of the UPMC system are barred from treating their patients at Warren Gen Hospital as of the new year. Many people, working and retired, have Highmark BCBS health insurance and will have to travel to Corry, PA (30 miles from Warren) or Jamestown, NY (20 miles) or Erie, PA (66 miles) for in hospital and out patient treatment. While the distances may not seem like much (the distances are from Warren, for many the distance will be more as Warren County is very rural), they are when many of these people are elderly and in poor health with extremely limited means of transportation. And nobody really wants to travel any farther than what should be necessary when they are sick.
For 114 years Warren General Hospital has been able to treat everyone in need. Patients could be admitted to the hospital and treated by their own doctor as long as they were accredited by the hospital, no matter what health care insurance one had. Now, corporate greed is forcing people out of their community hospital, and both those in need of hospital care and out patient hospital services and Warren General Hospital will suffer the consequences. The history of Warren General starts as an act of pure Christian charity with the founding of the Door of Hope in 1895, operated by the Society of Christian Workers and then with the chartering of the hospital (paid for by a local doctor) in 1898 with the hospital opening in 1900. The death of Warren General Hospital will probably happen in a few years as UPMC continues to reduce access to the facility, continues to loose patients to other area hospitals, reduces staff and services (directing patients to Erie or Pittsburgh to maximize the profitability of those facilities) until it becomes a drain on their corporate profit margins and the lights are turned off and the doors locked. If a death certificate would be issued cause of death would be corporate greed. Warren has experienced a lot of loss over the past 50 years due to corporate greed, but to loose the hospital, so vital to a rural community and county, could be what finishes it off. This from +NPR stations +WAMU 88.5 and +90.5 WESA

Pittsburgh Health Care Giants Take Fight To Each Other's Turf

by Jeff Brady

August 19, 2014 3:38 AM ET

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Morning Edition

5 min 47 sec

The headquarters for University of Pittsburgh Medical Center and Highmark Blue Cross/Blue Shield dominate the Pittsburgh skyline much as they organizations have dominated health care in the region for decades.

Jeff Brady/NPR

Pittsburgh's dominant health insurance company and its largest healthcare provider are, essentially, getting a divorce.
For decades, Highmark Blue Cross/Blue Shield and University of Pittsburgh Medical Center worked together. But as the line between insurance companies and health care providers across the country blurs, these longtime allies are venturing into each other's business and becoming competitors.
In the process, patients can get caught in the middle. Day-care worker Gail Jameson has Highmark insurance and she's been going to the same UPMC medical office for more than 20 years. "I could go in and just stop in if I needed to because it's close to my work," Jameson says. "I go past it every day."
She's about five years from retirement and was disappointed to learn her Highmark policy will no longer include UPMC providers. She has to find all new doctors through another health system that is unfamiliar to her.
The road to divorce began when insurer Highmark got into the hospital business. It bought the struggling West Penn Allegheny Health System, which was UPMC's main competitor.
"Highmark stepped in in order to ensure that there was competition in the marketplace and there would continue to be consumer choice," says Highmark President and CEO David Holmberg. In a town where UPMC controls more than 60 percent of the market, Holmberg says there needs to be healthier competition among providers.

YouTube Highmark's TV ad from 2013 encourages UPMC to sign a long-term service contract.

There's another reason an insurance company would decide to become a healthcare provider: the Affordable Care Act. It tells insurance companies what basic services to offer; who they must insure and even what percent of premiums can go to administrative expenses and profits. That takes away a lot of what insurance companies used to do, so they're looking for new reasons to exist.
"Insurers are trying to demonstrate that they bring value to the table and are doing more than just brokering a benefit ... and doing more than paying bills," says Gail Wilensky, senior fellow at Project HOPE.
Wilensky says some insurance companies are responding by building more efficient networks of high-quality providers. Highmark went a step beyond that and became a provider of health care itself.
UPMC responded by expanding its existing insurance business and refusing to sign a new long-term contract with Highmark, saying it could not both compete and work with Highmark.

YouTube UPMC's TV ad from 2013 explains why it can't sign a new long-term service contract with Highmark.

"We couldn't have a contract with them," says UPMC President and CEO Jeffrey Romoff, "Because they [Highmark] have the burden of keeping their provider side alive. So, for every one of their insurance subscribers they will want to steer them to go to their own providers."
The divorce of Highmark from UPMC is all but final now. An agreement between the two companies will expire on January 1, 2015. The state of Pennsylvania negotiated a transition agreement. It does things like ensure Highmark subscribers already in certain kinds of treatment at UPMC can continue receiving care.
Now the Pittsburgh health care landscape looks very different. "It went from one of the least competitive environments that you can imagine — a dominant insurer and a dominant health system joined at the hips with a long term contract," says Romoff, "To one without a long-term contract with, now, five choices."
In addition to the two new competitors, UPMC invited three large insurance companies into the Pittsburgh market: Cigna, Aetna and United Healthcare. "Competition is good," says Romoff, "It keeps us all on top of our game. It gives us incentive to not be fat and sloppy."
With competition come the marketing campaigns. UPMC is banking on its good reputation. Highmark will appeal to those concerned about price. "For some people their monthly premium and the cost of their health care may be more important than having access to everything," Holmberg says.
In Pittsburgh now people have a lot more choices — and decisions — to make when it comes to their health care. That's supposed to be a good thing. But for Jameson, who was satisfied with her Highmark-UPMC combination, the extra work is a pain. "I just don't like change. I shouldn't have to change," says Jameson.
It's not just patients dealing with change. Employers who buy insurance for their workers face difficult decisions too. With two insurance/provider networks that don't allow access to each other, Pittsburgh employers can be put in the position of, effectively, choosing which doctors treat their workers.
"Employers want to provide benefits that allow them to be competitive and attract and retain a productive work force," says Jessica Brooks, executive director of the Pittsburgh Business Group on Health. "They don't want to be in the business of making personal life decisions around who their employees can see and who they can't see," she says.
The Affordable Care Act aims to increase the quality and affordability of health care. Creating competitive marketplaces is part of the plan. It will be a few years before people in Pittsburgh and around the country know whether the changes happening now make those goals reality.

UPMC and Highmark, A Confusing Truce

By Essential Pittsburgh

Highmark and UPMC have finally come to terms, but aspects of the agreement may confuse many policy holders.

Credit Life Mental Health / Flickr

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26:39

The announcement of a five-year consent decree brokered by state officials seems to be bringing a truce between Highmark and UPMC. What exactly will the agreement mean for policy holders? State Insurance Commissioner Michael Consedine highlights some of the major aspects of the decree to policyholders who may be experiencing some confusion with these “out of network” hospitals.
Some of UPMC’s most prominent hospitals are not in the network, included Magee Women’s Hospital. Commissioner Consedine says the largest issues surrounding the agreement are not which specialty hospitals will remain open in the network, but rather contingency of those already being treated by UPMC doctors, oncology care, and emergency services.
“Emergency service is a big one. You know, downtown Pittsburgh, you get to go to the nearest ER that you want to go to. There’s an emergency situation so we’re not putting patients in the position of making those choices in the midst of a medical crisis….from a patient perspective, you don’t have to make the choices to what ER may or may not be accessible, both at West Penn facilities and UPMC facilities.”
Commissioner Consedine also mentions the aspect of contingency of care the agreement mentions regarding those who are being treated by UPMC doctors. Those currently being treated by UPMC doctors will be able to continue care until treatment is complete.
“With three million people in Western Pennsylvania, there are three million hypotheticals that we could get with different conditions. We wrote for purposes this first step, the consent to creed, to be very broad, on continuity of care provisions.”
Hospitals such as Children’s Hospital of Pittsburgh and Western Psychiatric will still be accessible with Highmark insurance.

NORTON META TAG

04 September 2014