Pennsylvania helps Highmark and UPMC come to agreement on care of patients after 2015

The ongoing dispute between Highmark and UPMC in Pennsylvania had created considerably concern in the state over what would happen to patients with Highmark health plans who receive care from UPMC after Jan. 1, 2015 when the contract between the two organizations ends.

Would all Highmark health plan members with UPMC doctors need to switch providers to avoid paying high out-of-network fees for care? What about seniors, cancer patients or patients currently in the middle of ongoing treatment provided by UPMC?

As talks between the two organizations broke down and lawsuits were filed, some of the disagreement spilled over into their respective marketing efforts and further fed public concern leading to the state getting involved.

On Friday, Governor Tom Corbett and Attorney General Kathleen Kane announced that a comprehensive transition agreement was reached on how and where patients can receive health care after the contract between the Highmark and UPMC expires in 2015.  

“For some time, the people of western Pennsylvania have been concerned about where and how they will receive their health care come Jan. 1, 2015,” Corbett said in a statement. “We listened to all parties, and through a shared commitment to protecting patients and insurance consumers, designed the framework for a transition plan that focuses on putting them first.”

The plan addresses continuity of care, protection for vulnerable patient populations, access to unique services only UPMC provides, cancer care and emergency care. It also creates a one-year “safety-net” period during which Highmark plan members who cannot find a new in-network physician can continue to see their UPMC doctor at the in-network rate.

The agreement doesn’t come cheap for either organization. Both agreed to provide $2 million to the state for public outreach and education during the transition and to cover the state agencies’ costs in reaching these agreements. They also promised to not engage in any more misleading or unclear advertising.

In a press release, Corbett called the work done by the state’s Insurance Department, Department of Health and the Office of Attorney General to reach the agreement “government at its finest” because it put patients first.

Specifically, the agreement requires that:

• A Highmark member in the midst of a course of treatment at UPMC will be continued on an in-network basis for as long as the patient and his or her doctor deem it necessary. 
• Vulnerable populations, such as Medicare, Medicaid, CHIP, Medigap and Signature 65 beneficiaries, will not be impacted and continue to have access to UPMC providers and facilities. 
• A contract will be negotiated for Western Psychiatric Institute and Clinic; UPMC Bedford; UPMC Venango (Northwest), Hamot and Altoona; and other UPMC unique services that may be delivered outside the Greater Pittsburgh area or any future acquired hospital by UPMC.
• UPMC and Highmark will negotiate an agreement so that emergency and trauma services will continue to be accessible at in-network rates at UPMC and Allegheny Health Network hospitals.
• Highmark members will be able to see UPMC local providers of unique services when the patient’s treating physician believes the patient needs such services and they are unavailable elsewhere. 
• Highmark members will be able to see UPMC providers for cancer treatment on an in-network basis if a patient’s treating physician recommends it.