Patients seek clarity as UPMC-Highmark split looms

The latest clash of Pittsburgh health care titans UPMC and Highmark made for a stressful several months for patients like Evie Bodick.

Not only has the 74-year-old Springdale woman been dealing with several health problems, including heart and lung issues, diabetes and cancer, but she was told last fall that if she stuck to her Highmark insurance plan, she’d have to find all new doctors — or prepay out of her own pocket to keep them.

One by one, Bodick reluctantly said goodbye to five physicians, all of whom work out of her go-to place for medical needs for years — UPMC St. Margaret on Freeport Road near Aspinwall, a 15-minute drive from her home on Rachel Street. She dreaded giving up her UPMC doctors and the way they worked as a team to help her.

She lined up five alternates within Highmark’s Allegheny Health Network, scattered in different locations.

Then came the about-face move by UPMC this month to drop its planned prepay rule for certain Medicare Advantage and cancer patients — even after UPMC splits insurance networks with rival Highmark on June 30.

As a member of Highmark’s Medicare Advantage Freedom Blue plan, Bodick no longer has to switch doctors.

But when she and others called to ask Highmark about the changes, Highmark said it couldn’t reassure anyone yet.

Changes not in writing

More than a week after UPMC pledged to relax its prepay policy for certain patients, Highmark-insured members still have not received guarantees or clarity on what the changes mean for them and their treatment options. UPMC announced the prepay exceptions days before a Commonwealth Court showdown against Highmark and Pennsylvania Attorney General Josh Shapiro, who lost his push last week to persuade a judge to block, or at least postpone, the looming UPMC-Highmark breakup.

The abrupt concessions followed months of UPMC warning Highmark members of the prepay rule, including via robocalls and advertisements during open enrollment periods in the fall and winter. Highmark had been asking for UPMC to reconsider the rule since it was announced Oct. 1. Shapiro filed legal action against UPMC in early February.

Despite “UPMC’s recent public statements about the elimination of prepay and access to Hillman Cancer Center, we have not received a detailed contract proposal on these issues directly from UPMC — nor has the Attorney General,” Highmark spokesman Aaron Billger said Friday in a statement.

“To protect our health plan members and patients, we need to secure contract language and agreements so that UPMC’s practices align with their verbal commitments,” Billger said.

UPMC plans to present Highmark with an official “term sheet” detailing the Medicare Advantage and Hillman Cancer Center prepay changes on Monday, UPMC spokesman Paul Wood told the Tribune-Review over the weekend.

The announced changes do not mean that UPMC is dropping its out-of-network prepay policy altogether.

Going out of network

Highmark and Blue Cross/Blue Shield members who are not eligible for Medicare and not seeking oncology care at a Hillman-affiliated facility still will be subject to the prepay rule at most UPMC facilities in Western Pennsylvania. That includes people who enrolled in Highmark plans via the federal health exchange or through their employers.

For those commercial market patients, the prepay policy means that out-of-network patients seeking nonemergency care at most UPMC facilities will have to make an appointment using a centralized system, obtain a cost estimate and prepay, in full, prior to receiving any treatment. UPMC also will charge the patient directly for any further costs that arise during treatment. Any reimbursement would come later and be between the patient and out-of-network insurer.

“I’m concerned not only about myself but about others who have serious health issues and UPMC has denied access to treatment,” Bodick said. “I wish UPMC would get a conscience and have a heart and care about the people and not the money.”

UPMC maintains that it has no obligation to offer nonemergency treatment to Highmark patients after June 30. UPMC says that it is making an “accommodation” by allowing Medicare Advantage and Hillman Cancer Center patients to do so.

Among UPMC hospitals and specialty centers going out of network are UPMC Shadyside, UPMC Magee-Womens Hospital, UPMC St. Margaret in Pittsburgh and UPMC East in Monroeville. Exceptions include UPMC Hillman Cancer Center (all locations), UPMC Western Psychiatric Hospital, UPMC Children’s Hospital of Pittsburgh and hospitals in rural areas.

Shapiro’s war wages on

Friday’s court ruling in UPMC’s favor means that Shapiro can’t hold off the June 30 split by changing the expiration date of a 2014 state-brokered agreement signed by the competing systems.

Shapiro maintains that although he may have lost the latest court battle, his broader legal war against UPMC has just begun.

Shapiro said he won’t be satisfied until he perceives UPMC to be behaving more like a public charity. Among other demands, he seeks to get UPMC to agree to contract with any interested insurer.

The attorney general plans to announce his next steps in coming days. Options could include pursuing actions against UPMC in the name of consumer protection, antitrust and public charities laws, or appealing last week’s Commonwealth Court ruling to the state Supreme Court.

On Wednesday, a day after a two-day showdown pitting Shapiro’s and Highmark’s legal teams against UPMC in Commonwealth Court, advocates and patients from the Pittsburgh region — including Bodick — met with a group of lawmakers and representatives for an informal roundtable meeting at the state Capitol.

They wanted lawmakers to know that UPMC’s relaxed prepay rules for certain patients and facilities do not resolve the situation for everybody.

They also warned lawmakers that the fierce health care marketplace competition that’s been happening in Western Pennsylvania soon could become apparent in the central and northeastern parts of the state as both Highmark and UPMC advance ambitious growth plans.

“My dream would be for the Supreme Court to say, ‘Listen: You’ve got to let everybody in, no matter what age, as long as they have insurance,’ ” Bodick said. “But I doubt that will happen.”

Highmark reiterated that it is open to working with UPMC — “if UPMC is willing to work in good faith,” Billger said.