Date: 13 Dec 2011 | Comments Off
Throughout the very public and generally contentious discussions between Highmark and the University of Pittsburgh Medical Center (UPMC), the Allegheny County Medical Society (ACMS) has maintained a position encouraging the two parties to negotiate in good faith, using an outside facilitator if necessary.
ACMS has been concerned that the lack of a contract will create difficult decisions for patients and their physicians. Patients, depending upon their choice, or their employers’ choice of an insurer, may find many physicians and facilities “out of network” which could substantially increase out-of-pocket costs. This happens with all plans that have a limited listing of “in network” or “participating” providers. Patients may then seek new physicians who are “in network” through their insurance plan.
The benefit to patients of “in network” physicians and facilities is an agreement to accept a discounted payment for services provided, usually with specified co-payments and deductibles, and to physicians and facilities to receive prompt payment for the care provided to the patient. Most patients in this area have enjoyed relatively wide access to care with Highmark’s broad “provider” network, including UPMC’s system of hospitals and physicians. This is an unusual marketplace for both the financing and delivery of health care services. There are no other similar situations around the country where we can look to examine how this situation will affect patients.
Highmark’s proposed acquisition of the financially challenged West Penn Allegheny Health System (WPAHS) has added a new dimension to this contractual battle. UPMC believes that Highmark has moved to structure itself after the UPMC model which links hospitals, employed physicians and a health insurance plan, to create an Integrated Delivery and Finance System (IDFS). Highmark has positioned its proposed integration as a necessary move to preserve the much smaller WPAHS as an alternative IDFS network to the UPMC system.
UPMC has stated that they will not contract with Highmark; western Pennsylvania now faces a very different medical care environment. The market has already changed with UPMC’s contracts with four national carriers that they previously did not accept. While it is always possible that positions will change, if a contract is not reached, employers will be forced to make a decision on their options. This decision will be affected by premiums and access to care, not only to UPMC and WPAHS hospitals/physicians, but to all providers and all acute, rehabilitation, and long-term care hospitals and facilities in our region. Patient care is often complex requiring access to multiple facilities and doctors for a particular problem and optimum care. It is not clear how these other facilities and the smaller hospitals and hospital systems which currently participate in most, if not all, insurer programs will be impacted. Employers will need to consider these unknowns when contemplating options for their employees.
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The goal of this requirement is to help patients understand who is providing their care and what level of training their caregiver has received.
