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.
There are valid concerns for patients, employers and physicians that should be addressed. The Commonwealth of Pennsylvania should examine its authority under existing law to encourage the parties to negotiate in good faith in a timely manner that will allow employers to make informed decisions for their 2013 employee benefits contracts. The administration should make a decision on whether or not to invoke Pennsylvania law and extend the existing contract through December of 2012. This is critical for employers as most benefit plan years are on a calendar basis. This will allow them to maintain the benefit plans that employees have selected through the benefit plan year without necessitating filing for federal approval of changed plans. They may then make informed choices of insurers and providers in the spring of 2012 for the plan year 2013. The Department has previously invoked this authority at the last moment to maintain pressure on entities to reach an agreement, but this situation affects many more patients than previous situations.
Patients and employers deserve a clear accounting on what ‘out of network’ charges will be from all systems and networks. Those amounts should be readily available and made public. A study should be undertaken to determine what state actions are needed to impose competition in the healthcare insurance and delivery markets to promote quality and value. There are areas that the PA Legislature can evaluate and then govern through law. The Legislature can address and clarify the authority of the Insurance Department. The PA Insurance Department needs enabling legislation delineating their powers to allow them to meaningfully act on behalf of consumers. The Insurance Department has limited authority to review and approve premium rates and that should be strengthened.
There are certain ‘one of a kind’ services and facilities that are critical to the community, either through the unique services that they provide or geographic location. Perhaps these should be treated as essential services, subject to open access under rates set by a public authority, much as a utility.
The Legislature should also act to address the issue of individual policies or coverage. Most insurers in Pennsylvania do not write individual policies, a significant issue for individuals, the self-employed and small employers. Health insurers writing group insurance in Pennsylvania should be required to offer individual coverage at rates approved by the Insurance Department. In an era of greatly increased “transparency,” insurance contracts should be available publicly and subject to review by the Insurance Department. Parties should agree to a standard protocol for handling the transfer of medical records and information when patients change physicians, or when patients arrive at non-participating facilities for care. The insurers also need to clearly outline how patients who are midway through treatment will be covered, such as patients undergoing chemotherapy or radiation therapy, or who have been prepared and authorized for surgery at the time contracts end. Perhaps existing contracts should apply until treatment is concluded or an attending physician believes patients can be transferred. All providers and parties involved should be aware that the Pennsylvania Patient Safety Authority has documented an increase in medical errors with the transfer of patient care.
The Legislature should consider any willing provider legislation; this would allow physicians who agree to accept payment schedules and participate in all quality measurement programs to participate in an insurer’s network. This would allow physicians not employed by a system more freedom to care for patients in the practice setting of their choice.
The Legislature should also review the Pennsylvania statute on corporate practice of medicine to support physicians’ roles as patient advocates, not dictated by the bureaucracy of insurers or health care systems. We must maintain the principles of patient care first and foremost, while addressing the financial need to pay for that care.
With respect to WPAHS, regulators should move expeditiously to review and examine the proposed acquisition by Highmark. The community deserves a rapid decision on the future of this system. There are outstanding physicians, nurses and medical personnel working in the WPAHS and critical medical services that are provided by those facilities, just as there are at UPMC. Expeditious resolution of this matter will allow this market to move forward and should increase competition.
ACMS respects Highmark’s and UPMC’s differences of opinion and recognizes the importance of both to our community. ACMS continues to believe that reaching an agreement will be the least disruptive to the patient and their physician and the continuity of care. We hope for a compromise that will benefit our patients, physicians and institutions while at the same time protecting the interests and concerns for both Highmark and UPMC. However, we recognize that may not happen; and therefore, UPMC and Highmark should formalize an orderly transition plan to minimize disruption of care and costs.
Physicians believe that our region will be best served by a competitive market for insurers, hospital systems, and physicians alike that preserves consumer choice and provides access to efficient, quality-driven physicians and facilities. We should be able to accomplish this in a larger system that provides for professional competition that continues to serve patients in the collegial manner that is the heritage of the medical profession. The community expects these two non-profit organizations to act in good faith as responsible corporate citizens and act in the best interest and shared values of our community.
That is our challenge, and our goal, as physicians – to serve and care for patients, to be the patients’ advocates, and do our best to heal and help them.
Adopted December 6, 2011