Last year, UPMC told subscribers to Highmark's new Community Blue health plan that, with few exceptions, they would have to find new doctors. For plan subscribers, UPMC was no longer an in-network provider: Even patients in the middle of treatments would need to find a new doctor — and even if they were willing to pay for care out of their own pockets.
But a recently announced consent decree between UPMC and Highmark, brokered by Gov. Tom Corbett and Attorney General Kathleen Kane, has addressed that problem to some extent. That's assuming you consider paying higher, out-of-network rates a solution.
Jim Donahue, executive deputy attorney general for consumer protection, confirms that the agreement allows Community Blue customers to use UPMC facilities at out-of-network rates, though the two entities must work out the details. They will have until July 15, according to the consent decree, to come to terms; if a consensus is not reached, the matter will go to binding arbitration. But without a consent decree in place governing the UPMC/Highmark relationship now, he says, likely court battles "would have led to chaos come January 2015," when the current UPMC/Highmark deal expires.
In the meantime, Donahue says, the agreement mandates that Highmark customers at UPMC facilities will get a 40 percent discount on the usual out-of-network rate. (Still, Donahue says, UPMC "has been known to have some pretty high charges.")
UPMC did not return requests for comment, but Community Blue has long been a flashpoint in the health-care giant's battle with Highmark. The insurer designed the plan to exclude most UPMC services from its network, and last year UPMC responded by barring many Community Blue patients from seeing doctors even if they paid cash. (It made exceptions for patients who lacked alternative treatment options, such as those seeking care from Children's Hospital, Western Psych or some rural hospitals, like UPMC Bedford.)
Now, however, Highmark spokesman Aaron Billger says questions about the fate of Community Blue patients are "being resolved by Highmark and UPMC." For now, Billger says, Highmark does "not believe that UPMC will turn Community Blue patients away" because "the consent decree states that UPMC will accept all Highmark members, even if it is on an out-of-network basis."
"While not yet formalized," Billger says, at a minimum "it is our interpretation that the consent decree provides Community Blue members with a 40 percent discount for out-of-network services."
That may be the fate of Community Blue subscribers both in Pittsburgh, where alternatives to hospitals like UPMC-Shadyside exist, and in outlying areas where they were previously barred from UPMC facilities. Those include Erie's UPMC Hamot and the Kane Community Hospitals: Under the consent decree, Community Blue subscribers may now access those facilities, but only at the steeper rate.
Melissa Fox, spokeswoman for the state's insurance department, says that by design, Community Blue is "a narrow network product. The consent decrees are not intended to change the contractual nature of those products." Still, she said, even Community Blue patients in some areas might benefit from the consent-decree protections ensuring in-network rates for treatment in "emergency situations."
In any case, Billger adds, "The most important thing is that details of how the consent decree affects Community Blue are being resolved by Highmark and UPMC."
Since its inception last year, Community Blue is fast becoming a popular option for Highmark customers. In the most recent open-enrollment period for the Affordable Care Act, for example, Highmark signed up more than 148,000 new customers. Of that, about 120,000 chose Community Blue.
Erin Ninehouser, education and outreach director for advocacy group the Pennsylvania Health Access Network, says the agreement is "better than nothing but will still hurt an awful lot of people."
The agreement has truly failed, she says, if it does not allow for in-network Community Blue access, particularly at all hospitals outside Pittsburgh. While Community Blue customers who live in or near the city will be inconvenienced by being forced to switch doctors, "for people in those rural areas, UPMC is their only choice. And Community Blue is so competitively priced that it's really their only option in health plans.
"This is not an agreement that protects our citizens and provides affordable access to community health care. The whole thing is a mess."