UPMC and Highmark Split

Photo courtesy of Pixabay.

By: Christina Pici, Staff Writer


As June 30th, 2019 approaches more articles and news stories are sure to come out concerning the long deliberated split between two of Pittsburgh’s largest health care providers, University of Pittsburgh’s Medical Center [“UPMC”] and Highmark.[1] June 30 is the day that the consent decree that currently governs the relationship between UPMC and Highmark will no longer be in effect.[2] However, the termination of the consent decree was subject of news interest four months prior to the termination because Pennsylvania Attorney General Josh Shapiro’s office is conducting a review of the split, focusing on issues of access to medical services and consumer costs.[3] Many patients are experiencing these issues because, for many years, UPMC accepted Highmark health insurance, and Highmark covered the bills of many Pittsburgh residents who could see any doctor in the UPMC network. Therefore, there is a lot of overlap for patients between these two companies.[4]

Problems arose between UPMC and Highmark in 2011 over amounts paid to UPMC for treating Highmark members. The issues finally came to a head when Highmark approved the acquisition of the former West Penn Allegheny Health System [“West Penn”].[5] This acquisition meant Highmark would be competing directly with UPMC for patients and insured members, as West Penn also offers health insurance and medical care.[6]

Consent decrees brokered by the state that have allowed some Highmark members to continue seeing UPMC doctors expires June 30.[7] Consent decrees are mutually binding agreements between two parties without admission of guilt.[8] It is estimated that around 175,000 seniors with Highmark Medicare Advantage coverage in the Allegheny and Erie counties will be adversely affected by the end of the consent decree because UPMC will require these consumers to pay up front for care.[9] More importantly, these Highmark members who have gone to UPMC doctors will be forced to find new medical care because they will no longer be able to go to UMPC as an in-network provider.[10] In addition, consumers seeking in-network access to both UPMC and Highmark doctors are likely to pay higher health insurance premiums than if they were to choose between the two providers.[11]

The Pennsylvania Attorney General’s office went to court on February 7, 2019, to pressure UPMC to change its approach to Highmark’s members, accusing UPMC of being out of compliance with the state’s public charities law in restricting access to its doctors and medical facilities.[12] Specifically, Shapiro’s office contends that UPMC is violating the Solicitation of Funds for Charitable Purposes Act, the Nonprofit Corporation Law of 1988, and the Unfair Trade Practices and Consumer Protection Law.[13] One of Shapiro’s largest complaints is that nonprofit organizations like UPMC receive tax breaks in return for providing services that a government entity would otherwise have to offer, and now because of the split between UPMC and Highmark, many of UPMC’s advances are being funded by taxpayers who are then denied access to UPMC facilities and doctors.[14]

According to the concerns laid out in the Commonwealth of Pennsylvania’s complaint against UPMC, the expiration of the consent decree in June is expected to result in UPMC’s eventual refusal to contract with other health insurers.[15] As a result, more patients will be seeking access to UPMC on a cost-prohibitive, out-of-network basis, which is in direct conflict with UPMC’s status as a charitable institution.[16] Moreover, the split between these two Pittsburgh health care giants spurred investigation into UPMC and the company’s commercial incentives, while simultaneously generating frustration and apprehension among patients in and around the Pittsburgh area who have turned to these two health care providers for solace in tough times.





















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