Medical ethics focus of insurance dispute between UPMC and Highmark [Pittsburgh Post-Gazette]
By Bill Toland, Pittsburgh Post-Gazette | |
McClatchy-Tribune Information Services |
But UPMC says its hands are tied by the language of the new
And UPMC says it would be "unethical ... to overlook the services and arrangements available to Community Blue subscribers, and impose more onerous economic terms on those individuals."
Ethical or not, the region's No. 1 health network is on solid legal ground.
By and large, "practices do not have to see patients," said
But "I haven't really heard of a system [saying], 'We're not [in-network] with you, [so] we're not even going to see your patients out-of-network.' ... It is pretty unusual."
Then again, the entire relationship between
UPMC and
The two
UPMC, in an online Q&A, says that "the extent that anyone suggested that UPMC would accept Community Blue subscribers for any services beyond emergencies and those specified in the mediated agreement, they were incorrect."
UPMC also says that it is forbidden from accepting Community Blue patients and then billing them extra, a practice known as "balance billing."
Health experts contacted by the
UPMC, on its website, has been saying since last autumn that customers of the new Community Blue product, which launched
While the issue has been brewing since summer 2012, the confusion came to a head on Saturday, when UPMC officially began turning away Community Blue customers from its practices -- even those who said they are willing to pay "out-of-network" prices or pay out of pocket.
How many customers might be affected is uncertain as
Even if the two parties can't agree on how many people are affected, it's ultimately UPMC's decision whether or not to see a patient on an out-of-pocket, or cash, basis. UPMC spokesman
And allowing patients to self-pay now would just delay the inevitable, since it's "likely that self-funding patients will only be able to obtain limited services from UPMC," according to the hospital system's online Q&A.
But several health care law and organizational ethics experts said UPMC's actions were morally ambiguous, particularly from a continuity-of-care standpoint.
It's one thing for a health insurer to change benefits, premiums or its directory of "in-network" facilities, creating obvious obstacles to continuity of care. Insurers can also steer patients away from the more expensive out-of-network options via strict referral rules, making the "choice" of out-of-network care more an illusion than a reality.
But it's another, more unusual thing for a hospital to formally bar a certain group of patients.
"It's not considered morally praiseworthy, but it's also not prohibited," said
Practices aren't obliged to see any particular patient -- for example, they can cut loose a patient for chronic tardiness, or refuse to see
The only law that requires a facility to treat a patient is the Emergency Medical Treatment and Active Labor Act, which requires hospital emergency rooms to triage and treat critically ill visitors. The point is to prevent ERs from "dumping" patients who are unable to pay for their care onto other health care providers.
Though the law is not on their side, the patients caught in the middle of the dispute -- mostly
"Nobody's taking ownership over this," said
One of her UPMC physicians is now off-limits because of the skirmish. Ms. Perelstine said she found out about her "firing" when she tried to make an appointment.
Not all of the affected subscribers are
This year, the company switched to Community Blue "because of ongoing rate increases," according to the company's general manager, who requested anonymity because he does business with UPMC.
His workers were cut off, he said, "including one that had a 25-year history with a doctor and was willing to pay cash. I feel as though I let my employees down."
Employers caught between the two feuding health care nonprofits seem out of luck -- and the various federal laws governing health care access and privacy provide no apparent relief.
For example, there's a waiver right, buried deep in the federal stimulus act of 2009 as a provision of the Health Information Technology for
The provision is effectively a privacy amendment to the Health Insurance Portability and Accountability Act, permitting patients to get care without their insurer (or spouses and relatives) finding out.
Usually, the waiver would be used for sensitive procedures -- a vasectomy or tubal ligation, for example, or maybe a heart issue that a patient doesn't want a life insurance company to discover.
But the waiver loophole takes effect only after a doctor or hospital has agreed to see the patient; it's not a back door into the UPMC network, said
The UPMC lockout also touches on the issue of patient abandonment -- the wrongful, unreasonable severing of a patient-provider relationship. But providers are able to avoid that charge by giving written notice, typically by certified mail, explaining the break-up and providing resources to help the patient find another physician or specialist -- all of which UPMC did.
Still, as a physician, Dr. Goold said the hard-line actions of UPMC's administration were tough to swallow.
"You have established relationship with patients. UPMC acting as it did disrupted patient-doctor relationship," she said. "I'm not surprised [if] physicians are upset. ... If it were me, I'd be upset.
"They're not really giving their doctors a chance to do the right thing."
But Dr. Goold also agreed with UPMC in that the design of the Community Blue product makes it unlikely many patients -- even those who now claim they want to keep their UPMC doctors -- would be able to make the cash or out-of-network payments on a long-term basis.
Eventually, "those patients will have a very strong incentive" to leave UPMC and find an in-network physician. That may be why UPMC is drawing a line in the sand, Dr. Goold said.
"Facilities don't usually identify a type of 'patient' they won't see, although physicians can certainly make that determination," said
She, too, said she hadn't heard of a hospital conducting itself in such a bare-knuckles way before but added that UPMC may well have good business reasons for its actions. "What if UPMC feels that Community Blue is driving down costs so much that it is hurting patients?" she said. In such case, the health system might feel obligated to pressure
On the other hand, "If this is simply an effort to put a competitor out of business, that is troubling," Ms. Berg said.
Yet this is the health care system that America has chosen -- one in which hospitals and health insurers are often adversaries over price. When they are negotiating, one of the easiest ways for a hospital to exercise leverage over unsatisfactory treatment from an insurer is to threaten to freeze out certain insurance card carriers.
"This is really harsh, I think," said
While UPMC says the issue is a "pretty small" one because of Community Blue's minimal customer base,
Several local health care observers noted that UPMC's insurance arm, the
"We do not block under any circumstance, nor have we ever, self-paying patients or out-of-network access to our facilities and physicians, and that includes
"To do anything less would be unethical and violate our obligation to patients and the community as a nonprofit charitable health care provider."
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