Rep. Christiana: Legislature needs ‘guts to stand up to’ rivals UPMC, Highmark

Oct. 03--State lawmakers need to muster up "the guts to stand up" to health care giants as Pennsylvania's health insurance marketplace is "headed toward an oligopoly" threatening to confuse and hinder treatment options for patients, state Rep. Jim Christiana said Wednesday.

The Beaver County Republican issued a statement in response to the latest controversy regarding Pittsburgh-headquartered nonprofit health care rivals UPMC and Highmark Health, whose insurance plan networks will be divided once a state-brokered consent decree expires at the end of June.

Christiana lamented that "patients are at the mercy of these companies unless the Legislature puts permanent solutions in place."

"The health care landscape is rapidly changing, and our public policy needs updated to protect patients from the market being dominated by a few organizations," Christiana said. "I hope my colleagues are sick and tired of having their constituents leveraged for market share, because I've been tired of it for a while."

Beginning July 1, Highmark-insured Medicare Advantage patients who choose to go to UPMC doctors and most UPMC hospitals will only be able to schedule a treatment or procedure if they pay the full cost in advance. Patients will then be required to seek reimbursement directly from Highmark, UPMC officials announced Monday, when 2019 Medicare Advantage rates were made public nationwide.

The prepay requirement clashed with assurances from Highmark that members of two of its 2019 Medicare Advantage Plans -- Freedom Blue and Security Blue -- would be able to see out-of-network doctors through the end of 2016 for the same cost as in-network coverage via a roughly "seamless" transition.

The uncertainty has flooded local senior enrollment helplines with calls from thousands of Western Pennsylvanians questioning whether they can keep their doctors once the consent decree ends next summer.

"These situations occur when tax-exempt nonprofits run their organizations like Fortune 500 companies, and the Legislature doesn't have the guts to stand up to them," Christiana said in his statement.

Highmark is asking UPMC to reconsider and bill Highmark directly "like they always have" and like all other out-of-network providers typically do.

Christiana did not elaborate on any specific legislative fixes he intends to support.

Patients started observing the effects of this region's changing landscape shortly after Highmark Inc. announced it was buying the former West Penn Allegheny Health System to form the basis of Allegheny Health Network in 2013.

Allegheny Health Network's hospitals and outpatient facilities compete throughout Western Pennsylvania with UPMC's hospitals and physicians.

UPMC said it wouldn't contract with an organization that owned competing hospitals.

Christina helped lead the bipartisan legislative push that resulted in the state-mediated consent decree in 2014 to govern relations between UPMC and Highmark until 2019.

The two giants have since squabbled and fought in court as each expands its reach across the state and nation.

"We can't have insurance companies leveraging their hospitals and their doctors to play this high-stakes poker game, locking certain people out based on the insurance card in their wallet," Christiana said in 2013, when he tried unsuccessfully to pass a pair of "healthcare marketplace fairness" bills.

The proposed legislation would have required physicians and hospitals within integrated delivery networks that have provider and insurer arms operating under the same corporate umbrella -- including UPMC, Highmark and Geisinger Health System -- to contract with any willing insurance company. Rates would be set by an arbiter.

At the time, UPMC criticized the so-called "any willing" legislation as unprecedented "coercion" that would result in "select and narrow networks to minimize expenses and coordinate care, and would impose yet another layer of state government intervention and price control in the health care marketplace."

Christiana and Frankel's pair of bills introduced in 2013 garnered more than 40 co-sponsors but died before making it to a vote on the House floor.

Natasha Lindstrom is a Tribune-Review staff writer. You can contact Natasha at 412-380-8514, [email protected] or via Twitter @NewsNatasha.

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