PITTSBURGH (KDKA) — UPMC and Highmark have reached an agreement on access to UPMC health facilities for Highmark insurance customers, after months of often negative attacks on each other.

“At the end of the day, they did come together, put aside their differences, and reached a resolution that was truly in the best interest of policy holders and patients,” observed Michael Considine, Pa. Insurance Commissioner.

With significant prodding from Gov. Tom Corbett and Attorney General Kathleen Kane, the transition agreement means it won’t be cold turkey on Jan. 1 when Highmark subscribers no longer have low-cost “in-network” access to UPMC and its medical staff in the five-county Pittsburgh area.

“Providing that access to the care needed and the doctors that they trust is the commitment of this plan to the people of western Pennsylvania,” Corbett told a press conference in Harrisburg on Friday.

Here are the broad details:

First, Highmark customers in the midst of treatment at UPMC can continue that treatment next year.

Second, emergency rooms at all UPMC facilities remain open to Highmark insureds at the lower cost.

Third, Highmark customers who develop cancer issues in the future will have ongoing access to UPMC.

Fourth, there’s a safety net for 2015 to allow access to UPMC for any Highmark subscriber who is unable to find alternative care elsewhere.

Fifth, those 65 and over, or on Medicare, Medicaid, CHIP, Medigap, or Signature 65 continue to have access to UPMC.

“This agreement is the first step in a long process to insure that patient access and affordable care in western Pennsylvania does not become a distant memory,” added Kane in Harrisburg.

“It’s not about success for Highmark,” added David Holmberg, CEO of Highmark. “It’s not about success for UPMC. This truly is about the success of the people of Pennsylvania.”

“This plan puts the people of western Pennsylvania first by establishing protocols to minimize the disruptions in the care as this transition unfolds,” noted Tom McGough, executive vice president of UPMC.

Deborah Rice-Johnson, president of Highmark Health Plan, says many Highmark customers will no longer have lower cost “in-network” access to UPMC beginning Jan. 1, but the deal is still a good compromise.

“We wanted a full contract, so, no, we didn’t get everything, but we think we got what’s best for the customer,” Rice-Johnson told KDKA money editor Jon Delano.

What Highmark customers will get is the continuation of care at UPMC if they are in the middle of that care on Jan. 1, and UPMC’s emergency room services will also be open to Highmark customers at all times.

Another important service, says Rice-Johnson, will be oncology or cancer treatment at UPMC, no matter when the cancer or its ancillary issues develop.

“Oncology is 100 percent in, even if you go to the Hillman Center. That is a huge win for the community,” Rice-Johnson said.

The deal cut in Harrisburg creates a lot of exceptions.

“People will be surprised at much access they have.”

But not everyone is happy with the deal.

“I just think that every hospital should be available to everybody in the city who has insurance,” says Dana Reinhart of West View.

Reinhart says she’s not helped by this deal.

“I have a child that I had at Magee. Now, I have Highmark insurance and if I want to have any other children I have to go to West Penn,” she said.

One part of the deal is access to UPMC oncology services at lower in-network rates for anyone who gets cancer.

“Members we talked to on the street, they were concerned about oncology. Well oncology is 100 percent in,” says Rice-Johnson.

But not everyone likes that special treatment.

“It’s discriminatory. They’re saying if you got this disease you’re okay, but if you got that disease, I’m sorry, we can’t help you. And that doesn’t quite seem right,” adds Sally Eppley of the North Side.

“When you start picking and choosing, then you start playing favorites, and I don’t think that will be fair,” notes Gil Broxie of Penn Hills.

Rice-Johnson says over the next few months much of the confusion will be cleared up.

“Individuals who may be using a primary care that will no longer be in-network we’ll be working directly with them to help them transition to an in-network provider, but we’ll be spending a lot of time educating,” Rice-Johnson said.

UPMC, Highmark Reach Deal On Highmark Access To UPMC Facilities In 2015 (6/25/14)
Corbett Asks UPMC, Highmark To Minimize Upheaval (6/2/14)
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