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UPMC-Highmark split is forcing worried seniors to switch insurers

UPMC-Highmark split is forcing worried seniors to switch insurers

October 14, 2018

As UPMC and Highmark battle for market domination, their feud is fueling frustration among Medicare-eligible seniors who could strike back by choosing neither of the rivals’ insurance plans, industry experts suggest.

“Seniors have to put up with the direct mailers and then turn on their TVs to see what are basically political ads. It’s deeply troubling. They’re frustrated and confused and scared,” said Sean Horn, a manager at MediConnect, which specializes in helping people age 65 and older choose health insurance plans.

Horn noted he’s not old enough to qualify for Medicare but personally received four mailers from either UPMC or Highmark in his South Hills mailbox since 2019 Medicare Advantage plan details became available last week.

“There’s a lot of venom … and I believe that more and more people are going to go with the national plans because they’re sick of both of them.

“This year’s open enrollment period is going to be the most pivotal shift that Southwestern Pennsylvania has seen in the last 20 years.”

Open enrollment for Medicare and Medicare Advantage — privately offered plans that include Medicare coverage plus other benefits such as dental, hearing and vision care — begins on Monday.

Both sides could lose

In recent weeks, state-funded and private helplines have been overwhelmed by a sharp rise in calls from Medicare-qualified clients unsure of what the mid-2019 network split between Downtown Pittsburgh-based nonprofit health systems Highmark and UPMC means for them.

They’ll have questions like whether they can keep their Allegheny Health Network doctor in Highmark’s insurance network but still see cancer specialists and get blood work done at out-of-network UPMC hospitals.

MediConnect insurance brokers have been telling individual clients, “Don’t put yourself in that position.”

“Why have to choose one doctor over the other?” said Brian Breisinger, who owns MediConnect as well as a national wholesale insurance company.

His firm sells Highmark and UPMC plans but has been pushing alternate options for clients whose primary concern is about access to doctors rather than getting a concierge of supplemental benefits such as hearing aids, home equipment, transportation and access to SilverSneakers fitness classes.

Last year, only about 5 percent of roughly 2,600 Highmark and UPMC insurance plan members that MediConnect enrolls made a switch.

In recent weeks, closer to 25 percent are poised to choose alternate plans that provide in-network access to both UPMC and Highmark — such as Aetna or United Healthcare, Medigap supplemental plans or traditional Medicare issued directly by the government.

Based on early indicators and feedback, Breisinger and Horn predict that the UPMC-Highmark network split may cause both rivals to lose members.

“We’re not seeing a mass shift, but our clients are concerned,” said James McTiernan, area vice president for Downtown Pittsburgh-based insurance consultant Arthur J. Gallagher & Co., which sells Medicare plans to groups ranging from 100 to more than 7,000 members.

“It’s hard to say how significant it will be,” McTiernan said. “Highmark is working very hard to retain their members, and the other carriers are working very hard, too.”

The bitter feud between UPMC and Highmark dates back years and reached a peak in 2014 when their longstanding commercial contract expired.

“There’s a huge fight going on between UPMC and Highmark. They’re like two kids fighting in a sand box,” said Scott Corna, a Pittsburgh-based licensed insurance agent for HealthMarkets.

Many of his clients have doctors in both health systems, as well as others who rely on out-of-network coverage options and flexibility. He has one client, for instance, who takes his wife to Chicago for special treatments twice a year.

“I’ll give the customers whatever they want,” Corna said.

UPMC and Highmark each say they’re confident in the value of their offerings and tout continued growth.

“We’re confident that consumers will recognize the breadth, depth and value in our MA offerings in Western PA and that UPMC Health Plan’s membership will continue to grow,” UPMC spokesman Paul Wood said.

“It’s important that seniors understand that the most efficient and least costly option to continue to see their UPMC doctors and use UPMC hospitals is to select a Medicare Advantage plan that has full, in-network access to UPMC, such as Aetna, Cigna, Humana, United Healthcare or UPMC Health Plan.”

UPMC has no obligation to treat Highmark members for non­emergency services once the consent decree ends on June 30.

UPMC’s prepay rule spurs confusion

Adding to the confusion of many seniors, UPMC recently announced an out-of-network prepay requirement that 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 2019 for the same cost as in-network coverage via a “simple and straightforward” transition.

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 obtain a cost estimate and pay the full cost in advance.

Patients also may be billed for any additional costs that arise during treatment, and “whether the insurer reimburses the patient is between the insurer and the patient,” Wood said.

Patients must schedule all appointments — including follow-up visits — through a centralized scheduling system.

Highmark — which described the prepay rule as surprising and “highly unusual” — had pledged to cover the extra out-of-network costs for the second six months of the year so patients wouldn’t have to pay more to continue seeing UPMC providers next year.

Highmark has asked UPMC to reconsider and bill Highmark directly “like they always have” and like all other out-of-network providers typically do.

“We don’t want to put the seniors in the middle,” Highmark spokesman Aaron Billger said.

No signs of a truce

Such a compromise probably won’t happen, McTiernan said.

Though it may be unusual, UPMC’s prepay rule appears to be legally permissible under federal rules governing Medicare plans, he said.

The latest chapter in the years-long war between UPMC and Highmark comes as seniors account for a rising source of relatively stable revenue for health insurers as baby boomers retire.

“Medicare Advantage plans are very competitive,” said Ann Marie Wolfe, analyst with Mark Farrah Associates, a health care research analytics firm. “These plans are prime for growth, and these companies know it.”

Nationwide, just 21.5 million seniors of 62.8 million eligible seniors — or about 34 percent — choose privately offered Medicare Advantage plans over traditional Medicare issued directly by the government, federal and industry data compiled by Mark Farrah Associates show.

In Pennsylvania, 1.118 million people have Medicare Advantage plans out of 2.8 million who are eligible for Medicare, the data show. The 2018 figure is up slightly from the end of 2016, when 1.088 million Pennsylvanians had the plans.

Highmark — which, like UPMC, has been moving on aggressive growth plans and investing billions of dollars in new hospitals and facilities — says it has observed a rise in popularity in Medicare Advantage plans in recent years.

Highmark also points to momentum in one of its Medicare Advantage plans that already makes UPMC’s network off limits, its $0 premium HMO Community Blue plan, which has grown from 14,000 customers three years ago to more than 25,000.

“We will continue to work with our members to ensure they have access to the highest-quality and most convenient care possible,” Billger said. “It’s important to remember that we have thousands of high-quality providers that remain in our networks.”

Many MediConnect clients are “holding out hope that these two giants” will find a way to compromise, such as by UPMC dropping its out-of-network prepay rule and continuing to bill Highmark, not patients, directly, albeit at a higher out-of-network cost — at least through the end of 2019.

“Unfortunately, it’s not happening,” Horn said. “We’ve been told, ‘Absolutely not. Highmark and UPMC are done working together.’ ”

Natasha Lindstrom is a Tribune-Review staff writer. You can contact Natasha at 412-380-8514, nlindstrom@tribweb.com or via Twitter @NewsNatasha.