UPMC, High­mark set terms for con­tract to ex­pire in 2015

Modern Healthcare - - REGIONAL NEWS - —Me­lanie Evans

Penn­syl­va­nia’s gover­nor an­nounced terms of the con­tentious breakup of Pitts­burgh in­sur­ance com­pany High­mark and UPMC, the city’s dom­i­nant health sys­tem.

UPMC and High­mark, which ac­quired UPMC’s strug­gling ri­val— West Penn Al­legheny Health Sys­tem—have fought ag­gres­sively and pub­licly over the ex­pir­ing con­tract for High­mark mem­bers to get in-net­work ser­vices at UPMC’s fa­cil­i­ties. High­mark has sought to ex­tend the con­tract, and UPMC re­fused.

Un­der the deal an­nounced by Gov. Tom Cor­bett, High­mark mem­bers will get con­tin­ued ac­cess to UPMC af­ter the con­tract ex­pires Jan. 1. No­tably, the deal sets re­stric­tions on “un­clear or mis­lead­ing” ad­ver­tis­ing and re­quires High­mark and UPMC to do­nate $2 mil­lion apiece for out­reach and to re­im­burse the state for its role in bro­ker­ing the deal.

Penn­syl­va­nia’s Depart­ment of In­sur­ance re­quired High­mark to de­tail a tran­si­tion for UPMC pa­tients as a con­di­tion of its April 2013 ac­qui­si­tion of West Penn Al­legheny. “For some time, the people of Western Penn­syl­va­nia have been con­cerned about where and how they will re­ceive their health­care come Jan. 1, 2015,” the gover­nor said in a news re­lease an­nounc­ing the agree­ment.

More de­tailed plans must be sub­mit­ted to the state by the end of July, but the terms will give High­mark en­rollees con­tin­ued ac­cess to UPMC on­col­o­gists, spe­cial­ists in be­hav­ioral health and pe­di­atrics, and UPMC hos­pi­tals out­side the com­pet­i­tive Pitts­burgh mar­ket­place.

High­mark en­rollees will be deemed in-net­work at all UPMC emer­gency rooms. Those al­ready un­der UPMC care for a con­di­tion or pro­ce­dure may con­tinue un­til physi­cians agree to trans­fer pa­tients to new providers and High­mark en­rollees will have one year to find an al­ter­na­tive doc­tor.

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