Changing Central Pa. health care market puts family in tough spot
A news story circulating in Central Pennsylvania the past few weeks may ring familiar to southwestern Pennsylvania residents: A chronically ill patient may lose access to specialists because the insurer and the hospital can’t come to terms.
Pittsburghers might recognize some key players, too.
Josh Corman, 35, works as a scheduler for UPMC Susquehanna’s Bone and Joint Institute in Williamsport. The hospital was acquired by Pittsburgh-based UPMC health system in October of last year, and, as expected, UPMC is shifting Susquehanna employees to its own health plan.
The problem: Mr. Corman and his wife, Jamie, have custody of their 2-year-old granddaughter, Claire Shreckengast, who was born with serious heart and neurological problems. Under the family’s current Highmark insurance, Claire has been treated by a half-dozen specialists from the Geisinger Health System, based in Montour County.
Geisinger does not accept UPMC Health Plan insurance, so she may soon lose in-network access to those specialists beginning July 1, leaving the Cormans facing the cost of paying for all of her office visits, tests and treatment. Even with a second job working in a Walmart meat department two nights a week and on weekends, Mr. Corman said, the medical bills would be unaffordable.
“I think they [Geisinger] are only hurting themselves, and in the meantime the community’s hurting, and that’s not right,” Mr. Corman said in a phone interview last week. “I shouldn’t have to worry about who my granddaughter is going to see for care.”
The accounts of Mr. Corman’s insurance situation have appeared in the Bloomsburg Press-Enterprise and in PennLive.com, the online website of the Harrisburg Patriot-News.
With an increasing number of health systems nationally taking on both roles of insurer and care provider — as UPMC, Geisinger and Highmark Health all have — there’s a stronger push to keep patients in-house. And that means offering health insurance plans that put up financial barriers between plan members and other systems.
“There is a strong incentive to promote their own delivery system, and in fact that can help them grow. This is really happening all over the country,” said Dennis Scanlon, a health policy and administration professor at Penn State University and director of its Center for Health Care and Policy Research.
The battles in southwestern Pennsylvania for patients and market share have been notably pronounced and prolonged, even requiring intervention by the governor’s office at one point, and the central part of the state may become the next heated battlefront.
Since the Cormans’ story surfaced, Geisinger has offered to see UPMC Susquehanna employees, but Susquehanna has rejected that, with a spokesman saying Geisinger should provide physician and hospital services to all UPMC Health Plan members in the area, not just those employed by the hospital.
Mr. Corman, for his part, emphasized, “I have nothing but good things to say about UPMC,” noting that the hospital has reached out to him and assigned a concierge to help the family find new doctors.
But UPMC’s offer to help will come with hefty inconvenience.
“We’re going to have to travel more; there’s just no way around it,” Mr. Corman said. “They’re offering for us to go to Pittsburgh, but that’s going to be really, really hard. That’s 3½ hours away.”
Claire’s current specialists are in Danville, about 50 miles from the Cormans’ Beech Creek home.
The Cormans are not the only ones likely to see a change in how they get medical care in coming months and years.
The 12-hospital Geisinger system has long been the major provider in the state’s central-northeast region, and Highmark and Capital Blue Cross, with a 75 percent market share, dominate the insurance market.
UPMC’s acquisition of Susquehanna Health System, which in turn is acquiring hospitals in Sunbury and Lock Haven, puts its footprint firmly in both fields. And with UPMC’s announced affiliation with Harrisburg-based Pinnacle Health earlier this year, the market is reacting.
Last month, Highmark Inc. announced it intended to pursue a four-county joint clinical venture with Geisinger.
Some, including Mr. Corman, have welcomed UPMC’s arrival.
“There are so many small hospitals around this area; affiliating with someone is inevitable. You’re not going to survive if you don’t,” he said.
Had Susquehanna Health System’s four hospitals affiliated with Geisinger instead of UPMC, he said, some worried it would lead to a downsizing that would jeopardize jobs.
The flip side of that argument came in a June 6 letter from Altoona orthopedic surgeon Angela W. Rowe to PennLive.com.
Dr. Rowe warned, “UPMC’s entry into the Central Pennsylvania health care market will be much less than wonderful for patients and physicians if our experience in Altoona is any indication.”
She said in a phone interview last week that patient referrals from UPMC Altoona to her Advanced Center for Surgery have dwindled to near nothing as patients are treated at the hospital or other UPMC-affiliated facilities.
A board-certified orthopedic surgeon, and soon to become the Pennsylvania Orthopaedic Society’s first female president, Dr. Rowe said her center is the state’s only surgical center licensed to perform total joint replacement on a lower-cost, outpatient basis.
“We sent them [UPMC] a letter and said, ‘We can offer you a lower rate for Medicare and Medicaid than you would get at the hospital’ and they said, ‘No,’ ” she said.
Dr. Rowe noted that those are government programs, so it is taxpayers who miss out on the lost savings.
Invited to respond, a UPMC spokeswoman did not directly address the Advanced Center for Surgery situation but wrote, “We continuously evaluate the number and types of providers in our network to ensure our members have meaningful access to high-quality care and typically not only meet, but exceed, the requirements for ‘network adequacy.’ ”
As health systems expand, one argument is generally that the moves will bring needed efficiencies while maintaining or improving on the quality of care, Penn State’s Mr. Scanlon said, but the evidence is mixed.
“It is not clear that bigger is always better,” he said.
For consumers like the Cormans, such changes can mean added layers of complexity as they make critical decisions about insurance and medical care, trying to balance what they can afford against the anticipated care they will need.
“I’m not trying to create waves or anything,” Mr. Corman said of his decision to go public. “I’m just trying to help my family.”