A history of health care is severed
Transplant patient laments anticipated loss of UPMC access
Last week, possibly for the last time, Bob and Lauri Shoup drove the 60 miles from their Indiana County home for Mr. Shoup’s scheduled checkup at UPMC Presbyterian hospital in Oakland.
It was an emotional visit — “a lot of tears and hugs,” said Ms. Shoup afterward. “It was heartbreaking.”
They’ve been making this trip for more than 30 years — starting in 1986 when a virus damaged Mr. Shoup’s heart, requiring him to undergo a heart transplant. He was only 27 at the time and not quite five years into his marriage with Lauri. They now have a grown son and daughter and seven grandchildren.
From the start, they knew they were in good hands even as they faced major heart surgery and a lifetime of aftercare that today includes Mr. Shoup taking more than 20 pills daily.
In the 1980s, Mr. Shoup was the beneficiary of living near Pittsburgh with access to Presby’s team of all-star heart surgeons — Bartley Griffith, Robert Hardesty and Robert Kormos — as well as the supporting team of nurses, coordinators and others.
“They really are our people,” said Mr. Shoup.
The Shoups’ relationship with UPMC is about to end, however, as they become another family whose medical journey will be disrupted next year by the UPMC-Highmark insurance war.
“This isn’t just one patient switching one doctor or even one hospital,” Ms. Shoup said, noting that her husband has been seen by a half-dozen UPMC-affiliated hospitals just in the past two months.
“None of these specialists will be available to him in just a few short months.”
The Shoups are part of a group that has enjoyed ongoing access to UPMC under the five-year UPMCHighmark consent decrees that will expire June 30.
Those two near-identical decrees signed in 2014 represent a sort-of divorce settlement between the two former partners and now rivals in the Pittsburgh health market, an agreement that lays out just how the separation will unfold. Part of that agreement offered special protections — and extended UPMC access — for Highmark members considered “vulnerable” such as Medicare Advantage beneficiaries.
Mr. Shoup is one of fewer than 2,000 Highmark members who come under the decrees’ “continuity of care” provision that has allowed patients with Highmark insurance “in the midst of a course of treatment” to keep seeing UPMC doctors on an in-network basis.
The Shoups certainly qualify: Since that first operation, Mr. Shoup has undergone a second heart transplant in 2001, then a kidney transplant in 2004 necessitated by his anti-rejection medications. Since 2001, his eyesight has continued to slowly deteriorate and, while that also might be tied to the medications, it’s not certain.
“You name a body part,” Ms. Shoup said, “and it’s either been repaired, replaced or removed.”
The Shoups don’t want to leave UPMC, but they will have no choice: The family is insured through Ms. Shoup’s teaching job, which only offers Highmark insurance.
As the two health giants have split, more employers are offering a menu of different insurance plans for workers to choose from, including national insurers such as Cigna, United Healthcare and Aetna that offer access to both health systems. But Highmark and UPMC Health Plan, each with its own network of hospitals plus access to independent community hospitals, remain the dominant insurers in the region.
Once UPMC falls out of network for Mr. Shoup, he will almost certainly be treated at Highmark Health’s Allegheny General Hospital on the North Side and he said he believes the quality of his care will not suffer. The Shoups also emphasized that Highmark’s insurance “has been very good to us” over the years.
What they mourn are the small things lost in making a switch, things that nevertheless make a big difference for patients. At Presby, “We know where to park, where to eat, where you can get a magazine,” said Ms. Shoup.
They also believe there’s something wrong about being forced to change doctors. UPMC “has been a real good partner for a real long time and it doesn’t make sense it’s coming to an end,” she said.
It didn’t make sense to many UPMC staffers either, apparently. “People have been telling us, ‘They’re going to give in. They’re going to take care of you,’” Mr. Shoup recalled. “People just thought somebody would give in, but they didn’t.”
Because of his diminishing eyesight, Mr. Shoup, 60, no longer drives at night. The couple says only one treatment they’re aware of offers hope for restoring his vision — a stem cell implant.
As it happens, that therapy is among the breakthrough treatments expected to be developed at the UPMC Vision and Rehabilitation Hospital in Uptown scheduled to open in 2020.
But “they’re not going to take me because I have the wrong insurance,” Mr. Shoup said.