Advice from Cleveland Clinic’s CEO
He says his counterparts at UPMC and Highmark must collaborate
We all but released balloons when the word came that UPMC’s resolve had crumbled: Pittsburgh’s biggest health care provider would rebuild a normal business relationship with Pittsburgh’s biggest insurance provider, Highmark.
But Karen Wolk Feinstein didn’t don a party hat.
An expert in health care policy, she grasped immediately the fly in the medicinal ointment:
“Cross- network access for all” makes a good soundbite but that’s not what we’re getting.
The truth is this: We’ll get what we pay for.
I don’t want to lose anyone’s attention in the thick weeds of this thorny topic. So, simply put, it works like this:
UPMC and Allegheny Health Network, the region’s two main health care providers, have opened their doors to all patients willing to pay the price of admission. However, most health care consumers are compelled by economic constraints to follow the rules of their health insurance plans. That means they most likely will stay “in network” — the network being defined by their insurance company.
In the wake of the fanfare over UPMC’s about- face ( the behemoth had been hellbent for years on refusing virtually all but court- mandated business with Highmark), we learned that many of us are covered by insurance plans that steer us to one provider or the other.
Those plans — known in the business as “narrow network” plans — generally cost less.
For those with UPMC health insurance plans, you’re steered to UPMC facilities. And I suppose that was self- evident to most of us. But, for those of us with Highmark — part of the national Blue Cross Blue Shield network — we believed we could go anywhere with our plan, the way it used to be some years back with this top- rate national plan. We thought wrong.
Because, in Pittsburgh, Highmark’s sister group is the Allegheny Health Network. So, Highmark offers several plans, some of which allow subscribers to get their health care where they choose ( a broad network). Other plans ( the narrow network plans) steer subscribers primarily to the Allegheny Health Network, leaving out UPMC property and personnel. Included in this narrow- network group ( in addition to the Post- Gazette newsroom employees) are a lot of teachers in the region, and all Highmark and AHN employees ( as well as retirees). And that’s thousands upon thousands of people.
I struggled with this for a bit. My head told me, “You get what you pay for. If I want to save money on my health care costs, I give up more choice when it comes to my health care providers.”
But my heart told me this just stinks.
I’m pleased to report that my heart is in fine company.
The word “collaboration” popped up repeatedly in my recent talks with Ms. Feinstein, president and CEO of the Jewish Healthcare Foundation in Pittsburgh, and Dr. Tom Mihaljevic, the CEO of the world- renowned Cleveland Clinic ( which, BTW, often outperforms both UPMC and AHN, based on several metrics).
A couple of my favorite quotes follow.
Ms. Feinstein: “In my vision of a perfect world, there’s collaboration. If one ( health care) system has developed world- class unusual clinical expertise in a life- threatening condition, the other system should refer ( its patients) to that system ( at predetermined, reasonable rates). If your life is at stake, even if you have the ‘ cheap plan,’ you shouldn’t be denied the care that you need and that is available.”
Dr. Mihaljevic: “In health care, we cannot view our job — our mission — as a zero sum game. Our general cultural sentiment — my very firm personal conviction — is collaboration more than competition. Consensus ( as to when to compete and when to collaborate). This is the best use of our organizational energy and focus.”
A theme emerged during my discussions with these enlightened, compassionate and informed experts:
Our community must demand more from Jeffrey Romoff of UPMC and David Holmberg of Highmark. Tearing down the barriers that actually prevented cross- network access was a first step. The finish line will not be crossed until the executives of these organizations can answer “yes” to the following question: Is each patient receiving the treatment from the professional and at the place that I would prefer if he or she were my brother, my mother, my child?
UPMC and Highmark/ AHN each should do its darnedest to convince us to see their respective doctors, choose their hospitals, buy their insurance plans. They should be in a fierce battle to win our hearts, our confidence and our business.
But the best way they could show us how much they care is by reaching consensus with each other on which areas in which they will not compete. There’s a bit of this going on right now. For example, Highmark has agreed to cover the costs at in- network rates for the treatment of cystic fibrosis patients at UPMC facilities, even if the patient has a narrownetwork insurance plan that steers generally to AHN facilities. That’s because the stakes to the patient are so high — their very lives — and the expertise at UPMC in this area is unquestionable.
We need more of this kind of collaboration and consensus.
As Ms. Feinstein put it: “Let’s be rational. We don’t need ( UPMC and AHN) each to hire superstars in the same areas of unusual expertise. We don’t need them to duplicate every single service. We don’t need them to develop mirror- image hospitals across the street. [ My words: think AHN’s Jefferson Hospital and the plans for a new UPMC hospital almost across the street.] There should be an understanding that ( a patient) stays in your own network where the systems areequal and life is not at stake. And when your life is in the balance, you should have access at reasonable rates to the team that is extraordinary — regardless of your insurance plan. The ( health care systems) should agree on a fair commercial rate with no ridiculous gouging.”
And if the parties can’t agree as to when to collaborate and when to compete, an independent panel could be established to coach them along.
Now, from Dr. Mihaljevic, a cardiothoracic surgeon by training and the top dog at a hospital system that has chosen to pass on adding health insurance to its business portfolio: “We do not want to dilute our obligation to our patients by embracing insurance,” he said.
He was too much of a gentleman to weigh in directly on his counterparts in Pittsburgh and the mess that we wallowed in for years because UPMC refused ( until late June) to do business with Highmark.
But he didn’t hesitate to share his vision of the right way to do things. I’m happy to report it meshed nicely with my heart’s desire.
“In every market we’re in, we compete in certain services but we collaborate in other areas where it is to the good of public health. ... I believe the presence of choice makes providers better in general ... [ but] the best arrangement for patients in Pittsburgh is for the ( health care systems) to adopt a consensus approach. They should agree on very specialized services that would be preferably done by one or the other. There’s always going to be service that both places provide and where they compete in an open fashion but those are the less complex issues, less life- threatening. This is a rational and an ethical use of services. None of us in this profession has ever gone wrong just doing what is right for the patient.”
I’ve been told by my contacts in Pittsburgh health care that UPMC and Highmark/ AHN aren’t just going to play ball with each other; they’re going to play nice. A Highmark contact told me a few weeks ago there will be announcements coming that prove the point. I certainly hope so. I’m waiting. The region is waiting. Meantime, Highmark/ AHN and UPMC should remember there are a lot of sideline spectators. And Cleveland Clinic is an easy drive from Pittsburgh and accepts most nationally branded medical insurance.