Pennsylvania's largest insurer has agreed to a broader interpretation of continuity of care provisions in a long-term accord with its main rival, while also touting what it sees as positive membership choice trends.
Barely a month into his tenure as Pennsylvania's new Governor, Tom Wolf proved his worth as mediator in brokering a resolution to a disagreement over which maternity patients with Highmark Blue Cross insurance could access the University of Pittsburgh Medical Center's Magee-Womens Hospital.
Last summer, Highmark and UPMC agreed to an accord under a consent decree, effective January 2015, that outlined conditions for certain Highmark members to keep in-network access to UPMC facilities, while also permitting each organization to try to compete on the basis of their integrated health networks.
UPMC, the region's largest provider system with its own health plan, had grown uncomfortable with Highmark, the region's largest insurer, increasingly offering narrow network plans that incentivized patients to use the seven hospital Allegheny Health Network, which the Blue Cross insurer acquired in 2012.
The latest dispute centered on whether women with Highmark Health coverage who learned of their pregnancy in 2014 could continue using UPMC's Magee-Womens Hospital and UPMC's ob-gyn practices, regardless of how far along soon-to-be moms were in their pregnancy.
According to Highmark's interpretation of the consent decree, only pregnant women who were actively receiving a "course of treatment" at UPMC ob-gyn practices or Magee-Womens could keep seeing the providers on an in-network basis.
After Wolf intervened, Highmark agreed to cover members who became pregnant in 2014 at UPMC facilities, including women who use independent ob-gyns but want to deliver at Magee-Womens.
"Any woman who became pregnant and sought treatment in 2014 and has Highmark insurance will have in-network access to Magee-Womens Hospital in 2015," Wolf said in a media release. "The needs of patients must always come first and I am pleased that we have reached a swift and necessary resolution in this matter."
"We are pleased that expectant mothers will continue to receive access to the care they need," added Pennsylvania's acting insurance commissioner, Teresa Miller. "Ensuring greater access to care and transparency for Western Pennsylvania patients is a top priority for this administration."
This dispute over maternity care access probably will not be last point of misundering for patients in the conscious uncoupling of Highmark and UPMC. With cooperation from Highmark and UPMC, Pennsylvania is running an information website, StayInformed.pa.gov to help consumers understand their access options.
Meanwhile, Highmark is arguing that members are choosing not to use UPMC facilities, citing preliminary claims data for 2015.
"It's down dramatically," Highmark spokesman Aaron Billger told the Pittsburgh Business Journal. "We have a new world that has been created by UPMC's decision not to contract with Highmark, and everybody is navigating that new world."