A week before thousands of people would have lost access to UPMC providers, Highmark Health and UPMC reached a 10-year agreement to let Highmark Blue Cross and Blue Shield patients continue receiving care at UPMC facilities in Western Pennsylvania.
On Monday, Pennsylvania Gov. Tom Wolf and Attorney General Josh Shapiro announced that the two organizations and Shapiro had negotiated a deal giving Highmark enrollees access to all UPMC hospitals and physicians.
Shapiro, UPMC CEO Jeffrey Romoff and Highmark CEO David Holmberg had been negotiating since a Commonwealth Court judge ruled June 14 that a five-year consent decree ensuring Highmark patients access to UPMC providers would expire as scheduled on June 30.
The unexpected agreement resolves a fierce, long-running battle between the rival health systems, which had raised doubts about the viability of exclusive provider networks across the country. Patients and public officials had protested the looming disruption of care.
The agreement will halt federal and state lawsuits brought by Pittsburgh-based UPMC and Shapiro in which Highmark intervened.
"I'm proud to announce this historic settlement today that restores fairness and access to affordable care for the people of western Pennsylvania," Shapiro said in a written statement. "Without this agreement, millions of patients … would have had their healthcare abruptly upended."
A UPMC spokesman said the issue was resolved "in a collaborative fashion" and that UPMC "appreciates that we were able to reach this agreement with Highmark on a long-term, in-network contract."
Highmark's Holmberg said in a written statement that the deal "brings certainty of healthcare access to thousands of people in our community."
The agreement, which takes effect July 1, will ensure that Highmark Medicare Advantage and commercial enrollees have in-network access to 11 UPMC hospitals and affiliated providers. Highmark said it and UPMC will finalize contract terms and conditions over the next few weeks.
A UPMC spokesman said the agreement does not require Highmark to include UPMC in all of its insurance products. But when it does include UPMC, it must include all UPMC physicians, hospitals and services and cannot charge Highmark members more out-of-pocket to go to UPMC than to Highmark's Allegheny Health Network facilities or any other in-network providers.
Wolf said at a news conference that while Highmark and UPMC would remain competitors, they now are better able to make decisions for the future, knowing what their relationship will be for the next 10 years.
The fight began in 2011 when Highmark became UPMC's competitor in the Western Pennsylvania hospital market. The two powerful integrated systems aggressively moved to establish exclusive plan-provider networks.
Both sides had been ramping up for the final break-up on June 30, with Highmark's Allegheny Health Network hospital chain expanding rapidly and UPMC planning three specialty hospitals in the Pittsburgh area.
Earlier this year, Shapiro sued UPMC in Commonwealth Court, arguing that UPMC had violated its charitable obligations to the state. He asked the court to enable open and affordable access to UPMC's provider network through negotiated contracts; require baseball-style arbitration if negotiations fail; and bar UPMC from engaging in excessive and unreasonable billing practices. He also sought to replace UPMC's and Highmark's boards.
UPMC sued in both Commonwealth Court and federal court to block Shapiro's efforts to force UPMC to keep its provider network open to Highmark Health and other health plans.
The Hospital and Healthsystem Association of Pennsylvania unsuccessfully sought to join UPMC's side in the suit, arguing that Shapiro's plan would potentially force all not-for-profit hospitals in the state to do business with any insurer regardless of payment or other contract terms, which would destabilize hospitals financially.
Lou Ann Jeremko, executive director of the Consumer Health Coalition in Pittsburgh, called Monday's announcement "huge and life-changing" for people with chronic diseases who have established relationships with UPMC providers and now will be able to continue seeing them. She credited community activism for maintaining pressure on Shapiro and the two health systems to reach a deal.
"We are very happy for all the efforts of consumers who kept their voices strong and loud, supporting Attorney General Shapiro as he went through this effort," she said. "I'm too celebratory now to be mad. But where we'll be 10 years from now, I don't know."
