University Times

University Senate Matters

Nathan Hershey

If you are a Pitt employee enrolled in the HMO or the Point-of-Service program of the UPMC Health Plan and, on June 30, you or a dependent were under the care of a physician who is a member of Premier Medical Associates or Alliance Medical Inc. [hereinafter "Highmark physicians"], you probably were aware of an impasse between Highmark and the UPMC Health Plan regarding continuity of care from Highmark physicians as of July 1. The UPMC Health Plan and Highmark had failed to agree on an arrangement by which Pitt plan members could continue to receive services from Highmark physicians.

Although I was aware of the problem, I did not fully appreciate it until I received a visit on July 7 from a faculty member, concerned about a family member who would be seriously affected by the failure of UPMC Health Plan and Highmark to agree. I sent an e-mail that day to Arthur Levine, senior vice chancellor for the Health Sciences, seeking his intervention on behalf of Pitt employees. The following Monday I was contacted by one of Dr. Levine's senior staff who, after a brief discussion, arranged for two UPMC Health Plan officials to explain to me the plan's view of, and position on, the problem. After that meeting, I met with the officer who manages the Highmark physicians groups.

As time passed, additional Pitt employees contacted me. In mid-July I informed the chancellor of the problem and sought his intervention.

By mid-August it appeared that nothing had been accomplished to end the impasse. About that time, in preparation for a course I teach, I reviewed a document of one of the UPMC Health System's subsidiaries and learned that Dr. Levine's assigned person was an employee of that subsidiary. Was this individual working to resolve the problem or, rather, to have me attribute the impasse to Highmark?

I decided to take matters into my own hands as best I could. I had already had another contact or two with the chancellor, expressing my concern and my hope that he would help resolve the problem. I telephoned Jim Klingensmith, group executive vice president at Highmark, and asked whether Highmark would permit the Highmark physicians to continue to provide services to Pitt UPMC Health Plan members who had relationships with these physicians as of June 30. He answered in the affirmative. I called Dr. Levine's staff person and asked for a straight "yes" or "no," as to whether that was acceptable to UPMC Health Plan. He said he could not make such a decision, but would refer it to higher-ups. Within the hour he called to say UPMC Health Plan would consider Klingensmith's offer if it were in writing. I called Mr. Klingensmith and, on the following Monday, he sent the requested letter to Patricia Liebman, UPMC Health Plan CEO.

Further exchanges of correspondence followed. I had kept the chancellor informed of my activity. The chancellor told me that he had been in touch with Jeffrey Romoff, president of the UPMC Health System, about the matter. The chancellor serves on the UPMC Health System board's executive committee.

The resulting agreement is that UPMC Health Plan members who had been using certain Highmark physicians as of June 30 will be able to receive care from them under the UPMC Health Plan as if they were full UPMC Health Plan-participating physicians. Information about the agreement should be in the hands of affected employees soon.

I have described my role in some detail because I was not burdened, as University Senate president, by being an employee, officer or board member, or dependent on the largesse or benevolence of the UPMC Health System or its subsidiaries. A major concern of mine about the events that transpired is how the person assigned by Dr. Levine saw the problem. He appeared to be more concerned with giving me the impression that the UPMC Health Plan was right and Highmark wrong, than in achieving the result that I, and Pitt employees, sought. Holding high positions in both the University and UPMC Health System provides at least a potential for conflict of interest. Were there reasons for UPMC Health Plan to prevent the Highmark physicians from being able to continue care to some UPMC Plan members? Would allowing access by UPMC Plan members to those Highmark physicians lead to a transfer of UPMC Plan resources to Highmark physicians — resources that might otherwise be available to compensate UPMC Plan physicians, if UPMC Plan members would have had to secure services from them to gain maximum financial benefit of the UPMC Health Plan? I will again address my concerns about conflict of interest in the context of the relationship between the University and the Health System later in the academic year.

I want to acknowledge the assistance of those who brought the problem to my attention by stating facts that enabled me to better understand the problem and to dramatize it to others; the help of faculty colleagues I used as sounding boards as I discussed the issues; the assistance of a former student who now serves as the chief executive of an HMO, who provided me with ideas as I wrestled with ways to bring about a resolution of the conflict, and the chancellor's efforts to resolve the problem, particularly his direct contacts with Jeff Romoff.