Out of Network, Out of Luck

By Theresa Brown
The New York Times, October 12, 2013

For several hundred patients at the University of Pittsburgh Medical Center, it started with a certified letter informing them that they were no longer allowed to see their physicians. The reason? They were unlucky enough to have insurance called Community Blue, which is offered by a rival hospital system. Astoundingly, they were barred even if they could pay for the care themselves.

One patient, in the middle of treatment for lung cancer, said at a hearing before a State House of Representatives committee that she was prohibited from seeing her U.P.M.C. oncologist. Another, with the debilitating autoimmune disease scleroderma, said she was dismissed from the U.P.M.C. Arthritic and Autoimmune Center. A third, a five-year breast cancer survivor who needs follow-up care every six months, was cut off from the doctor who had been with her since she was first given her diagnosis.

Community Blue is sold by a company called Highmark. Like U.P.M.C., it is both a hospital system and an insurance provider, part of a growing trend toward vertical consolidation in the two industries. These and other companies insist that such consolidation streamlines the caregiving system and thus benefits the patient. But in the short term, they are waging a vicious war over patients — and as the experience in Pittsburgh shows, it’s often the patients who are losing.

Historically, U.P.M.C. was the biggest health care provider in Pittsburgh and Highmark the largest insurer. U.P.M.C., though, has been selling its own brand of insurance for over a decade, and Highmark recently affiliated with a local multisite hospital system, now known as the Allegheny Health Network.

U.P.M.C. responded to the formation of the Allegheny Health Network by labeling Highmark a competitor and a threat to its financial sustainability. It has also announced that its current contract with Highmark will not be renewed, meaning that in December 2014 almost all U.P.M.C. hospitals will be open to Highmark customers only at out-of-network rates, which are among the highest in the country.

At the same time, U.P.M.C. is running an aggressive ad campaign for its own health insurance plan, and Highmark subscribers with Community Blue have been denied access to their U.P.M.C. physicians.

More health systems nationally are following the lead of U.P.M.C. and Highmark, combining health insurance with the provision of care itself.

The worry is that integration will yield not better care but higher profits achieved through monopolistic consolidations and self-serving business practices.


Integrating health care is a great concept that theoretically should improve coordination of care, reduce duplication, provide incentives to meet quality and outcome targets, improve access to appropriate specialized care – in general, improving quality while reducing costs. That is the idea behind the Accountable Care Organizations established by the Affordable Care Act. How is it working out in the real world?

We’ve watched as insurers have consolidated. Although they tout that they are providing higher quality at lower costs through managed care, in fact they have used their oligopolistic leverage to limit patient access to their selected network providers. Although they contend that they are selecting the highest quality providers, in fact, they are excluding quality institutions such as academic medical centers and going with the cheapest contracts they can extract from the health care community.

In response, we are witnessing an explosion in consolidation of health care providers – hospitals and physician groups – often into single entities. Obviously this results in “must have” groups that in turn have leveraged their oligopolistic negotiating power in dealing with the insurers.

Not to be outdone, we are now seeing insurers and consolidated health care systems joining together to increase their control of markets, and thereby share in the spoils. When you see patients with lung cancer, breast cancer, and scleroderma being cut off from their care strictly on the basis of realignment of the health care business models, you can dismiss the concept that these changes are changes that are designed to benefit patients. The ugly competition that is taking place between Physician-hospital-insurer entities (Phi) is cutthroat and certainly not in the patients’ best interests. (Phi seems to be an appropriate symbol for these entities since, in Lacanian psychoanalysis, it is the symbol for “the phallic function.”)

The Affordable Care Act very specifically was designed to keep control in the private sector. Private sector business models will always do what they are designed to do – anything to make more money. If we really do want a system designed to provide the best care possible with our available resources, we need to dismiss the private insurers and put our own public stewards in charge. They would have the responsibility of answering to us.