UPMC’s Altoona situation unique
On Monday, the same day as Altoona Regional Health System becomes part of UPMC, St. Vincent Health System in Erie will become part of Highmark’s Allegheny Health Network.
That means that on the same day that UPMC becomes virtually the sole provider in Blair County, it faces a much-reinforced rival in Erie County, where in 2011 UPMC acquired Hamot Medical Center.
And while UPMC has said repeatedly that its acquisition of Altoona Regional most resembles that of Hamot, the rivalry with St. Vincent in Erie and the lack of a rivalry here is a key difference.
That difference is what accounts for UPMC’s plans to try to strike a deal with Highmark to provide access for Highmark subscribers here, even as it plans to shut out access for Highmark subscribers in most of the rest of its territory, where there are credible alternatives, as in Erie.
In recent months, UPMC has virtually declared war with Highmark, after Highmark began putting together its Allegheny Health Network, which like UPMC’s system is an integrated delivery setup that includes both a wide range of medical facilities and insurance plans.
The war is over what UPMC said is Highmark’s announced intention to “steer” 41,000 patients from UPMC to its own network – an exodus in what is necessarily a “zero sum” game that would be damaging to UPMC, with layoffs and hospital closures, according to a recent UPMC op-ed in the Pittsburgh Post-Gazette.
A contract with Highmark for access to all UPMC facilities would only aid and abet that “steer and tier” effort, which Highmark would skew against its rival with “high co-pays, co-insurance and deductibles, presenting only the illusion of in-network access,” the op-ed stated.
Therefore, “UPMC and Highmark will compete head-to-head as integrated systems, each with its own insurance arm providing in-network access to a different group of hospitals and physicians,” stated G. Nicholas Beckwith III, chairman of the UPMC board of directors in the op-ed.
The rhetoric in that manifesto contrasts with UPMC’s arguments a few months ago when asked about suggestions that Hamot steered childhood diabetes patients away from St. Vincent’s, as described in an Erie Times News story cited by unionized Altoona Regional nurses questioning UPMC “business practices.”
At that time, in that context, UPMC didn’t cite the need to compete against a hospital rival.
Rather, it explained its actions by saying that for all patients at all times, it makes recommendations for care based only on patients’ best medical interests.
The story describes the cases of Amanda White, whose daughter Alashija Bishop is an epileptic and type 1 diabetes patient; and Pasha Huston, whose daughter Madyson was a newly diagnosed diabetes patient.
UPMC Hamot in Erie sent Alashija repeatedly to UPMC’s Children’s Hospital of Pittsburgh, for lack of an in-house pediatric endocrinologist at Hamot – despite the presence of two pediatric endocrinologists a mile away at St. Vincent’s Hospital, including board-certified Dr. Luis Aparicio, according to the Times-News story. Hamot was planning to send Madyson to Children’s Hospital, but ended up advising her to go to St. Vincent’s only because there was a snowstorm that day that prevented an ambulance from coming up from Pittsburgh to get her.
In Alashija’s case, the trips to Pittsburgh were an expensive hardship on the family. In Madyson’s case, they threatened to be.
Dr. Luis Aparicio, the certified pediatric endocrinologist at St. Vincent’s Hospital in Erie, told the Mirror he thinks UPMC has ordered all its employed family doctors in Erie to keep referrals in-network and not to refer patients to Aparicio and his non-board-certified partner Joseph Hines.
And that would be OK, except that Hamot doesn’t have a pediatric endocrinologist in Erie, Aparicio said.
That has led to patients like Alashija and Madyson going to Children’s in Pittsburgh unnecessarily, according to Aparicio.
It’s only the rare, “very, very, very ill child who needs something we may not have here in Erie,” he said.
UPMC practices “aggressive competition,” Aparicio said.
“I can’t say if it’s ethical or not,” Aparicio said of the in-network issues. “Maybe in their hearts they really believe they have to send this patient to Pittsburgh.”
It’s not as if Hamot has had a problem with his services, he said.
He dropped his privileges at Hamot after the UPMC takeover there in 2011, believing the hospital was marginalizing and taking advantage of him by referring endocrinology patients to UPMC-employed doctors, where possible, and keeping him mainly as a backup.
“We didn’t see the love,” he said.
Since his break with Hamot, there has been a “complete shutdown of any new type 1 diabetes children being referred to us,” he said.
“It’s sad” to run hospitals like corporations, where “everything is the dollar,” he said.
Pasha Huston is the mother of 12-year-old Madyson Huston, who would have gone by ambulance to Children’s in Pittsburgh from Hamot the day after Christmas, except for the snowstorm.
Pasha and her husband originally thought Madyson had thrush, but her family doctor suspected diabetes and sent her to Hamot.
The family doctor was right, but Hamot found she wasn’t in ketoacidosis, a potentially life-threatening complication of diabetes, Pasha said.
Still, Hamot wanted to send her to Children’s.
So Pasha’s husband left the hospital to arrange for someone to take care of his plow route and their dog, with the understanding he would meet them in Pittsburgh.
But the Pittsburgh-based ambulance couldn’t leave the city because of the snow.
So Hamot personnel eventually let her know there was an endocrinologist across town at St. Vincent’s.
They discharged Madyson, and suggested the family drive Madyson over.
Hines came to St. Vincent’s through the storm and took care of the girl, Huston said.
Madyson remained there four days.
The first couple weeks after that, Hines adjusted her insulin, and there were repeat visits.
Madyson has been back to Hines about five times.
She adapted well to her medications and learned to handle the testing and give herself injections.
“She’s fabulous now,” Huston told the Mirror.
Had they gone to Pittsburgh on the day of the snowstorm, they would have had to pay for hotel and gas, find someone to take care of their other two children and miss work, Huston said.
“It’s nice knowing [St. Vincent’s] is right here in Erie, 20 minutes away” – especially if there’s an emergency, she said.
“I think it sucks,” Huston said of the apparent policy represented by Hamot’s original plans to send Madyson to Pittsburgh.
Aparicio is wrong in saying things have changed and Huston is wrong in thinking local care is a substitute for what’s available for childhood diabetics in Pittsburgh, according to Dr. Dorothy Becker, director of the diabetes program at Children’s.
Diabetic patients have been coming from Erie to Children’s for decades, and the staff hasn’t noticed any difference since the UPMC takeover at Hamot, except for a decline associated with the economy tanking several years ago, Becker said.
Some Erie doctors recommend it, sometimes as soon as they diagnose diabetes, and some don’t – and some patients choose to come, and some don’t, Becker said, stressing that she was speaking based on her impressions, rather than hard data.
Many children with new-onset diabetes go into ketoacidosis, and all who do are at risk of death, she said.
“Those kids should be treated in a tertiary care facility,” she said. “One with availability to diabetic experts and intensive care.”
It’s “well-documented” that the more experienced the center, the lower the mortality, she said.
And for any new-onset child diabetic, education is critical, Becker said.
“That’s where we do have a pretty unique situation in Pittsburgh,” Becker said. “We have a phenomenal educational team.”
That team is more important than the doctors, she said.
Education begins at “day one” and stays with pediatric diabetics the rest of their lives in the form of good habits, she said.
“If we don’t get them in the first couple weeks,” when things sink in better, “we never catch up,” she said.
The pediatric education team of dieticians and nurses does it step-by-step, patient-by-patient, all day, every day, she said.
Patients’ learn twice a day or daily for the first few weeks and continue to learn for months, and the tight control they can exert prevents or delays complications, according to Becker.
The program is known internationally, and people gravitate from around the world to work in it, she said.
Her predecessor, Dr. Allan Drash, who died four years ago, “set the model going,” and the rest of the world has followed, she said.
The program is still getting better, and mortality for childhood diabetes over the past four decades has plummeted, she said.
The latest epidemiological cohort from the 1970s shows that kids from that era who grew up with diabetes are living as long as others from their generation.
“We know we can make them healthy parents,” she said. “I’m in the business of making these kids healthy grandparents.”
Children’s has 13 pediatric endocrinologists, who discuss and argue and “keep each other honest,” she said.
That helps when treating a disease as complicated as diabetes, whose literature is too extensive for anyone to know completely, she said.
The program may be more expensive in the short run, insurance doesn’t pay for most of it, and the hospital loses money for most or maybe all of the program’s patients, she said.
And it can be a hardship for families to drive to Pittsburgh, she acknowledged.
“But if in the long run, it keeps people alive” she said.
It makes sense “to go to Mecca,” especially if it’s not that far away, she said.
As for keeping patients “in-network,” she refers patients to the care that’s best for them, whether that is at UPMC or not, she said.
“No one’s forcing people,” she said.
Keeping patients “in-network” through referrals and recommendations is both a health care provider and insurance issue, according to David Dausey, a public health professor at Mercyhurst University in Erie.
All health care organizations do it, he said.
“Anybody who says it’s not going on is not in the real world,” he said.
Organizations look out for their own financial interests, he said.
But they tend not to talk about it, because it isn’t “politically correct,” because it can hurt their reputations with the public and can even endanger their nonprofit status, he said.
“You end up with strategic misinformation,” he said.
Changes in patterns can be “insidious,” he said.
To get the truth, it’s better to look at actions, rather than words, he said.
“UPMC is extra-sensitive to these things,” he added.
Still, it’s hard to argue with an organization like UPMC when it says it always steers patients with their best medical interests in mind, he said.
UPMC has “superior care,” and while referrals within its system might not be convenient or inexpensive, they almost always lead to top-notch treatment, he said.
“It would be very, very difficult to prove otherwise,” he said.
Mirror Staff Writer William Kibler is at 949-7038.