UPMC and Highmark consent decree: an analysis of the Pittsburgh market and implications for members

The Western Pennsylvania commercial health insurance market is heavily dominated by a select few insurers, including the University of Pittsburgh Medical Center (UPMC) Health Plan and Highmark, Inc. Because of their size and influence, these two multi-billion-dollar organizations are competitors, but from different perspectives. UPMC evolved from being a health care delivery system to an integrated payer-provider, while Highmark began as a Blue Cross Blue Shield health insurer and acquired Allegheny Health Network. In the process of entering new markets, each respective system encroached on the core services of the other organization, disrupting the normal trends of health insurance member enrollment and patient delivery for the Pittsburgh region. This dynamic shift caused failed negotiations for renewal of contracts between the two integrated delivery finance systems, and the establishment of a legal document to determine when Highmark members were eligible to be seen at UPMC facilities. In order to protect members during the contractual dissolution of the two enterprises, certain provisions were enacted for each entity to follow. Known as the UPMC Highmark Consent Decree, this document provides temporary protections for vulnerable populations but expires in 2019. This analysis will discuss the implications for members in the Western Pennsylvania region, the benefits and disadvantages of the decree itself, and a projection for the health care market in Pittsburgh after the contract ends. The importance of public health in this analysis focuses on what the positive and negative implications are for health care insureds in the Western Pennsylvania region. The paper defines what was successful in this process and what could have been improved in order to achieve the optimal result for consumers, providers, and payers in the region. Additionally, this case study will be compared to the national market trends in health care mergers and acquisitions as well as the effects of these trends on market competitiveness and consumer behaviors