The University of Pittsburgh Medical Center (UPMC) is the predominant health care provider in western Pennsylvania with 40 hospitals and $19 billion in revenue. Highmark is a health care company that provides health, dental and eye insurance plans with 4.5 million members. Until approximately 2011, UPMC accepted Highmark’s insurance plans, including its Medicare Advantage Plan. What happened in 2011 is that Highmark Health was born in the purchase by Highmark of West Penn Allegheny Health System for about half a billion dollars. Thus, Highmark and its current network of eight hospitals and 2,400 staff physicians now competes head-to-head with UPMC. UPMC responded to the 2011 transaction the next year by deciding that it would no longer accept Highmark’s insurance (mind you, UPMC offers its own health plans covering more than three million individuals so it seems that neither Highmark nor UPMC is, as it were, “staying in their lane”). The narrow dispute relevant to this article arose from UPMC’s decision to no longer accept Highmark’s insurance.

Pennsylvania’s then-attorney general (AG) stepped in anticipating that the predominant provider refusing to accept insurance from a major insurer would have negative effects on patient care. After two years of talks, in 2014, UPMC and Highmark signed consent decrees along with the AG’s office and Pennsylvania’s Department of Health and Insurance Department. The consent decrees focus on granting in-network access for certain populations within Highmark’s membership (such as seniors) to certain of UPMC’s unique or exceptional providers and hospitals.

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