Highmark could be the industry's next trendsetter

Some of Highmark's trendsetting actions have put the Pittsburgh-based insurer in the national spotlight this year.

Highmark became the first insurer to end coverage of gynecological surgery involving a tool that may actually spread cancer. Ending payments for procedures using morcellators, which are electric, hand-held devices that doctors use to mince tissue, was a "complicated decision," Highmark CEO David Holmberg told the Pittsburgh Business Times.

"We decided to be decisive and stop paying for it until the clinical evidence suggests it's not an issue," he said. "We felt this was an important one for the community we serve." Holmberg added that the insurer ultimately chose to stop coverage because of its commitment to patient care and desire to responsibly manage limited resources.

A few months later, Highmark sued UPMC for overbilling it by $300 million for cancer drugs, claiming that UPMC shifted the billing of cancer-related claims from a doctor's office service to a hospital outpatient service, which costs more. That case, should Highmark win, could have national implications for other insurers seeking to block providers from similar overcharging practices, FierceHealthPayer previously reported.

Highmark alleged that the billing practice can significantly raise costs without boosting quality of care. And Highmark isn't the only insurer with that opinion. The Medicare Payment Advisory Commission called for reimbursement of certain medical services--including cancer care--to be the same, regardless of where the care is provided, the PBT noted.

Since Hollmberg is Highmark's third CEO in two years, it's difficult to predict whether the insurer will continue charting new waters in the industry. But he told the PBT that "we're going to be a leader on the tough issues. We believe the most important thing we can do is to be a leader."

To learn more:
- read the Pittsburgh Business Times article