New Medi-Cal contract gives Clinicas more autonomy [Ventura County Star, Calif.]

Oct. 17--After negotiations that started more than a year ago, a contract has been finalized giving a private clinic network more control over the care of its 14,000 Medi-Cal patients.

The new contract was announced this week by the Gold Coast Health Plan, which administers Medi-Cal for 100,000 people in Ventura County. It gives Clinicas del Camino Real more Medi-Cal compensation in return for more responsibilities and an increased share of financial risks previously shouldered by Gold Coast.

Clinicas, a nonprofit organization, runs clinics across the county aimed at underserved populations, including low-income families and disabled people who qualify for Medi-Cal.

"When organizations share that risk, there's better care provided and access is increased," said Roberto Juarez, CEO of Clinicas.

The new contract revolves around patients' access to cardiologists, urologists and other specialists. In the old arrangement, referrals from Clinicas' primary care doctors to specialists had to be approved by Gold Coast, which also paid the specialty doctors.

In the new contract, Gold Coast pays Clinicas a larger monthly fee for each Medi-Cal member assigned to the clinic network. Clinicas, which already pays the primary care doctor out of the monthly payments, will now manage and approve its own referrals to its own network of specialists. Clinicas will also be responsible for paying the specialists.

"If they manage the specialty services very efficiently, they can make some money," said Michael Engelhard, CEO of Gold Coast. "If they don't manage it very efficiently, they can lose money."

Engelhard said the money paid to Clinicas in the new contract is equivalent to what Gold Coast in the past paid separately to the clinic network and its specialists.

Clinicas is the first clinic system in Ventura County to establish what is called a shared-risk Medi-Cal contract. Juarez, who is vice chairman of the commission that governs Gold Coast, said the model is used regularly elsewhere. It reduces the burden on Gold Coast and allows Clinicas to manage the care of its own patients, he said.

"It's forward-thinking," said Dr. Robert Gonzalez, director of the Ventura County Health Care Agency, which runs its own clinic system and two hospitals. He said the agency is analyzing different contract models that include ways of sharing risk with Gold Coast.

"It's a type of extension of managed care that most providers would be interested in," said Gonzalez, also chairman of the county's Medi-Cal commission. "It gives you more control of management of care and the health care dollar."

Gold Coast launched its managed care Medi-Cal services to Ventura County residents in July 2011. Concerns about Gold Coast's operations caused state officials to assign an outside monitor to work with the plan. Resignations and dismissals created leadership holes in the plan's administrative team.

Plan leaders say they are on the road to recovery, improving their payment issues and rebuilding their leadership team. Hired from one of the state's largest public health insurance plans, Engelhard took over as CEO in September.

The early troubles played a role in extending negotiations with Clinicas over the shared-risk contract, Engelhard said.

"To be honest, we had such turmoil ... we just didn't have the right executive staffing to see this to completion," he said.

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