Community and Adventist teaming to create Medi-Cal health plan

Community Medical Centers and Adventist Health announced Thursday they are creating a new healthcare network for Medi-Cal patients in Fresno, Kings, Madera and Tulare counties.

The joint-venture health plan, the first of its kind in the central San Joaquin Valley, could mean health care for about 200,000 Medi-Cal managed care patients will come under the umbrella of the two largest hospital-based systems in the Valley.

Eventually, the collaboration could steer children to Community’s downtown Fresno regional medical center, which is building a pediatric sub-specialty network of doctors. Community has been in a fight with Valley Children’s Hospital in Madera County to capture the Valley’s pediatric patients.

The new health plan needs approval by the state, but hospital officials said it could begin coordinating health services by as early as next fall.

The arrangement will build on an agreement Adventist already has with Health Net for the administration of benefits for Medi-Cal patients in Kings County. The Hanford-based Adventist said last week that it had formed an Adventist Health plan, and beginning Jan. 1, it will take over responsibility from Health Net for 13,000 Medi-Cal members. Medi-Cal is the state-federal insurance for the poor.

Community and Adventist are asking the state Department of Managed Health Care to allow them to amend the Adventist Health Plan. The two health systems will remain independent organizations, but the new health plan will be equally financed, jointly owned and operated collaboratively, the hospital officials said.

The joint venture will allow health care to be coordinated to improve the region’s health status, said Jeff Conklin, Adventist Health Plan president and CEO. “The Affordable Care Act encourages everybody to find ways to provide care more efficiently.”

Community and Adventist will need the buy-in of Anthem Blue Cross and Health Net, which have been administering health benefits for Medi-Cal members in the Valley. Community and Adventist would contract with Anthem and Health Net to administer the Medi-Cal health benefits. “We are not in any way intending to compete with Anthem, CalViva, Health Net,” Conklin said. “They hold the Medi-Cal arrangements with the state and we provide care in the community.”

Health Net has said it will retain about 7,000 Kings County members who it manages for CalViva Health, the locally governed Medi-Cal managed care plan for Fresno, Kings and Madera counties. Health Net also administers CalViva benefits in Fresno and Madera counties. In Tulare County, Health Net manages Medi-Cal members who are not under CalViva. Anthem also manages Medi-Cal benefits in Fresno, Kings and Tulare counties.

Anthem spokesman Darrel Ng said the insurer had no comment at this time on the venture between Adventist and Community.

Brad Kieffer, a Health Net spokesman, said Health Net had not seen a formal proposal from the hospital systems, but “we are open to collaborating on the best ways to serve CalViva members and we anticipate there will be future discussions.”

Adventist has said that the 13,000 Kings County members who will be transitioning to Adventist Health Plan beginning Jan. 1 will keep their primary-care doctors and specialists and use the same hospitals. On Thursday, Conklin said health care will be provided locally under the new health plan with Community, but the health systems have yet to establish a network of doctors.

Aldo De La Torre, senior vice president of managed care and strategic alliances for Community, said Valley Children’s likely would not be a part of the network. “There might be a possibility that you will be referred to a pediatric specialist that may be different than you have had in the past,” he said.

Valley Children’s officials were not available for interviews Thursday, but the hospital acknowledged the Community-Adventist collaboration in an email to staff. Valley Children’s signed a managed care contract with Adventist in October, the email said, and continued that officials are “confident we will continue to work with Adventist as their pediatric partner to improve access to pediatric care. In addition, we continue our own discussions with health plans and providers on how we can work together to improve access, reduce cost and, most importantly, improve quality.”

Adventist spokeswoman Christine Pickering said that “Valley Children’s is a provider in our Kings County network. Together with Community, we look forward to expanding our network as we plan for the four counties.”

Community, which operates Community Regional Medical Center, Clovis Community Medical Center, Fresno Heart & Surgical Hospital and Community Behavioral Health Center, will be taking on some risk in managing Medi-Cal Patients. And so is Adventist Health/Central Valley Network, which operates four hospitals and 32 community clinics in the Valley. But both systems already provide a lion’s share of the Medi-Cal care in the Valley, and the collaboration should allow for more economical and appropriate health care, Conklin said.

The Affordable Care Act has added thousands of new people to Medi-Cal in the Valley, De La Torre said. “That influx obviously puts stress on a system, which requires partnerships, collaboration.”

This story was originally published December 17, 2015 at 6:38 PM with the headline "Community and Adventist teaming to create Medi-Cal health plan."