Negotiations between Sutter Gould Medical Foundation and a leading Medi-Cal health plan have stalled, which could require patients to find other health care providers.
Health Plan of San Joaquin, a managed-care plan serving Stanislaus and San Joaquin counties, said Tuesday that Sutter Gould wants an almost 30 percent increase in reimbursements to renew a contract that expires Nov. 1.
If an agreement isn’t reached, the health plan said more than 7,000 members who use Sutter Gould clinics will need to choose other doctors or they will be assigned to other primary care providers.
Maria Quintero of Modesto said a Sutter Gould receptionist told her this week she was no longer a patient there. Quintero does have approval for a spinal injection Oct. 20 to treat her pain before the contract expires. She said she hopes the appointment will be honored.
“There are more than 7,000 members who are going to be affected,” Quintero said. “I think both parties should take a look at this and really think about it because it affects a lot of members.”
David Hurst, a spokesman for Health Plan of San Joaquin, said in a news release that discussions continue with Sutter Gould. “We remain committed to trying to avert any disruption in care for our members.”
Hurst said Wednesday the health plan had received calls from members who were “distraught” that their appointments with Sutter Gould were canceled even though the contract remains in effect through this month.
The health plan will work with Sutter Gould to make sure patients receive treatment under the state’s continuity-of-care regulations and contract provisions, especially those undergoing cancer treatment, Hurst said.
In a statement, Sutter Gould said it has been in confidential negotiations with Health Plan of San Joaquin and wants to avoid “any unnecessary disruption and inconvenience to our patients and HPSJ Medi-Cal members.”
Sutter Gould’s statement said that financial losses from serving Medi-Cal patients cannot continue.
“California ranks dead last in the nation in (Medicaid) reimbursement to providers,” Sutter Gould stated. “With nearly 1 in 3 Californians now covered by the Medi-Cal program, those losses are unsustainable. That’s why we are advocating to our legislators to increase Medi-Cal reimbursements.”
Sutter Gould provides health care to thousands of Medi-Cal patients in the Northern San Joaquin Valley as part of its not-for-profit mission, its statement said. Medi-Cal is California’s version of the federal Medicaid program for low-income residents.
Hurst charged that Sutter Gould has a history of seeking reimbursements at a higher level than other medical groups. “We are hopeful that as a nonprofit medical group, their mission-driven charter may move them to continue to serve this largely vulnerable population,” he said.
Quintero, who has lived in Modesto for a year, said she was under the care of Sutter doctors when she lived in the Santa Cruz area, where she had private insurance. She has been unable to work, she said, since suffering an accidental injury and was pleased when Modesto-based Sutter Gould accepted her as a Medi-Cal patient.
Now, she may have to find another doctor.
In Stanislaus County, people on Medi-Cal can choose Health Plan of San Joaquin’s network of physicians and hospitals, or a HealthNet managed-care plan.
In the news release, Hurst noted that the state’s Medi-Cal program has limited resources and increasing enrollment.
“Health Plan of San Joaquin is simply not in a position to meet Sutter Gould’s demands for a nearly 30 percent increase in reimbursement,” Hurst said. “That wouldn’t be sustainable, nor would it be fair and equitable to the hundreds of traditional and safety net providers in our network who are committed to the needs of our Medi-Cal members.”
The health plan said it sent letters this week to affected members, advising them of the status of negotiations and that their Sutter Gould doctor won’t be in the Health Plan of San Joaquin network. It is working with the state Department of Managed Health Care on an orderly transition to prevent disruption of health care services, the release said.
Difficult contract negotiations between managed-care plans and large medical groups are common, sometimes resulting in posturing and letters to patients saying they will need to change doctors. Sutter Gould would remain in Health Plan of San Joaquin’s provider network after Nov. 1 if a new contract is negotiated.
Ken Carlson: 209-578-2321