OPTIMA Sets New Provider Guidelines : Health: Board reveals detailed rules for participation for first time. One-of-a-kind program is replacing state-run system.

Health officials revamping Orange County’s Medi-Cal system kicked off the contracting process for medical providers Thursday, declaring they had reached a major milestone but are daunted at how much further they had to go.

The board of directors of OPTIMA, as the locally run system is called, substantially approved the document intended to guide providers in their quests for three-year contracts, unveiling the detailed rules for participation.

OPTIMA is a one-of-a-kind organization that will bring some 300,000 Medi-Cal beneficiaries into managed-care networks, including primary care doctors, specialists and hospitals. The system pays a set fee per member and replaces a state-run, fee-for-service program that critics say doctors too little and is loaded with red tape.

Becoming part of the new program, however, will involve some legwork for prospective providers, who must turn in their applications by Feb. 15. Contract awards will be announced the following month.

Even some board members said they were surprised at the complexity of the application and were worried about providers inexperienced with managed care meeting what one official termed its “very complex” requirements.

To help applicants, a conference was scheduled for Dec. 19, and technical assistance workshops also were scheduled. But the board seemed most concerned about OPTIMA’s own ability to meet the challenge of bringing a substantial portion of the county’s 300,000 Medi-Cal members into the program as early as next summer. Members will be enrolled beginning in July.

“How in the world do you have a management plan, to say that in eight, nine months you’re going to be able to handle 220,000 people?” asked Arthur Birtcher, the board’s vice chairman. “I am very concerned about that. I really don’t see how we can do it.”

OPTIMA’s executive director, Mary Dewane, said she “in part” shared Birtcher’s concern but added that, with the help of consultants, she believes the organization can meet the timetable.

“I believe that this is doable or we would not have advanced it,” she said.

The criteria approved by the board require any provider networks that participate to include a significant portion of traditional Medi-Cal providers--those who have been serving the Medi-Cal population all along. OPTIMA officials have said they do not want to destroy existing relationships between Medi-Cal patients and their doctors, but want to expand patient choices and access to care.

In addition, the board made special accommodations for about a dozen hospitals in the county that traditionally have served a significant number of Medi-Cal and indigent patients, allowing them to enroll unlimited numbers of members under OPTIMA. Other hospitals in the OPTIMA program generally will be limited to 10,000 members each.

Managed-care networks must be prepared to enroll at least 10,000 members, and their cap will be 30,000 members.

“One of the policy goals is to make sure patients have substantial access and choice by placing a lid, if you will, on the number of lives handled by any group,” said Mike Stockstill, OPTIMA public affairs director.

Mary Piccione, executive director of UCI Medical Center in Orange, thanked OPTIMA officials at the meeting for all their hard work, but she urged the organization to be cautious during the transition from the fee-for-service program to managed care. She said she feared that the existing system for poor patients could “fall apart” if it is not carefully nurtured in coming months.

“Physicians are taught, first and foremost, to do no harm,” she said. “I think in this program, these words cannot be better abided by.”