Document:

Exhibit
10.159

 

AMENDMENT TO

MEDICARE+CHOICE PHYSICIAN GROUP SERVICE AGREEMENT

 

This
Amendment is entered into effective December 1,
1999, by and between California Physicians’ Service, Inc. dba Blue Shield of California (“Health Plan”)
and NorthWest Orange County Medical Group (“Physician
Group”) in order to modify the Medicare+ Choice Physician Group Service
Agreement, which was effective September 1, 1990, as amended.

 

In
consideration of the recitals, covenants, conditions and promises contained in
the Agreement, the parties agree that the Agreement is hereby amended as
follows.

 

1.                                       Effective September 1, 1999, Anaheim
Memorial Medical Center purchased Martin Luther Hospital. Anaheim Memorial
Medical Center incorporated Martin Luther Hospital into its State license on a
retroactive basis effective September 1, 1999.  As of December 1, 1999, all
references to “Martin Luther Hospital” in the Agreement shall now be references
to “Anaheim Memorial Medical Center.”

 

2.                                       All other provisions of the Agreement or its
Amendments or Addendums not inconsistent herein shall remain in full force and
effect.

 

IN
WITNESS WHEREOF, the parties hereto have executed this Amendment as of the date
and year first written above.

 

	
  BLUE SHIELD OF CALIFORNIA

  	
  NORTHWEST ORANGE COUNTY

  
	
   

  	
  MEDICAL GROUP

  
	
   

  	
   

  
	
  By:

  	
    /s/ Lisa
  Rubino

  	
   

  	
  By:

  	
    /s/  Pratibha Patel

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
    Lisa Rubino

  	
   

  	
  Name:

  	
    Pratibha
  Patel

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title

  	
    Chief
  Executive Officer – Medicare Region

  	
   

  	
  Title:

  	
    President

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
    7/13/??

  	
   

  	
  Date:

  	
    11/8/99

  

 

1Exhibit 10.160

 

 

AMENDMENT
TO

MEDICARE+CHOICE PHYSICIAN GROUP SERVICE AGREEMENT

 

This Amendment is entered
into effective December 1, 2000,
by and between California Physicians’ Service, Inc. dba Blue Shield of
California (“Health Plan”) and NorthWest Orange County Medical Group (“Physician
Group”) in order to modify the Medicare+Choice Physician Group Service
Agreement (“Agreement”), which was effective September 1, 1990, as
amended.

 

In consideration of the
recitals, covenants, conditions and promises contained in the Agreement, the
parties agree that the Agreement is hereby amended as follows:

 

1.                                Effective
December 1, 2000, Attachment A-1, Matrix of Financial Responsibility for
Anaheim Memorial Medical Center, and Attachment B-1, Fund Allocation and Risk
Sharing for Anaheim Memorial Medical Center, are replaced with Attachment A-2,
Matrix of Financial Responsibility for Anaheim Memorial Medical Center, and
Attachment B-2, Fund Allocation and Risk Sharing for Anaheim Memorial Medical
Center. These two Attachments are attached hereto and incorporated herein by
reference.

 

2.                                Effective
February 1, 2001, Attachment A-2, Matrix of Financial Responsibility for
Anaheim Memorial Medical Center, and Attachment B-2, Fund Allocation and Risk
Sharing for Anaheim Memorial Medical Center, are replaced with Attachment A-3,
Matrix of Financial Responsibility for West Anaheim Medical Center, and
Attachment B-3, Fund Allocation and Risk Sharing for West Anaheim Medical
Center. These two Attachments are attached hereto and incorporated herein by
reference.

 

3.                                Effective
February 1, 2001, Section 14.2, Termination, is amended to read in
full as follows:

 

“Termination. During the one
(1) year term effective February 1, 2001, through January 31, 2002,
Physician Group shall not terminate this Agreement except in the event of
material breach and failure to cure as set forth in Section 14.7 or in the
event of any of the conditions listed in Section 14.4 below. After this
one (1) year initial term either party may terminate this Agreement without
cause by giving the other party at least ninety (90) calendar days written
notice. The obligation of Physician Group to provide Capitated Services
following the effective date of termination will be as set forth in
Section 14.5.”

 

4.                                All other
provisions of the Agreement or its Amendments or Addendum’s not inconsistent
herein shall remain in full force and effect.

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

 

*** Confidential Information omitted and filed separately with the
Securities and Exchange Commission.

 

1

 

IN
WITNESS WHEREOF, the parties hereto have executed this Amendment as of the date
and year first written above.

 

 

	
  BLUE
  SHIELD OF CALIFORNIA

  	
  NORTHWEST
  ORANGE COUNTY

  MEDICAL GROUP

  
	
   

  	
   

  
	
   

  	
   

  
	
  By:

  	
  /s/ Lisa Rubino

  	
   

  	
  By:

  	
  /s/  Pratihba Patel, MD

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Lisa Rubino

  	
   

  	
  Name:

  	
  PRATIHBA PATEL, MD

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  Senior Vice President/Chief

  	
   

  	
  Title:

  	
  PRESIDENT

  
	
   

  	
  Executive, Medicare / Government

  	
   

  	
   

  	
   

  
	
   

  	
  Health Plans

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  12/05/00

  	
   

  	
  Date:

  	
  11/27/00

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  PREMIER PHYSICIAN SERVICES LLC

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
   

  	
   

  	
  By:

  	
  /s/ James P. Agronick

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Name:

  	
  JAMES P. AGRONICK

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Title:

  	
  CHIEF EXECUTIVE OFFICER 

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Date:

  	
  11/27/00

  

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

2

 

ATTACHMENT
A-3

 

MATRIX
OF FINANCIAL RESPONSIBILITY

 

This matrix of financial responsibility outlines
the distribution of financial responsibility among Hospital, Physician Group
and Health Plan. It is not exhaustive, but serves as a guide by which broad
categories of medical services are used to identify the distribution of
financial responsibility for particular services. All Covered Services which
are the financial responsibility of the Hospital as set forth in this
Attachment are Shared Risk Services. This matrix also delineates Capitated
Services between Hospital and Physician Group.

 

	
  Hospital:

  	
   

  	
  West
  Anaheim Medical Center

  
	
   

  	
   

  	
   

  
	
  Physician Group:

  	
   

  	
  NorthWest
  Orange County Medical Group

  

 

A.                                    Inpatient Services, Ambulatory
Surgery and Major Diagnostic Procedures

 

This heading includes facility and all
ancillary/non-professional charges for Covered Services provided to inpatient
and day surgery patient in a licensed facility, including inpatient hospital
acute, sub-acute or skilled nursing facility services, including room and board
and ancillary services. It includes facility and ancillary/non-professional
charges related to ambulatory surgery or ambulatory diagnostic/therapeutic
procedures (e.g., endoscopy, bronchoscopy, laparoscopy, angiography, etc.)
requiring a surgical or other specialized suite or general anesthesia. It
includes pre-operative and pre-admission testing. It includes Covered Services
provided by facilities other than Hospital and services provided by out-of area
providers upon referral.

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  1.                                       Acute
  Hospital Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2.                                       Intensive
  Care Units and Coronary Care Units

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3.                                       Hospital
  Surgical Unit

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4.                                       Sub
  Acute Hospital Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5.                                       Skilled
  Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  6.                                       Inpatient
  Hospice

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  7.                                       Inpatient
  Medications

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  8.                                       Surgically
  Implanted Prosthesis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  9.                                       Nursing
  Services (including special duty)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  10.                                 Lithotripsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

 

*** All references to the matrix of financial responsibility have been
deleted.

 

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  11.                                 Discharge
  Medications (5 days)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  12.                                 Ambulatory
  Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  13.                                 Psychiatric
  Day Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  14.                                 Facility
  Component of Cataract Surgery (inpatient and outpatient including lens
  implant)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

B.                                    In Area Emergency Room Services

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  1.                                       Emergency
  Room / Treat & Release

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a - Facility /Ancillary

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b - ER Physician

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  c - HBP Professional
  (lab/rad/card/etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.                                       Emergency
  Room—Within 24-hours of admission

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a - Facility /
  Ancillary

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b - ER Physician

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  c - HBP Professional
  (lab/tad/card/etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

C.                                 Professional Services Including Hospital Based Physicians and
other Specialty Physicians

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  1.                                       Anesthesiologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a -
  Surgical / Other Procedure Anesthesia Inpatient and Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b -
  Pain Management / Inpatient and Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.                                       Radiologist—Diagnostic
  Interpretation, Interventional Procedures and Radiation Therapy Including
  Implants

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a -                                                      Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b -                                                     Outpatient
  Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  c -                                                      Physician
  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

 

*** All references to the matrix of financial responsibility have been
deleted.

 

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  3.                                       Pathologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a - Anatomical
  Pathology Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  1 - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2 - Outpatient (inc Pap
  Smears)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b - Clinical Laboratory
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  1- Pre-Admission

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2 - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3 - Outpatient Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4 - Physician Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  4.                                       Neurologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a - Inpatient EEG, EMG
  and NCS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b - Outpatient EEG, EMG
  and NCS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  5.                                       Nephrologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a - Dialysis
  Professional Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b - Other Professional
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  6.                                       Cardiologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a - Inpatient and Hospital Outpatient Diagnostic
  Procedures (e.g. ECG, treadmill, holter, echocardiagram, wall motion,
  thallium scan, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b - Physician Office Diagnostic Procedures (e.g.
  ECG, treadmill, holter monitor, echocardiogram, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  7.                                       Pulmonology
  / Respiratory Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a -
  Inpatient Diagnostic Services (e.g., PFT/Blood Gas/Apnea Eval/etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b -
  Outpatient Hospital Diagnostic Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  c -
  Physician Office Diagnostic Procedure

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  8.                                       Interventional
  Professional Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a - Interventional Cardiology (e.g. PTCA,
  angiography, percutaneous, valvuloplasty, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b - Interventional Gastroenterology (e.g. ERCP,
  endoscopy, percutaneous, biopsy, drainage, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  c - Interventional Radiology (angioplasty,
  embolization, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  d - Bronchoscopy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

 

*** All references to the matrix of financial responsibility have been
deleted.

 

F.                                      Other Professional and Ancillary Services

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  1.*                                Home Health Care
  (professional medication, supplies) and respite care  

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.                                       Durable
  Medical Equipment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.                                       Prosthetic
  Devices (includes initial pair of frames and lenses following cataract
  surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  4.                                       Supplies
  (except as used in physicians’ office)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  5.                                       Health
  Education Programs (including literature and course offerings):

   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a - Programs offered by Hospital on an inpatient or
  outpatient basis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b - Programs offered in physicians’ office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  6.                                       Dietary
  counseling and education

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a -
  inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b -
  outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  7.                                       Psychiatric
  services and mental health counseling services including alcoholism and CD
  rehabilitation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  8.                                       Social
  services and discharge planning

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  9.                                       Physical
  rehabilitation services, including physical, occupational, speech therapy and
  rehabilitation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a -
  inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b -
  outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  10.                                 Outpatient
  Dialysis (Tech. Fac., Supp. & Meds)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  11.                                 Medical
  transportation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  12.                                 Cardiac
  Rehabilitation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a -
  inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b -
  outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  13.                                 Facility
  component for fluorescein angiography and all treatments with lasers

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

* Note: Home Health Care,
which is in lieu of outpatient care or ambulatory care (i.e. Chemotherapy, transfusions
and neuro-rehab), will remain the financial responsibility of the provider
responsible for that outpatient care or ambulatory care service as stated in
the Matrix of Financial Responsibility.

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

 

*** All references to the matrix of financial responsibility have been
deleted.

 

 

	
  14.                                 Chemotherapy
  treatment including medications and administration not including oncologist
  professional fees

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a -
  inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  b -
  outpatient (includes treatment in home health settings)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  15.                                 Other
  services considered to be customarily a hospital inpatient service

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  16.                                 Radiation
  therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  a -
  outpatient technical

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  17.                                 Outpatient
  hospital Respiratory Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

G.                                    Out-of-Area
Services 

 

H.                                    Other
Services

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  1.                                       Outpatient Prescription
  Drugs  

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.                                       Routine
  Refractions and Eye glasses 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

I.                                         Excluded
Situations and Procedures—Any service not covered pursuant to the Evidence of
Coverage.

 

In the event financial
responsibility for a service is not established by the above, services
generally paid for under Medicare Part B will be considered a Physician Group
Capitated Service, services generally paid for under Medicare Part A will be
considered a Hospital Capitated Service and services not covered under Medicare
Part A or Part B will be considered a Physician Group Capitated Service.

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

 

*** All references to the matrix of financial responsibility have been
deleted.

 

 

D.                                    Laboratory, X-Ray and Diagnostic Procedures (Technical
Components)

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  1.                                       Pre-admission
  and inpatient laboratory, x-ray, ECG and other diagnostic services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.                                       ER laboratory,
  x-ray, ECG and other diagnostic services-treat & release

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.                                       ER laboratory,
  x-ray, ECG and other diagnostic services (within 24-hour admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  4.                                       Outpatient lab

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  5.                                       Non-invasive
  outpatient diagnostic procedures including all chest and skeletal x-rays,
  routine CT scans and routine MRIs.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  6.                                       Invasive
  outpatient diagnostic treatment services (e.g. angiography, endoscopy). This
  excludes outpatient radiology and pathology services.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  7.                                       Outpatient MRI,
  CT, fluoroscopy, ultrasound, mammography, and nuclear medicine studies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

E.                                      Physician Services (not including those services described
under Section C)

 

	
   

  	
   

  	
  HOSP

  	
   

  	
  PHYS

  GRP

  	
   

  	
  HP

  	
   

  
	
  1.                                       Primary
  care office visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.                                       Outpatient
  specialty consultations and interpretations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.                                       Inpatient
  primary care and consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  4.                                       Office surgical
  procedures

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  5.                                       Physician office
  outpatient ECG services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  6.                                       Office
  laboratory

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  7.                                       Outpatient chest
  and skeletal x-rays

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  8.                                       Office visual examinations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  9.                                       Office hearing
  evaluation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  10.                                 Emergency Room
  Physician Fees

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  11.                                 Routine physical
  exams and evaluation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

 

*** All references to the matrix of financial responsibility have been
deleted.

 

 

ATTACHMENT B-3

 

FUND ALLOCATION AND RISK SHARING

 

	
  Hospital:

  	
   

  	
  West Anaheim Medical Center

  
	
   

  	
   

  	
   

  
	
  Physician Group:

  	
   

  	
  NorthWest Orange County Medical
  Group

  

 

1.                                  Allocation of HCFA Capitation.   Each month, Health Plan shall allocate the
gross capitation that it receives from HCFA, on behalf of Enrollees affiliated
with Hospital and Physician Group, as follows:

 

	
  Hospital
  Capitation

  	
   

  	
  ***

  	
   

  
	
  Physician
  Group Capitation

  	
   

  	
  ***

  	
   

  
	
  Pharmacy
  Capitation

  	
   

  	
  ***

  	
   

  

 

•                                          Hospital capitation shall be paid to
Hospital.

 

•                                          Physician Group capitation shall be paid to
Physician Group.

 

•                                          Pharmacy capitation shall be retained by
Health Plan to pay expenses of providing the outpatient prescription drug
program.

 

2.                                       Shared Risk
Program Between Hospital and Physician Group.   As
an incentive to control hospital service utilization a shared risk program
shall be established exclusively between the Hospital and the Physician Group.
A copy of the shared risk agreement between Hospital and Physician Group shall
be furnished to Health Plan.

 

2.1                                 Shared Risk Services—Definition.   The following are Shared Risk Services:

 

All Covered Services which are the financial responsibility of the
Hospital as set forth in Attachment A-3.

 

***

 

	
  Initials    

  	
  /s/ [ILLEGIBLE]

  	
   

  	
  [ILLEGIBLE]

  

 

21

 

*** Physician Group agrees to establish reserves
in lieu of withhold, which reflect Physician Group’s potential liability to
Hospital under Shared Risk Program.

 

***

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

22

 

***

 

2.7                               Copayments and COB. Copayments payable for Covered Services
shall be deducted from shared risk costs. Amounts payable, for Coordination of
Benefits or worker’s compensation shall be deducted from shared risk costs, up
to the amount of shared risk costs for the particular service. Amounts actually
received by Hospital through third party liability recoveries for Shared Risk
Services shall be deducted from shared risk costs in the period in which such
payment is actually received, up to the amount of shared risk costs for the
particular service.

 

***

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

23

 

***

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

24

 

***

 

3.                                       Pharmacy Risk Sharing
Program. Health Plan
shall establish a pharmacy budget. Health Plan shall pay all covered pharmacy
claims and pharmacy benefit administrative costs payable to third parties
(pharmacy costs).

 

3.1                                 Pharmacy Fund Settlement.  Within one hundred and twenty (120) days
following the end of each calendar year, there shall be an accounting of the
pharmacy budget and pharmacy costs. Such accounting shall include an estimate
of incurred but not reported (IBNR) claims.

 

3.1.1                        Pharmacy Deficit. In
the event that pharmacy costs exceed
the pharmacy budget, fifty percent (50%) of such deficit shall be paid by
Physician Group through direct payment to Health Plan, through funds payable to
Physician Group pursuant to the shared risk program outlined above, and/or
through a reduction in Physician Group capitation sufficient to fund fifty
percent (50%) of such deficit in six months.

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

25

 

3.1.2                        Pharmacy Surplus. If pharmacy costs are less than the pharmacy
budget, fifty percent (50%) of such surplus shall be paid by Health Plan to
Physician Group.

 

4.                                Reports and Timely Settlement.

 

Health Plan shall be responsible for
maintenance of records and development of reports required for administration
of the risk sharing programs outlined herein. Within thirty (30) days
following the end of each calendar year of this Agreement, Health Plan shall
prepare an interim report of the status of the Shared Risk Program for such
year (Shared Risk Period). Such report shall include a calculation of the
Shared Risk Budget and Shared Risk Costs incurred during the Shared Risk
Period. Such calculation shall also include an adjustment for Claims Carried
Forward.

 

Physician Group shall have thirty (30) days
following the receipt of reports to review such final reports produced
by Health Plan. Absent objections in such thirty (30) day period, the final
reports shall be considered acceptable and all payments due pursuant to such
reports shall be made or, in the case of deductions from capitation, shall
commence within fifteen (15) days following the acceptance of such reports or
the expiration of the thirty (30) day review period.

 

	
  Initials    

  	
  /s/ 

  	
   

  	
   

  

 

26

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