Transcripts For SFGTV Health Service Board 81315 20240622

I now call the regular meeting of the Health Service board city and county of San Francisco to order. Holy stand and repeat the pledge of allegiance. [pleage of allegiance] the board secretary will call the roll. Rollcall. Resident scottvp lim commissioner breslin, supervisor farrell excused commissioner rigo expected commissioneromission or sass. We have a quorum. Item number two, shifted one, im sorry jacob thank you. Item 1 action item. Approval with possible modifications of the minutes of the meeting set forth below. Together meeting of june 11, 2015. Are there any additions or edits to the minutes . I move we approve. Its been properly moved we approve the minutes is distributed and posts. Is there a second Second Chapter properly moved moved and seconded. Approve the minutes as distributed with the regular meeting of approve the minutes as distributed with the regular meeting of june 11, 2015. Is there Public Comment . Hearing none, we are now ready to vote. All those in favor say, aye. Opposed, nay. The nay had. [gavel] item 2, item to discussion item. General Public Comment on matters within the boards jurisdiction not appearing on todays agenda. Is there any Public Comment . Yes, please my name is diane perla. I spoken to you before about nine my dispute withgetting this oral appliance cupboard on the follow is it and i got a phone call from the kaiser represented same that they had decided they were not going to cover it. I would get a phone call from ms. Hill at the Health Services system explaining why because i asked her to send me a written statement so i would understand whats going on. This was about a month ago and i never heard from anyone at the Health Service system. I just think i am entitled to get an answer of what was decided and why. Thank you. Before you go accuracy, just remain there. I want to formally request that your request be given to director dodd and that she follow up with you through her staff member. Thank you. Any other Public Comment . Hearing none, i like to go to item 3 which is the presence report. I do have a few items that i wish to cover. First, i have a privilege under the auspices of the board to participate in an International Foundation Employee Benefits Plan Trustees institute, which was conducted here in San Francisco on june 15 of this year. This was a very wide range in presentation. I found a lot of information in some of the sessions. Some of it was very, in my humble opinion, very elementary, but i think that you have to take that into account given a persons background and experience in the field of benefits. Overall, the program was exceptionally well done. In order to qualify for a certificate of attendance, you had to attend 13 sessions. I did that. I think its worthy that i go on television and say that i got my certificate in the mail, and two days ago. Saying that i really wasnt there. I know there was some question at least in my office, about where i was. I was at the sessions. There are any number of these items that i think will serve us well as trustees, or in our case, commissioners, as we have a little later in the fall and open forum for this board, which director dodd and i have discussing in terms of items for discussion at that session. Not only is it a fiduciary responsibility information that weve asked our good counsel to begin to pull together. It was a very extensive session about. It was another session on various trends, economic and Healthcare Trends that plan fiduciaries and planned designers and administrators need to be aware of. One of the areas to me also very interesting was the fact that there was a session on specialty drugs and a mystery, if you will about how indeed they are developed and priced. For us to pay for. This is been a central question for most multiple employer plans across the country and we been experiencing. As well and its been a big issue at the state. So, ill be happy to share the content of the sessions with any of the members of the board. I downloaded a number of the presentations and plan to send those over to catherine and her team so they can share them with the rest of the board, and wider as necessary. Earlier this week, director dodd sent as a wall street journal article. It summarized a bit of the full report of the academy of actuaries, American Academy of actuaries report, which was released on august 5. So delighted to see our actuary out there, neil, i want to tell you i went i read the full report, neil. Im going to send electronic version of that to kathryn because i think its warrant some review by all members of the board. It is in english. It is in english. Theres not a lot of formulas in it or anything else. Its really a very excellent summary of trying to find the Drivers Behind core medical inflation and the cost related to that more broadly across the country. It would be worth our while to kind of have that in our background as a prep piece, if you will, for the november form that were going to be having. So it can serve as a springboard for that get the wall street journal did a fine job in summarizing it, any actuarial report i think will give you a little more detail about how thathow they to some of the summary points, that particular link came from the International Employees benefit plans on base. Thats how i found. It just was one of those things as part of their daily updates. We are all members of that group and so youll be getting an email daily from them. A lot of the stuff does not apply to is that you can skip right there. Occasionally, there are these articles that are there. There is also a report that has come across my attention by a Consulting Firm by the name of deloitte. Not a small firm. It is a survey on Consumer Behavior for people that are participating in exchanges. Its the first such nationwide report on that issue. Some of the conclusions might tend to be surprising to some folks well people are going just to go to the exchange to get it insurance covers. Every some of the early indicators are that people are trying to make informed choices about various kinds of services, that they are indeed, trying to inquire about Preventative Care and how its to be utilized in their circumstance for themselves or family, and there are other things that we would want to assume that people are doing around how they are using their Health Benefits. Day in and day out. Doctors visits, owing to the hospital, whatever happens today. So, this is another piece that ill send along to catherine for distribution, but i think its an enlightening starting point because in my mind, the question is, are members doing similar things . We are seeing things in this particular larger arena that might be very useful and the question is, can we learn from that and encourage our members to do likewise. Sauce on that along to everybody for your perusal. Lastly, as far as my report, it is my great privilege and honor to say that we have a full Health Services board. I expect a little pause reaction around the table. With the appointment of dr. Stephen elliottgood im not going to recite his entire resume, but hes had a very very distinguished medical career here in the bay area. More recently, at kaiser, but also part of the uc system serving at uc San Francisco. He has taught in medical schools. Hes done very special work in hiv and aids research. He has served as a medical leader in many many dimensions, both here locally, weaselly, and nationally. I am honored that you were willing to take time out of your day to be a part of our group, and i look forward to working with you commissioner falkenstein. Do you have anything youd like to say . College essay is actually a privilege to be asked to join this board. Ive been a resident of San Francisco since 1977 and in practice here i started my training internal medicine at ucsf at that point, and retired in february of last year. So, 30 some odd years of medical practice. I would say that i practice in essentially every hospital in the city, after which dont exist anymore. It wasnt my fault. Partial halo, french i could go on and on. I was cheap that staff at davies. I spent half of my professional career in what we call fee for service. But starting in st. Lukes and then in 1998 joined kaiser in the discipline of infection diseases and hiv medicine that i was also president of the dental medical society for agent. I really feel this board and the medical community that very well into my own passions. I hope to learn a lot from every Single Person in this room. Thats whats fun about this. Thanks thank you commissioner. We will look forward to working with you. So with that, that concludes the president s record in alaska theres any Public Comment . Good after good afternoon commissioners. Clairepresident of retired employees and a former member of this board. I like first of all to welcome the doctor. Its really wonderful to see a full board again and it sounds like youre the kind of experience that will be helpful and beneficial to all the members and two other members of the board. So welcome. I also want to comment you, commissioner scott, going to and the conference finally. It was something that we did a lot more when i was on the board in earlier days, when the citys budget was so bad that all travel and training was removed from most budgets, are board get into the traveling to those conferences anymore, and the staff couldnt even though i think our travel and was to be paid out of the trust. But, its very important. Theres much to be learned in those conferences and i would strongly urge that we really, while there are a number of those presentations that are available electronically, there is something much more valuable in the person to person, the actual conference to beat it. It sounds like you discover that. Because you interact with others. You find out who knows what and who doesnt. Just that, networking, milling around, when everyone called is extremely valuable. We also previous commissioner went through quite a career in the Public Domain withinbecause he served on our board and is also work for whatever actuaries. So i think the possibilities are there and id like to encourage everyone to take advantage of those conference opportunities. The ones that are specific to publicnot public health, but our public lands. They are the most beneficial and theyre so much to be learned. So, thank you very much. Its very interesting to hear the information that you presented and i look forward to trying to access some of that good i just want to add likely, retirement board yesterday did it fiveyear demographics report. I think while their populations are not the same, there is some very valuable Information Available on that report. I can get it electronically or be happy to share it. Thank you very much. Excellent. We look forward to receiving it if we can. Thank you. Is there any other Public Comment . Hearing none, item for item for discussion item. Directors report. Director. Catherine. Director of Health Services. My report is behind tab for. Much like we have a complete Health Service board we are very close to having a complete hsf staff. We are in the final stages of filling the graphic artist position, which is woefully needed. Since we added bonus, rosemary, our communication managers work has just quadrupled. So we did an initial interview and would do the final interviews on the 21st of this month. And have a graphic artist and an assistant person in place. It just unfortunate we could not have done it. We the budget was signed into law on i think august 1 and we will have filled this position 21 days. This is record time for the city and county. But, a lot of the open enrollment work was done. Nonetheless, we are also in the final process of hiring the analytics staff person was going to work on the claims database. We have with us to new staff people. Marie, murphy. Read you want to read your and please stand. Please stand. Marie has a phd in sociology. Thats not why i hired her. Shes a Research Assistant for the departments. I will credit her with the eloquent testimony that in your book today on the codes on advanced care directives. We also have with us this should allhow to icy alaskan . I was right on. He is working on emerge to image 9. 2. Transition. We are delighted to have him. He has years of experience with kaiser. So, welcome. Jeff kleiner, who is not here, after 25 years, we promoted into senior eap and were adding a staff position in eap. This is the first time would increase staff for Employee Assistance program in 12 years. The operations manager, our new Operations Member Services manager will begin on august 17. He will be at the next Board Meeting and he comes from usc w has lots of experience. And we will continue to keep two positions empty per the requirement of having attrition savings in the budget. Which is kind of ironic. Nonetheless, were almost fully staffed. Maybe someday we wont have to keep positions empty. In terms of operations, all customer goals were met. I just want to point out, we stopped 17 people on the holdover list. Thats down significantly since i came. For those of you who dont know what the holdover list is, if you are laid off, you get Health Benefits at the same benefit rate you have for five years. Thats for you and your dependents. Every year we are required to make them certify that they dont have access to other coverage. So nothing for people actually have other coverage. Because they found other work. Open enrollment, preparations begin in june and we are in the midst of editing and editing. The changes include the new United Healthcare national lapd ppo. They also include the new fsa vendor for our fsas. We implement the cobras in july. We are doing what they call six meetings as we convert to peoplesoft 9. 2. So thereve been several of those trying to make sure that transition goes smoothly. I think it significant to say we enrolled 700 new retirees in the last two months. So, thats a huge amount of work for our benefit staff. Im going to skip through other than to say among you all approved the budget for the enterprise contract management solution, and that was approved yesterday. Now all we have to do is select a vendor and start scanning and its very exciting. Im waiting for years for that. The web statistics are in your binder. Finance wise, we went before the board of supervisors. We responded to the board of supervisors budget analyst twoand were successful in having a majority of our cut being stored and restored and we want for the board of supervisors and i was approved and the funding on electronic contact Management System was what was in jeopardy. So its exciting to actually see that come to fruition. In your binder, you will recall you requested that wellness present to you every quarter. Stephanie fisher, i wellness manager, is that eight Data Analytics training in sacramento. She cannot be here. She asked me to highlight a couple of things. So in the mitre ar in the binder are to reports. The highlights include that we had to 93 unique participants in the First Quarter of the year. And for 90 in the Second Quarter of the year. In the Health Wellness center. Eap served 61 new contents and continues with 95. So thats another place where i just have to comment dhr. They really are moving requisitions through quickly. Deposition, jeff was promoted on monday and we had the position filled within two weeks. So hopefully, this will continue. We have a fitness event that attracted 270 people in three hours. It went through 10 different stations of things that can do. That is like. The key thing is we were new people. There were the same people that come to our classes. I want to thank the vendors who all came. The provided activities and handouts. We have recruited an additional 64 wellness champions in Different Departments. We now have well over 120 of them. Stephanie fisher presented the accomplishments of the wellness program, and the wellbeing assessment. We all took that wellbeing assessment last december. They finally calculated all the data and presented it by department. So, you were at a meeting that the mayor called. You were given a report on what percentage of your employees took the wellbeing assessment, and what the wellbeing assessment said. So, were peopledid they want help and stress management class undernutrition . Helping exercise . Help do they want to Work Environment to improve . Not only did you get the results, but she thenshe and her stafftthen gave you suggestions of what you can do to address the issues that showed up in your data. She offered to meet with Department Heads and she met with several already especially the large Department Heads. To go over specific ideas and things they can do to respond to the wellbeing issues that came up in their department. I just will say, lucille attended the event and kind of got all the Department Heads excited. Not that lucille is uplucille from the giants. Not that she is the picture of health. But she was lithe and at the meeting. The Diabetes Prevention Program Research study that we are doing with kaiser, that has been submitted. It was approved. To the irb. So that study will disseminate effectiveness of a worksite wellness online intervention versus a Group Intervention intervention to prevent diabetes good were getting ready to mail several departments employees and have people take the test again to do a prediabetic screening metabolic syndrome screening. I did want to highlight in rosemarys reports on the eap services. I want for my new the increase. The number of people, even though gene retired after over 25 years of service. In the Wellness Center visits, i think what is interesting is that weve had new people. These are people that are not previously engaged. So, thats always exciting. The interactive seminars decreased. Township your seminars. Because of fewer seminars. But they included nutrition by taliban. Managing stress dealing with difficult people. Understanding or metabolism. We are really getting the word out there so people know how to manage their health. I have also included just a statement on the 12th parity law that insurance are not the filling of promise. Marie murphy will be working on querying all of our vendors to really say, how do you define mental parity and are retreating Mental Health the same rate we are treating physical health. Mental bonuses, as you know, is a chronic illness. In response to the chairmans request, weve implemented an email address and phone number for the board and we did have responses because we made that public at the medicare meetings. So, i put one of them that camethose go togratefully. The board now has kind of a sounding board for people. I will point out in terms of vendor issues, the uh see is in the final stages of negotiating a contract with john muir. There are 28 claimants that might be effective should they not be successful in negotiating a contract, but maybe theyre not sending anything appear theyre not required by law to. We dont have a managed care plan there. Ive added some items of note. Let me just go back for a moment to Data Analytics. It actually entered our first set of data. After you know, it was this time last year you were approving the abcd and we now have data and we are actually its exciting to have entered data. Thats from marina was also at that time. If i might, in terms of a telephone number for the hss board. I like to at least have that part of this broadcast. Absolutely part of this broadcast. Absolutely part of this broadcast. Absolutely 4155540662. The email is health. Service. Board. At sf dog. Org. Thank you. I just added some items of note. You referred to them earlier to my commissioner scott. The mergers and it positions continue both at the insurer level and at the provider level. The largest ever is the anthem is acquiring cigna. Its still being contested in terms of monopoly power. But it willit shows that the market is narrowing down for from five dollars to three. In terms of the insurance market. Uht will remain the largest in terms of revenue, but anthem will have a Larger Customer base onceif this goes through. This continued uncertainty about seton hospital, which is where many of our patients are admitted. The daughters of charity secured 259 from Blue Mountain is going to operate a health system. Thats a nonprofit for three years after which they could acquire the chain and transition it to a forprofit system. So, thats the current plans for seton. Average california. You may hurt has increased their rates by 4 . Interestingly enough, the Medicare Trustees report, which referred to earlier, is saying that medicare policy are going up 4. 2 . Thats the range were looking at. Last week, for the third time since the passage of the Affordable Care act, the cmsthe federal Government Produced their readmission penalties and thats one of the key indicators of quality care. One of the things we monitor in our organizations. Among hospitals that were find include sutter, oscillates, summit. Summers seep into the centerrenzo. Kaiser south of San Francisco. St. Francis usf el camino and johnny are good i went to the listenable to where we had patients. No one is perfect. Thats how cms is funding things. I know additional items other than i will be out of the country the next two weeks. Mitchell, who will hopefully be back tomorrow, will be in charge. April Financial Officer will be in charge of all things finance. Im fairly confident over that amount thank you, director. Get any questions from the board regarding any aspect of the report . Is there any Public Comment . Hearing none, we will accept the report as given. We will move to discussion item number five. Item 5, discussion item ages just Financial Reporting as of ages just Financial Reporting as of may 31, 2015. Pamela levin. I would like to take this public opportunity to knowledge the tremendous work effort of catherine and her team. In preparation of the budget and its submissions and all the interactions that go on to get that monster done. I thank you for that. I commend you for your hard work. Im pretty a pretty positive outcome after we went through it all. So thanks. Thank you. Payment of 11 Deputy Director chief Financial Officer. I do want to take a minute to introduce our new im sorry. Contracts manager. She started in june and has coalesced so well with the team that seems like shes been here for long. Her name is . Amara marilyn. Would you please them. Well, welcome to hhs. Thank you. Today im reporting on the revenues and expenses of the Employee Benefit trust fund. Also known as the trust fund and the general Fund Administrative budget. Through may 31 as well as fiscal year ending objections through june 30. Where we are right now, just kind of in broad generalities, is that the fiscal year closed on 30 june. There are still transactions that are being processed and we always are behind a month in terms of its report. However, the projections that we have here are the general fund our actual actually based on last week and it was absent just a couple of transactions. The trust fund is the audit is started, and we think we are going to bounce around where are at and what are present in the report. The audit wont be concluded until october, and i believe that it will be presented to you in december. The balance of the trust fund on june 30, 2014 was 92. 8 and right now we are projecting and right now we are projecting at 70. 5 million. It will be similar between that and 80 million. I believe at the end. The projected decrease of fort 14. 3 million includes the reserves for unpaid claims and as a result of the following changes city plans has a 3. 4 million decrease in fund balance. This is attributable to 2. 2 million increase in fund balance and offset of 5. 6 million decrease in fund balance. We have had favorable claim experiences. Weve had pharmacy rebates. But, what we did was we used some of the fund balance, 1. 2 million, subsidizing the 2014 rate so that was the first half of fiscal year 1415, and then we also used 3. 7 million were the 2015 rates, which is the second half of 1415. Then, we had also used. 0 7 million without funding premiums in 2014 bringing in the 939383 contribution model. You will note, if you remember, we get by down the 16 rates also for city plans. The flex plan to my right now we are seeing a decrease of 17. 2 million in fund balance. I hope we have 2. 5 million in pharmacy rebates, that is offset by a 19. 7 million decrease in fund balance. Associated with 12. 7 million unfavorable claims experience, we are monitoring that on a very regular basis. Having discussions with the acos, and trying to improve or reduce claims or claims expense in the amount were paying out for claims. There is also a 4. 9 Million Associated with subsidizing the 2015 rates from the claims stabilization reserve. Then, 1. 1 due to the use of erp funds. Other seems to be is in the past because a lot of it occurred in the first half of 1415. Fiscal year versus calendar year, and plan your. Then, there was 1 million associate with funding premiums in the 2014 plan year for unions, except 939383 contribution model knows from the last part of the 2 the shield profit pledge. Other balances that are attributed contributing to the 14. 3 million decrease, overall decrease, in fund balance, is we havetheres always send him. This is the dental insurance plan. Even increase in fund balance with favorable claims. Kaiser and blue shield insurer hmo plans. We have an increase associated with that premium revenues including the use of er which reduce members premiums. We have an increase in interest, . 7 million due to the cash balance that weve been carrying, including the erp funds that we know ended in the end of 2014. Forfeitures, weve had a decrease in fund balance associate with transfers to the general fund. To the general fund. To the 1415 budget. That, for performance guarantees, we have a . 4 million increase in fund balance. We are working withto make sure we are cover all required deserts. We do this during the process of the audit of the financial statement. Overall, we are in a healthy state for the trust. Not overly healthy, but not unduly healthy. So, just where im fairly comfortable with it. In the general Fund Administrative budget, we projected a balance of 1. 3 million by year end. Thisa lot of that is due to delays in hiring. We have asked for carryforwards or we will. Its in the process. 200,000 in professional services. 70,000 in work orders. So, the general fundsounce of 1. 8ounce of 1. 80 million will be turned to the general fund it as i mentioned, there still some offsetting entries that are being put into the system, and i monitoring those very carefully. Are there any questions . Questions by members of the board on any aspect of the Financial Report . Maybe one question on the 12. 7 million unfavorable variance with blue shield, to have a sense of whether that is from i merely an issue related to price of services was at issue more related to Volume Services . Neil. Outlast the actuary to come in. I think its kind of a combination of goals. I think more so than we are not been successful in keeping people out of the emergency room. Theres not a good sense of making sure that the services are given in the appropriate venues. For instance, there is somei mean, my senses there still some surgeries done in patient that should be outpatient. Theres a lot of discussions about length of stay has increased. Theres a lot of bouncing about. One of the things we did have was the 12 increase due to sutter. During the negotiations, when they stop talking blue shield and sutter stop talking we ended up having to pay the sutter hospital rates which were 12 more than we wouldve paid otherwise. We are not seeing the type told that acos had inwhen the acos first started. Neil, j do you have any comments . Please introduce yourself. Neil kosher. Aion ashtray for Health Systems check that the question was volume versus price. Yes. Their answer is there is an increased volume and prices have gone up. To add to what your cfo spoke to, i would say cost specifically specialty drugs, escalated in this time period with several fc drugs coming on board. His increased cost specific to just that. By an estimated 4 million of that 12. Its representative of that is the other issues and the fact that the aco though we are optimistic on a performance the level we shouldve started with. So those are several of the drivers. So, it was a common there was a 12 price increase by sutter as well . The 12 price increase there was one month in discussion about how they were going to go for because they had separated ways for the negotiation. They were trying to reset their contract. The blue shieldsutter hospital conjugate we did see that experience that was a onemonth do. Any other questions . No. Any other questions from the board . During that time am a do, weve seen a couple real serious cases that contribute to the increase in the medical claims. I did not hear. What . Some very serious cases in whichclaims. Claims. Okay. All right. I will just say this. We been getting quarterly of reports on fellowship and because of the worst dismal report were now can be meeting with her monthly. Ill just give you an example. When we looked at the average length of stay, which is above what was when we started, i asked about discharge planning and utilization management and brown and towing and sutter discharge planners only work 955 days a week. I made the suggestion that healthcare and recovering and being discharged was a sevenday week probably tenhour day. Hopefully, they will take some instruction when is your next meeting with them . The phone meeting on him i think its september 5. It just got set. Be sure that im notified . Absolutely. Thank you. Thanks for a much. Any Public Comment court on the Financial Report . Hearing none, well move to item number six. Item 6, action item, approval of testimony on cms regulations regarding reimbursement codes for dance Care Planning. Dir. God. Catherine, as you begin to do this, and again, as were these points of continuing education, there are any number of policy issues that are. Com by way or out in the broader arena of discussion. Catherine has tried towhether it be at the state level or federal level, at least register it perspective from our point of view. Some of these, is a large employer, we need to be active in. So, its a matter of why are we worried about reimbursement stuff from cms. What the devil does that have to do with the city and county of San Francisco . Well, these policy questions begin to translate into real dollars and it comes to how cost are driven, other managed and how theyre determined. So, its quite appropriate that we comments were given the opportunity. More poorly, as we have been doing more recently, seek out the opportunities. So, with that, please. Thank you commissioner scott. You all recall during healthcare reform there was a proposal to include medical reimbursement for position counseling and ecologic care. It was used as a campaign hot potato. Death panels. Just be clear what were talking up. With that behind us, cms very appropriately put forth to reimbursement codes. Theyre called cpt codes. Allowing for the billing of time spent with patients discussing the critical matters at the end of life, which are often called advance Care Planning and advanced directives. I will also have attempted to put in our performance guarantees with our vendors what percentage of your of our members in their Electronic Health records and because theres no building to date for this issue, its notno one counted. You have to go back and go record by record and do searches for the words to find it. So, giving this a billing code will allow us to measure our vendors in terms of how well they are doing and having this Important Information in medical records. So, i will just say that we commented, as i pointed out or we get a very beautiful job on the issue that families face. It helps families prove quality of care. It also saves money because the majority of medicare dollars are spent at the end of life. Blue cross wisconsin is often cited. Even 90 of all the people who lived in across wisconsin regardless if theyre over 18yearolds there been a dance directive. Its part of their egos. Their medicare spending is 25 less than medicare spending. In other places. So, the suggested rule said that we should do this counseling at an annual physical and when someone is sick. We are suggesting that we not limit it to that. If someone isi offer you the example of kaiser that includes exercises of vital signs. You go in and get your Blood Pressure and temperature and your weight then they say, how often do you exercise and for how long. I always kind of go,but maybe will begin to add, you dont have an advance directive on file would you like to make an appointment to discuss that with your primary care provider should thats the hope. Regardlessyour dance directives change depending on where you are in your life. Sometimes, you make one and you want to change it. We also recommended that they include actual training for the people who do this. That they not be allowed to be reimbursed for group settings. Its individual counseling talking about peoples individual circumstances. We encourage them to include Nurse Practitioners physicians, nurses and social workers in the reimbursement codes provided they have trained. We think that advance care directives should occur early and often so, we have before you the testimony and i think its very thorough and i hope you recommend to send it forth to cms. Either questions of the director on this topic . Yes commissioner breslin how do you have is is that in with Palliative Care would this be pallet of care . This would it would be Palliative Care. This is been about counseling care but, if i were very sick, and i did in advance directive, i might say i dont want curative care. I just want harriet Palliative Care. Where i were very sick and i could say that in advance. You know, under these conditions, we included the reference to the physicians order for last sustaining treatment. Under these conditions, if you cannot put me on a respirator or on oxygen to be memake it easier for me to breathe come up thats okay but if im ever going to come off it, dont put me on it to begin with. Its talking about how you want to be treated in advance. I understand appeared to have Palliative Care or do with coverage for pallet of care . Pallet of care isnt a code or is enlisted in her evidence of coverage, but i believe all of our vendors practice Palliative Care. Like special certificates for persons practice . Yes. You can be certified. Medical boards offer certification. Then they would get paid . Winner medical specialist you get paid a little extra through medicare. Which is why they went first for the certification. Oncology positions, internist to domaybe you can speak to this dr. Paul. Yes. Im not clear that theres additional billable reimbursement because one has some specially training in Palliative Care. It probablyin my fall open for different organizations among fall under different payment schemes. You know, i do think this is really nice document from my perspective. In our measurable outcomes, and i think all the things that concern me, its great to encourage cpd codes and all that cv into documents that the discussion happened, but the outcome if someone does have attorney up our healthcare has indicated advance directive and is a form in california called post. The position order for lifesustaining treatment. This is a legal document that allows any individual who is admitted anywhere to have his or her wishes honored even if the Healthcare System they were taken to urgently isnt part of their system. Because it is a physicians order, even from a physician whos not on staff at that organization. It let me remind 98 was put on life support despite her two daughters vigorously opposing this. Because the physician was not on staff. It was a different hospital and it took them several days to get their 98 motor off life support. This solves that. As we begin these discussions with more direct terms, those kind of documents did some concrete evidence that this is actually happening. As much as not about costsaving. Its about caring out people wishes were dignified and. Either other questions or comments from the board . Is there any Public Comment . Good evening. Im going to comment on how they been doing [inaudible]. Thank you for those comments. Are there other Public Comment . Thank you. Claire rcf says he says im writing the article for our newsletter, but i could be clear on this. I know that were probably going to encourage all our members to have these kinds of documents on file, but it sounds from this discussion that these are things that need to be updated regularly. You could put something on file and end up with one set of directions, but as you pointed out, dr. Dodd, if your life situation changes, you may want to change your directive. A lot of people forget to do that. We have a problem with retirement system would advocate to update their beneficiary. We have a lot of problems like that. So, i am wondering if itsand some people dont want to have that document on file. They prefer to have their representative hang onto that so that it circumstances present themselves they can come forward and say heres the directive and what we do or dont. I like a little more clarification on white be the most prudent way to do this and how we would also make sure that members understand that if they do put this kind of document on file needs to be regularly reviewed and updated better latest wishes are what i most accurately reflected. Times, when they go in when their health changes, theyre not a position necessarily to do that changing either. So, whatever additional insight you can provide would be very very helpful because i like to put that in our articles. I . Director doug,. Com point on page 5, claire, it talks about frequency and under what conditions. You can probably take out language and put it right into your newsletter. Also, just like we do with Everything Else during open enrollment season annually, the mighty that trigger. We talk about updating beneficiaries and doing all these other things. Maybe that something might want to call out is another health item to be checked as a person is doing these other things. It just a notion. Is in all of our guides. Very good. Are there any other Public Comments on this item . If not, im willing to entertain any motion. I move we approve the testimony on cms regulations regarding reimbursement codes prevents care plan. Its been properly moved that we accept and approve this item. Is there a second . Second its been properly moved and seconded that we accept this item. Is there any discussion by the board . A Public Comment . Hearing none, seeing none, no Public Comment were now ready to vote. All those in favor say, aye. Opposed, nay. [gavel] so ordered. Item 7 item 7, action item, apartment of Committee Chairs and members for fiscal year 20152016. Pres. Scott happily. Happily. Happily. We now have a full board and are able to announce the appointments of the respective chairs of the Standing Committees for the Health Systems board. I would like to call to your attention the yeoman work done by our chair and governance. Commissioner breslin. Last year. I had the good fortune to participate somewhat in that work. Along with the former commissioner. So, where it says position commissioner currently vacant, commissioner folstein. Thats you. I gathered as of this record. That group does not limit her issues in a be doing with a short term. For the finance and budget committee, ive asked commissioner lim to chair that committee. Commissioners for oregano and sass will be members of that committee at either good fortune of being ex officio to everything as well, when i can. Now, you may or may not recall that we had additional committees that were part of our former governance structure. Tools membership and something called rates and benefits. All those have been folded into the work of the board itself. We meet as a committee am a whole as when those items are due to be discussed. We thought that was a more efficient way administratively to talk about those topics, because at the end of the day, its everybody piling in to my if you will on those topics. It does not mean that they will in any way be subject to less scrutiny that supports an oversight in the work that we will be doing. So, with that, i would entertain a motion to accept the approval of these appointments for the ensuing year. I move we set these appointments. Is there a second second its been properly moved and seconded that we accept the approve the apartments as outlined in the agenda. Any comments from the commissioners . Questions . Any Public Comment . Hearing none, and seeing none, no Public Comment were ready to go. All those in favor say, aye. Opposed, nay. [gavel] so ordered. We are ready to move to either made. Item 8, discussion item. Introduction to voluntary benefits am a director dodd. Thank you good you have a memo that i sent to the chairman. We have not, in the past, provided voluntary benefits to anyone besides the miscible executive association. Its part of their mo you. Every year i get calls from Different Department head saying, the summary with a card table in our lobby trying to sell us some kind of insurance. Are they part of your shop. These, i dont use a derogatory termthese companies try to tag along with her open enrollment season but they also pop during the year. They talk they tell people they need to buy Disability Insurance or longterm Care Insurance or any number of the kinds of insurance. I think more and more, having that availability where weekend that the actual vendors were we contact a vendor who thats the vendors, is really important and something that, whether the device or even pet insurance, where we want to be able to offer that protection to our members. We get calls same such and such Insurance Company isnt doing this. Ive been off for four weeks and we will say, well, we dont administer that particular kind of insurance. So, the idea here is to make voluntary benefits available to all employees of the city and county. And have people feel better sense of protection. This would not cost us anything. It would be additional administrative work or both are finance and benefit staff. There is a cost, but its not a seven dollar per member per month. Its a work cost. I hope that you will agree that we should go forward and do this. To this point, as director dodd and i talked about this, you have these folks that do show up at these odd moments. They look very official and many of them are well intended that got all the appropriate whatevers. But this is not a matter of the Health Services system taken on an endorsement of these vendors. I want to be very clear about that. We are trying to, in some systematic way, determine if people do show up, who they are and what they are representing so that we can indeed, if called upon, communicate that to the members of the system. So, this is not about us endorsing these vendors or the benefits that they are often bit i want to be very clear about that. They have these kind of random acts of presentation with no context whatsoever. Its also not serving anyone and we dont want our members to become prey , if you will, to kind of the outcome of whatever the folks are marketing. So, its a matter of trying to put some structure around it and i think until we are little more systematic about collecting data and thinking through how we bet these and i would communicate about it, were still get a be stuck in this twilight zone. This is a first step in that process. It will come back for further discussion action as it might require. So, that just my two cents worth to add on to what the director said. Are there any questions by any of the members were any commissioners at this point on the subject but had a question. Is there any history of this happening within the city and county where they either hire a vendor to that people who set up tables for any reason in public spaces . It seems to meit seems a little bit of a can of worms in terms of opening upbut they cut benefits. Do we have ado we allow one vendor or do we have have a minimum of three vendors to provide pet insurance . How do we know whos done the vetting. Who do the employees call if they have a problem with their pet insurance . Do they call even though we say no, we are not involved, what we have been involved. He put ourselves in their come i think. Im confused. Thank you for the question. Thats the situation as it is today. Anybody can set up a table. Some of the unions, police and fire in particular, have longstanding payroll deductions with a couple of these vendors. In an effort to expand their market share, they then show up at a lobby of the mta board whatever. Wherever they cannot get shootouts. She wouldnt not choose. There have been problems with whats been offered. What we will do is i quasirfp to select to whats called an aggregator who does that the vendors. Then want to work with the emerge and there will be a payroll deduction. If there are problems, caused ma may come to us bu it will be a vendor we have said has been vetted by her aggregator, whoever that ends up. Then, we will deal directly with that organization. Right now, municipal executives hasnt been called Employee Benefits specialist. They offer wellness good they offer accident insurance. They offer longterm and shortterm Disability Insurance. Theres a problem with those insurances, and they call our staff, our staff will call boy benefit specialists and Employee Benefit specialists will fight it out with that Insurance Company on our employees behalf. So, it really is protection idea. Other questions . There is more to come on this, but is there any Public Comment . Thank you commission did not speaking for myself. In nearly 40 Years Experience with the city, ive encountered this problem. Numerous times. A number of different issues. One is that also local 21 has Employee Benefit specialist analyst on cafeteria plan some things they offer that are similar to mba. They are, i think those are the only today have any specific going on. A lot of this has to do with whether or not Department Heads will give permission for anyone to be onsite to solicit employees. Sometimes its the manager of that worksite that is being approached. Sometimes its through the unions. Sometimes its through nefarious means. Not to talk about it but ive seen a number of things over the years with regard to access to city employees. There is a rule, i believe, that exists that says basically, no one is supposed to have access to city employees, especially during wartime. But this rule is continuously violated and has been for the four years ive been work working with the city. This issue has come before Health Service before. Again, we sent out notices to Department Heads to other managers, indicating that these are not benefits that are supported by our system. These are not benefit section by our system. The payroll system is a big issue with all this because they were not going to give any more payroll slots. So that may be a hurdle. I dont know if her beyond that these days with the emerge. But theres a long long history. This was going on long before i start with the city four years ago. It sounds like it still continues. Its really a matter of having the research and dialogue to work with the union. Most of our unions, it represents to the employees, also have an aggregate of other services that they offer to their unions. Then they make those available to their members. Members are not always sure that those Services Come through their unions, and not to the city especially if they get a payroll slots. Thats kind of what house people, that they think it comes through us. Because its off on their payroll. Therefore, it must be sanctioned by the city. Its not sanctioned by the city is not sanctioned by the Health Service boards. Its just thatit mightve been for example, for some of these benefits that were granted to a Different Union that the payroll slot was available and someone else was able to use it. So theres all kinds of subtleties involved here. I think you will find as you go along, there will be many hurdles to overcome and that you have to have a lot of dialogue to find out these companies are, who has already vetted them and who is providing those services. It may be that maybe Health Service would want to touch it. By the way, theres a typo. I had to point that out. A typo in the last sentence on the memo. That will be administered. I think it should be dead. Thats the enemy, thank you very much. Other Public Comment . Dialin or look resenting the uf retarded as did i just a question. You would go with a plan like this anywhere with things like certain Wellness Programs or pet insurance. Would you be excluding retirees from taking advantage of any of this . This is an active member benefit. Because it has to be deducted from payroll check on a specific line. So, yes. Other Public Comment . Your name, please. Stephanie johnson and i think that [inaudible] thank you for your comments. Any other Public Comment . Hearing none, number that concludes this item. For discussion. As i said, therell be more to come. We may find, given the level of complexity in the ins and outs of this particular issue, it decide to do nothing. Thats also a possible outcome here. Item number nine. Item 9, discussion item. Report on network and health plan issues. If any. Vic do we have any plan representatives here that wish to bring any ring to our attention at this time . I said this at our prior meeting, but i will say it in their absence. We thank them for their hard work in working with us and with our staff and with the actuary to get ready for open enrollment which will be happening shortly. Again we thank them for their continued work with us. Number 10 item 10 discussion item opportunity to place items on the future agenda. Just as a headsup, i guess i can do this now at this part of the meeting, catherine, will probably not be meeting in the month of october. Theyll be on a future agenda. We are looking forward to having a board for quorum in november. Will be working diligently to frame some areas are both education and information of the board might as well as, we hopefully the general public likes to watch the pursuit. On a wide range of topics. It is my firm belief that we kind of get into the cycle and becomes inside baseball. So, everyones and in a while we need to stop and take a longerterm view and a wider view of some of the issues that are ahead of us not in that meeting in november will be devoted to that. I hope that you will ask all your family and friends to come out and participate. We just dont have an empty chamber here. So thats just a heads up as we go forward about a broader schedule. Are there any other Public Comments about future agenda items . Herbert leitner. I think the idea of a public forum is wonderful idea. I want to be very clear i