Lease agreement between mercy housing and south of market childcare that describes a order and preference of occupants for Childcare Center first going to concern of livering in transbay 6 and 7. The second preference is to people in the transbay redevelopment project area, south of Market Redevelopment area or the zip codes 94103, 6 and 7. The third is for children of families with a parent working in transbay. In any case, at least half the total number of children should be from low to moderate income families. There are about 40 children will be accommodated and the fees are subsidized good afternoon. My name is [inaudible] the enrollment will be, we anticipate that well be able to get license for 40 to 50 children. I might guesstimate 45 children. Half are from low income families, state subsidize contracts that will provide and cal works contracts and other contracts the city [inaudible] well serve infant, toddlers and preschool aged children and the other 50 percent are private families do you know how many childcare facilities there rin the vicinity . I know you are running several. We have 2 facilities one on folsom we are licensed for 90 children. 60 percent are low income and the rest are private families and then we have another facility on [inaudible] all most 90 percent of the children at that site are subdized low income. How many . 48. You have 3 facilities. This is our third facility. In mission bay we have a couple of them. [inaudible] on king street. The Mission Housing development and the is a childcare operator and there is the family, the 3 family spots accommodates 12 at mercys 24 street development. Ucsf also operators a childcare operator and there are other proposed within commercial developments including the proposed Head Quarters on blocks 26, 27 youll see in the fall and potentially killrow development on block 40 on 16th and owen street. I think there one in candle stick there is one existing that is adjacent to the als griffith Housing Development that will be relocated, yes these are the ones we operate. I believe there is also a childcare facility in hills plaza. Yes, there is one. You know the waitic list in just south of market is long. In one of the sites there are 500 on the waiting list. [inaudible] did you say 5 thousand . 5 thousand, yes. We are talking toddlers. Infant and toddlers are limited in San Francisco because the cost is very high so that is why we are very excited about it project. It isnt just Affordable Housing it is affordable childcare. I have a feeling we will be able to get license for 48 children so they create 48 slots that are really needed. I also believe transit sent r has childcare facility and the sit affof office through early care and education, thank you so much, city wide coordinating body because Many Developers pay a childcare fee and it is the coordination that happens through that office to provide the construction there is the Financial Plan that has to be put together in place for the operating. For new childcare facilities they run through that office. Thank you for all the work that you do and for mercy for incorporating childcare. The number is just staggering. Yes. Wow. I would go for childcare versus parking. It is a negotiating point. I heard from a couple frents moving to east bay because is is for housing and childcare issues. Thank you very much for all the work you do and mercy too. The childcare facility looks like to will be fun. You can be a child again. Okay, so i think no more questions. There is a motion by commissioner mondejar. And there will be a second by commissioner sing. Before we take a vote i want to recognize the spectacular accomplishments and performance on the sbe program. Kudos. Please call the roll this is for agenda item 5 c, revisions to the scumatic design for transbay block 7. Commission members please announce your vote when i call your name. Commissioner mondejar, yes. Commissioner sing, yes. Commissioner booustoes is absent. Madam chair rosales. I have 3 ayes and one absent. The next is for agenda item number 5 d, authorizing a permanent loan. Commission members announce your vote bh i call your mondejar, yes, commissioner sing, yes. Commissioner rosales. I have 3 ayes and one absent. Motion sudopted. Please call the next item. The next item is 5 o, 8erizing pursuant to transbay Implementation Agreement a fairs amendment to the memorandum of understanding what the city and county of San Francisco acting through department of public works to increase funding for the transbay folsom street Improvement Project in an addition amounts not to exceed 345, 861 for a total not to exceed 829, 253, 00 transbay redevelopment project area discussion and action resolution number 522015. Madam director. Thank you madam secretary. Commissioners there is a item in transbay as part of our support for building neighborhood infrastructure to support the dense housing and mixed Income Housing and the commercial development component. We also have a charge to facilitate the open space and streetscape improvements so this contract is building out that complete neighborhood and propose to extaepd our contract with department of public work tooz move into the the next phase of work for the folsom street improvements which are critical for providing that neighborhood infrastructure. With that i would like to ask kevin mat sooda to walk you through the proposed contract amendment thank you exectev director bohe, president rosales and directors. This item is to approve the First Amendment to the memorandum of understanding with the San Francisco department of public works transbay folsom street Improvement Project. The mou incorporates a scope of work of transbay folsom Street Project agreement which divided into 2 phases of work. The phase one scope of work provides Design Review services 350 percent documents, [inaudible] conceptual designs for Traffic Signals and approval for the project designed by ocii through its contract with [inaudible] Landscape Architects or cmg. Sfpw entered into the Transportation Agency and San FranciscoPublic Utilities to assist in the project. Both scopes of work for phase 1 and 2 are addressed in the mou, to date only phase 1 cost of 483, 662, 00 is contracted with sfdpw. Currently the project team completed nearly all the phase one scope of work including the 50 percent construction documents thus requiring a First Amendment to the mou to begin work on phase 2 related work. Phase 2 covers 100 percent construction documentation bedding and contracting suvss, construction manage lt inspection and acceptance services. To main the project schedule and properly sequence to thwork, ocii is breaking out phase 2 into 3 subphases. Subphase 2 a, 2 b and 2 c. Subphase 2 a provides the funding to complete the necessary work from 50 percent construction documentation to 100 percent construction documentation or permit submission. Scope of work for subphase 2 b include the necessary work to bid and contract the project and anticipated to be brought back to the commission for consideration in october of this year. Subphase 2 c, scope of work covers the Construction Cost and that is anticipated to be brought back it the commission in the First Quarter of 2016. This slide shows the project limits starting at the top left hand corner is second and folsom street and the project extends 6 city blocks easterly towards spear street. Development block 1, 8 and block 9 of transbay front this project, they will be required to provide all of the public improvements while at this project we meet at the newly constructed curb lines that will be installed. This is a perspective view that shows some of the gardens and streetscape with colored concrete granite accent pieces, new trees, [inaudible] and construction at the rain gardens. For subphase 2 a, the scope of work required to be performed includes taking the traffic signal dephrines and finish it to completion to 100 percent construction documents. Private property investigations into the presence of subside walk basements because that information is snood from a survey of the different Building Permit applications at the site. Item 3 is the Public Outreach regarding the construction of the project and that is on top of the cac meetings that we conduct and the outreach redevelopment has. Pub lrk works also has a outreach process. Item 4 is Community Benefit district coordination regarding items that will be maintained by city, city departments and the cbd itself. 5 is application and permit fees for removing and planting new trees, driveways, side walk legislation and improve. Permit fees and item 6 is project cost to oversee all the suba work. The cost is 310, 861. 00. In addition there is a need for sfmta livable streets to review the drawings and have approval coordination offunds are needed for livable streets section to review documents, draft required legislation to the board and presents the project to multiple city wide committees. The cost for this item is an additional 35 thousand dollars that was not originally considered in the mou. Combined with subphase 2 a required funding of 310, 861, the aggregate total cost of the First Amendment is 345, 861. Ocii desires to have sfdpd to perform the work through the First Amendment and increase the professional service fee tooz include 345, 861 in addition to [inaudible] overall total aggregate amount of 829, 523, 00. Expenditures for the transbay folsom street streetscape are recognized in the [inaudible] staff will include project expenditures for the next period in sufficient funds are available to continue with the First Amendment. Approval of the First Amendment to the mou with dpw allows the completion of feasibility and planning studies for portionoffs the streetscape open space plan and related community outreach. These activities will have no result and Significant Impact on the physical environment and exempt from sequa. So, that concludes the staff presentation. We have 2 representatives from San Francisco department of public works, oscar g and marsy cumacho. Thank you. Do we have any speaker cards . No. Okay. I can ask. Do we have any comments for items 5 from the public . Moved by commissioner singh commissioner members please announce your vote when i call your name. Commissioner mondejar, yes. Commissioner singh, yes. Madam chair rosales, yes. I have 3 ayes and one absent the resolution is adopted. Thank you. Please call the next item. The next item is 5 f, conditionally authorizing the exectev director to enter into a Grant Agreement with the city and county of San Francisco acting through the department of public works for up to 450 thousand in tax exempt bod proceed for palou avenue streetscape and jening street Plaza Capital impruchbments consistent with recognize obligation schedule item 387. Subject to approval by the ovsite board and department of finance. Bay view hunters opinion redevelopment, discussion and action rez solution 532015 commissioners there is one notable relief mechanism that is enacted in disaleutian law and that is the ability to expend pretwonet 11 bond proceeds. We do have the ability to transfer those bond proceeds to the city and county of San Francisco for projects that are consistent with the bond cuv nns and you have seen a number of these previously authorized in the south affmarket area and the bay view and we are nearing the second to last of the bond proceeds. Now all we have left is the tax exempt housing bond proceeds after this for your consideration so through a great deal of Due Diligence the staff worked with the city through department of public works to come up with a program for the proceeds in the bay view Hunters Point redevelopment. I would like to ask [inaudible] with ocii staff to walk you through the proposal and the process. Good afternoon commissioners and executive director. As director bohe stated earlier this year there are several items that have compl before you related to the the access bond proceeds sfr iimeer here to seek authorization to enter into Grant Agreement acting through department of public works for up to 450 thousand dollars in tax exempt bond proceeds for palou avenue streetscape and jening street Plaza Capital improvements within bay view Hunters Point redevelopment area. Back in february i was here before you for a portion of bay view bond proceeds. We estimate we have 896 thousand bay view bond proceeds in february i came before you with a Grant Agreement with the office of economic and Work Force Development for third street pedestrian improvements as well as sf shines in the amount of 446 thousand so today im here for the balance of that so that we can expand our bond proceed in a manner that is consist wnt the work we have done previously in bay view Hunters Point. All of the Capital Improvements we are proposal reflect the previous work we have done with other city agencies as well as with other community stakeholders. This was a exciting opportunity when we were seeking and frying to find projects that were shoveal ready and had Community Feedback and in line with the preechbious redevelopment plan and talking with community steakholders and other city departments, the department of public works was in the midst of streetscape improvement plans which is in the project boundary and in the process of houstic Community Meetings where they were looking at repaving, adding traffic [inaudible] and several other butte fiication elements and possibility for public arts as well as additional bull bout squz planting of street trees. As part of that community process, dpw came forward saying there is a interesting project at theert insection and i have exhibits dpw staff walk ed through with you is jen asian jenings and [inaudible] improving it so it would not be a area of flight. So, with that, i think i would like to start our presentation. With me today we have marshy cumacho from department of public work squz oscar g and well start this presentation which is the intent of the Grant Agreement to cover several Capital Improvements that we will go through in the slide presentation that relate to improvements along palou avenue or additional improvements along jenings plaza concept that came out through Community Feedback. Good afternoon. The first slide i would like to show is half of the Streetscape Project that rubs from third street to [inaudible] which is a gate to the Hunters Point shipyard. The star represents theened of jenings which turned out to be a right of way owned by public works. This slide shows just a detailwhat happened, we had a couple Community Meetings, we had 3 and at the very First Community meeting the community said there is a couple locations on palou where we would love pizazz or something as people drive through they say this is wonder ifal. One of the areas they selected at the other end of palou there is a mini park so that was a area the community targeted. The other end pow lieu by chris gate, they gave addresses of 2 properties which as you go down palou in the orange it was a public works right of way and the one next to it is a long skinny parcel owned by the School District. So, at theright now they are just si cyclone fenced. At jenings when you turn around there is a wonderful view of the bay. Jenings go down and you are like you are in a room. We told the community we would try to find out who ownathize lots or they can go forward or with it that it wouldnt necessarily be part of the Streetscape Project and we found out that our director was excited about when we talked to him and said is this really a right of way and not a private lot. Then the next Community Meeting we told the community our findings and what we did is told them about the 2 lots and they gave us ideasat that meeting which fsh the second meeting they gave ideas of a amtheater or farmers market, childrens playground or combination of uses. We talked a little about that and this was a Informal Design workshot but we didnt want to talk about it to be much because we didnt know if was reality. The other interesting thing is in thearial you can see right about thenow the lot is blue, but above that is elevated i think it is George WashingtonCarver School above it and the School District also owns theto the left of the blue lot is the long skinny parcel, but even if we didnt get the School District lot it is a large space. On our third Community Meeting we told them there was a possibility of a grant so people were getting excite td about it and we told them when we thought we would come and talk to you about it and what we would do is if we get the grant we hold a couple Community Meetings specifically to work out the jeningplaza. The next slide we have some ideas. At this point because we arethings are so rough there are all kinds of elements that could be included in the plaza dependent on how much many we have. There could be planting and pace making, paving, street trees, lighting and fencing because the idea is to keep the yiria secure and clean and not let it become reblighted. The squej sin process now and we are just starting the design fauz so the timing is great because we would love to be able to include jenings plaza. You have full design Team Including experts and then you would also have bid and built at the same time so it would be come part of the Streetscape Project. We are planning to finish the design phase in the fall of this year and go to bid early next year with the construction being completed by spring 2017. Right now the palou complete street were a joint project, which means we have a paving budge lt of 3. 45 million. The sewer joined so there are different blocks with the new sewer lines at 1. 9 million. The streetscape portion is 3. 68 million and then we have a design budget for jenings from dpw of 100 thousand that we would do contribute to the design fees. The 450 grant would strictly be construction budget. So, if the Grant Agreement is authorized we will submit it for authorization to the Oversight Board at the meeting sep tember 14, 2015 and the Grant Agreement will become effective on the date the dof concurs with the Oversight Board resolution. The Grant Agreement is effective for 24 months. Based on the schedule provided and the timing related to the other funds we expect to complete the project within that period or the contract will close out if dpw is ahead of schedule. This concludes the presentation. There are member thofz community here and marsy is here to answer questions and im here to answer questions as well. Thank you. Thank you. Do we have speaker cards . I do. Mr. Chris logan. There is a 3 minute here, that means i get 3 minutes is that correct . Tell me when you want me to go. Go. Thank you tiffany for your explanation for the funding, i think that was important. My name is chris logan, i lived on palou since 1999 and moved here from Orange County which is different from San Francisco. I moved to San Francisco because i loved the diversity here. Racially, just everything. It is really excitingi stayed on palou because where love the bay view. It is great place to live and it has a lot of great potential. We have a lot of long time really nice residence who care about our community. It is unfortunate most of the publishty for our community is taken by a small minority of people who are not the long time residence who are really committed to our schools and churchss and the arts. It is exciting to see the whole bay view area become cleaner and prettier and safer. The true signature of a society is fomunitation thorf arts and San Francisco is known for its squarts the bay view is a luchbly conclave of the arts. We have the original opera house there, we have a lot of public art and by public art qu think what the young lady was rirfing to are the murals, a lot of murals. If you havent been 393rd street near palou you should take a ride there, there is a lot of pretty stuff. New york sate has chelsy and soohoo, those were wrairias run down and blighted for years. Artists were the only ones who could afford to live there but now it is vibrant desirable places. San francisco can repeat that success new york had with helping revitalize the bay view Hunters Point area. A small park where Community Members can gather and help the city achieve your goals revitalizing the area and that gives a opportunity for a mural public arts and trees and this will help attract and retain residence and that is very important. Commissioner mondejar talked about Affordable Housing. Bay view and huntsers point are the last affordable areas we have so this will have the city achuv the goals on multiple levels so hope youll prove approve that. I dont want to mispronounce your last name. Im [inaudible] i also live on palou, i live on the block just east of the jenings plaza. I get on and off the bus right in front of it every morning to go to my job at ccsf. I would love to see your support for this grant. It was eluded to it was a blighted area but it is a fence off parking lot which you can see in one of those pictures, cars park on the sidewalk in front tof all the time. There is constantly garbage and not just on the ground, but home garbage couches and beds. As [inaudible] palou will look different in a few years and it is [inaudible] while Everything Else was improved. I think lots of Amazing Things can be done there. The view from there is awesome. You can see all the way down toyou can see bay view hill and San Bruno Mountain and i think i forgot to mention, i live there with my wife and son and soon to have a second kid soon so a place for the community to gather, it would be awesome. I know lots of people on my block and west of there that want a safe place for a block party and people on bay view and palou are very energizeed where they live and the people around them so hope you guys put your support behind this. Thank you thank you i dont have any other speaker cards. Okay. There is a motion and second. Commissioner sing h moved and commissioner mondejar 2nd. Please call the roll. Commissioner mondejar, yes. Commissioner singh, yes. Madam chair rosales, yes. I have 3 ayes and one absent. Thank you for coming. Please call the next item. The next order of business is item 6, Public Comment on non agenda items. Do you have speaker cards . I do not. You do not, okay, then we can move to the next item. The next order of business is item 7, report of the chair. Madam chair i do not have a report. The next order of business is item 8, report of the exectev director 8 a results of the initial phase of the Selection Process for evaluating proposal submitted in response to request for proposal for 100 yurnt affordb housing praunlect plus one managers unit at 1153 street, block 3 aest, Mission Bay South redevelopment project area. [inaudible] transbay redevelopment project area. Madam director. Commissioners there are 2 informational memorandums in your packet. Actually the initial results of the staff analysis for the rfp that was issued in april you just received today as part of your packets. That is the rfp for 150 unit, 50 unit for formally homeless50 units for homeless and 50 units for families. The homeless units were up too [inaudible] require a operating subsidy and the 50 units are for families earning up to 60 percent area medium income. Rereceived 3 proposals that were responsive to your rfp criteria. Those 3 were from Development Teams comprised of [inaudible] with China Town Community development center. Community Housing Partnership and the third proposal was from Tenderloin Neighborhood Development and bridge housing. Based on the Multidisciplinary Panel convened included experts and representation from the city including Human Service agency that provides additional substaes, Mayors Office of housing and our staff and the initial results of the staff analysis concluded china town and [inaudible] were the most response ovthes 3 and met the criteria. There will be a presentation to the Mission Bay Citizens Advisory Committee on september 10 [inaudible] will get Community Feedback with our staff and well present the results of that finding as well as come to you for authorization for an exclusive negotiation agreement i Pre Development loan to get the project moving. Ill pause for any questions. We can move on for discussion and give a brief report on transbay block 8. It will come back before you shortly in the fall. The ena and predevelopment loan. The discussion about transbay and the related [inaudible] as you recall as part of the approval of owner participation agreement they were require today give quarterly reports on the status of securing a grocery tenet for the 12 thousand or so square feet for the ground floor grocer and there is subbasement space. The first steps related to that [inaudible] the developer, you heard Jonathan Shum or may have been hime give a brief report. They indpaijed a Specialized Marketing Firm that did a Retail Survey so they Specialized Marketing Firm analyzed all the retail within. 3 miles of the site to gauge what is out there and they also did a study in essence of where people shop for their groceries and they did a theoretical analysis if there were to be a Grocery Store on that site what would be the weekly sales volume and topping that, trader joes was at the top of 300 thousand per week all the way down to 150 thousand and chaij for a local independent grocer. It dozen mean those are the stores that would go there, but the Retail Market and the potential and possibility. It show thrz is a great deal of retail leakage with respect to stores in the area because people travel outside going the safe way at 4th and king, the safeway near jackson on davis street, Bristol Farms, they are going to whole foods, south of market and other specially stores. There is a market opening across the street from transbay block 8, that isnt yet open. This is existing retail and this is the first step in order to identify a grocer or food supplier that would go in and serve not just transbay block 8 but has a broader submarket for the entire rincon hill district. We expect to bring you these quarterly reports as the developer submits them and that offer as opportunity for the commission to provide input or feedback as it progresss. The transbay block 8 we expect will close on time in october and the sales proceeds will go to the tjpa and commence construction in the spring with 2 years later or so opening or more. That conclude my report. This was the first report. They indpaijed a specialized experts which helps us and the commissions deliberations for retail. We also are partnering with Transbay Joint Power Authority which has a sig cnts amount of retail in the transbay sener. Each of the Developers Hire their own broker. Gallb for their tower on block 6 they hired collier so we are engaging in a coordination effort to make sure as the projects are built it provides the necessary suvss people need. I would add the range of service because when you look at page 15 of the report, trade area dem ographics, it looks like it is diverse. I would like to see better numbers on the African American and hispanic category but when you look at average house hold income at 17 aith8, 506thality is a wealthy district and wouldnt want decisions to be made on the idea that people with a lot of money can afford certain choices. That is why i keep pushing for price points across all spectrums because if we have a lot of affordable households there, to your point especially with no cars, maybe they leave the kids at the Childcare Center. I know. That is an amazing average of Household Income what we work with the developerthis thir first report, making sure plan projection take into account the 35 percent affordable which has a diverse set of incomes and racial make up. Up interestingly, the theoretical projections about weekly sales volume, the most price conscious even with this analysis of the average howhold income, the most price conscious of grocers trader joes had the highest weekly sales. Whole foods, safeway, all the rest it teared from the. Even with they dont this project on dem ographic and average income, we dont know if it take synchronize to account our projections and delivery of the affordability units and will investigate that. It seems trader joes no matter what your income, that type of grocer is the most profitable. Just from personal experience just because you make a lot of money dozen mean you want to spend it all on basic necessities andlike food and housing. 178 sounds like a lot but if housing is huge and medium age. Seem to match the Mission Medium age. Of which household it is 1. 6. We dont have families. Average, there is we dont have families, but if we build affordable unit the 3 bedroom units this might change because this is currently, this is the current residence and even on the ethnicity 5 percent, African American and 7 percent hispanic you will get a mix. You will see mixes at every dem ographic level as we move forward. Ya. The Grocery Store i like the canyon market. Like the grand canyon. Market. Ya. What i like is that it has a diversity of choices. It notit is the cheapest place but there are food choices in it that people of differentnot just choices in terms of prices but choices in terms of offerings andthe kitchen is all latino so they create a bunch of things and make tamales so it is a interesting gourmet ish type market thatit is like a between whole foods and the Small Mission grocer, sort of like a midpoint. I was surprised, weekly sales of 300 thousand. It dove tailsoc ii staff worked with mta with the bus lines. The number one issue for existing residence is how to get to the Grocery Store so the 10 [inaudible] was routed so residence have the ability to hop on and hop off within a block or 2 at most of trader joes and safeway which reflects the sales volume. Where is Bristol Farms . It is in the west Field Shopping Center adjacent to the food court. I dont consider that an alternative it is like a grab and go. The sales solium is the fast casual lunch crowd. It is a augmentation of the food court and they have the most square foot unit. There is the ability to purchase goods but the fast casual market midday and evening. [inaudible] on powell and between geary and mason maybe or ellis. Wallgreens has this new very modern store, which also they have groceries, they have grab and go, very modern, very quick and they call it the corner of healthy and something. I could not believe the lines. I wasit is on powell street. This new concept on the corner of healthy and something. When i walked there and notice d a long line and it is wallgreens. Very modern, they have groceries and sandwiches like a cafy. I thought it was amazing. The prices are very good. It like the Bristol Farms you are talking about. It may cater to the hotel crowd. Could be, but there were a lot of young people. I took advantage of it because it looked very nice and engaging and inviting and healthy. I did want to add through our forward planning because we vanumber of other blocks in transbaythis is the Transbay Development map. It is a attachment to your transbay ablock 7. It is the first one and overview of where we are. Transbay block 2, which is also across the street from block 6 and 7. Block 8 is the report and block 2 is an affordability development in the pipeline and because it is 100 percent affordable versus mixed income, we have a greater ability to control the framework of what would be at the ground floor and talk early and often with potential Grocery Store operators. We have been engaging with safeway to understand their requirements and we will be talking with trader joes. So the extent certain needs are not met on transbay block 8 we are looking at a continuum and to plug the holes where needed. There will be a gap which is wie the push to provide forachy sessable transit which is something muni did now, not waiting years from now, it is something they could do and did at our insist squns the residence and stakeholders so on opening day they have immediate accessible access within a block or 2 tothrough the buildout over the next 4 or 5 years fill up the neighborhood. You talk to anyone who likes to now instead of drive, walk, things that are relatively close especially in a area like this, transit rich and no hills t is like the model that everyone thinks is so sexy about the mission but we have to make it affordable. Not every piece of it obviously but cant imagine the market place or whatever it is called is going to be your Friendly Neighborhood Grocery place to pick up milk and eggs and bread for the kids and not cost 40 bucks. I didnt say that. The fact that if we can deliver own all of that, that is like i like the idea of talking with sfmta so when everything goes on line it goes on line seemlessly and that is the experience of quality of life. That is where the affordable units are part of the neighborhood and it speaks to them rather than being in a island in a larger world. It is also birthing like the Google Express because it is hard to getthere are no corner Grocery Stores so you see a lot of Google Express bikes and vans because[inaudible] ya. And post mates. You want to deliver [inaudible] that is what makes San Francisco special, that neighborhood feel and if we create a new neighborhood even in the sen center of town that is what makes it special. It is a very exciting area. Z pretty soon well have grocery food trucks because of the population in my neighborhood south of market where we are building. Hat that is a good idea. You see the food trucks where people buy din er and pretty soon you will see grocery food trucks. Grocery trucks. Safeway has that service, they deliver to your house. Yes, they do. That is why i say google exspess, they serve all that. Safeway, whole, foods, trader joes, castco, wall greens deliver in that timeframe. The phils coffee piece is great. The more local retailers that are moving from their home neighborhoods to other neighborhoods [inaudible] it is a little pricier. Phils has a coffee shop they station down the street from the [inaudible] and i mean phils coffee just open on market near wells fargo. You will see all these lines in the morning. Phils coffee, blue bottle, petes. Phils is on market and blue bottle is on sampson before that. First or freemont. In the plaza. They have this order ahead so when you go therethere is still a line to pick up your coffee with the melted ice. You get there and say where is the ice. Anyway, it is just also generating a lot of business and start ups like the food trucks and pretty soon i can see grocery trucks. This is exciting and im glad we have the survey results and im looking forward to what the selections going to be. Ya. As you said the neighborhood so, we have a few more items and we are about to close the next item please the nextordser of business is item 9. Commissioners questions and manners. Madam chair. Any questions, matters we havent covered already . Commissioner sing i think we should adjourn the meeting in memory of rosorio. She was one of the best commissioners. She was my Vice President and actually not too long ago she came to our house and had dinner with a few more people, you know and i really feel very [inaudible] it was a private ceremony from the family, but if somebody wanted it go i sent out the information to tiffany there. That is very appropriate, thank you. I didnt get a chance to know her, but from the response and what i have read about her, it seems like she was a very well loved. Very very nice Girl Community leader. Very long time. I didnt know her well, but as a young woman when i did Community Service in calleges my mission was Mission Vocational school and she was there then. She has been thereas a member of the community very well regarded. I thrink is a memorial set in september. It happens tobe my birthday so i wont be there. Please call the next item the nextordser of business is item 10, closed session. There is none. The next order of business is adjournment. Madam chair. The meeting is adjourned at 414. In memory of rosario [inaudible] thank you. 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 FoundationEmployee BenefitsPlan 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 PreventionProgram 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 set up board form. A board form theyll be open to the public. Okay. I think its a wonderful idea, what time will be held it will be in a regular meeting slot is a tender plan at this juncture a lot more details as we go for. One concern i have is is dont people work during these hours and how much input are you going to get . I mean, im privileged position because a retiree. Now, most people work,. They may have concerns to. How will we get some input to this quorum . Will try to address the concern is we do our plan. Thats all i can do today. I . Any other Public Comments on this item . Hearing none, will move to item 11. Item 11, discussion item, opportunity for the public to comment on any matters in the boards jurisdiction. Is there any Public Comment on item 11 of the agenda . Hearing none, and seeing none, we are ready to stand in adjournment until were next convened publicly. [gavel] if you are interested in our local City Government and would like to work with 18 other enthusiastic citizens committed to improving its operations, i encoura [chain saw whirring] [growling] listen, you are extremely terrifying just the scariest undead thing on tv, and i really mean that. I am worried that you could give my kids nightmares if they see you, so im gonna have to block you. [sighs] so, thats it. Oh, and tell the zombies theyre blocked, too. Come to order and the skeet will call roll commissioner pating commissioner king commissioner chow commissioner chung commissioner sanchez commissioner karshmer the second is the approval of the minutes of august 4, 2015. Before you guess for approval a motion is in order. So moved. Are there corrections to the minutes. I think the only typo on item 10 it is obviously sf dph. My apologies thats the only one i found or saw sorry my other comments if not then the minutes are before you for approval all in favor, say i. I. Nancy pelosis the minutes are approved directors report. Good afternoon, commissioners sitting in for director garcia on a well deserved vacation hair directors report the first is to talk about the first cohort of interns on august 3rd dpw Human Resources provided a orientation the year up a National Program that provides a pipeline of threatened to 2 hundred and 50 partners by matching their needs for the communities that are loyal and trained the first cohort is 9 interns working with Technology Managers throughout the Fields Services and help desk function department supplied Community Health epidemiology known as arcs to have a surveillance report foyer it and online we highlight the disease from hiv are hepatitis b and c and sftv. Con cable disease in San Francisco we hope that provides a snapshot for the Population Health division august authenticating is International Overdose warns heroin fatalities in San Francisco have declined since 2000 from hundred 20 annually to 10 annually under 2010 to 2012 the change occurred in the Community Partner institutional listing drug treatment and making it available for drug users as a overdose antidote the Population Health division in collaboration with behavorial fund the Drug Overdose education project called dope to district this to folks if snow and the Community Organizations that serve them in the past six to eight weeks the staff observed an increase in the what is confirmed to be a drug the reports of over dozens have been record it is important to note despite the offer dozen referral it has not been known in San Francisco the physician to providers noticing them of the recorded increase in the small occurrence that concludes the directors report im available to answer any questions. Well, not to the director on the directors report. Commissioner oh, okay so, yes. Thank you commissioner karshmer. There has been numerous articles in the paper about the epidemic outbreak not sure for the use i want to have you embellish not clear what it is the paper as facts emily heart is here to talk about this topic. Please. Please welcome. Im Research Correspondent and the center for Public Research so ive been working on our opiates overdose and familiar what is happening recently in terms of the new cottages youll see a lot of sort the offer dozen emancipation proclamation demonic for the prescription inventing necessarily and on the east coast a lot of the recent Senior Citizen necessarily outbreak overdose a few differences we were able to get some of the product tests at sf dph we dont know if this is being produced or pharmaceutical were trying to fourth thats the difference typically on the east coast we know there is a lot of alight drugs that is traveling there the east coast cities another thing weve seen in San Francisco we are overt into this epidemic sort of the increase no over dozens most recently, we were informed through the dope and the syringe that is different and is really a positive carrot for San Franciscos effort to decrease im you see increases in the mortality and were seeing you know the anecdotal reporting coming through the dope project and catching it from there is more taillights anecdotally we have gentlemen, yes one person we believe that died due to the drug so weve got age isolated incident the one thing we encourage we get as itch drugs into the community to prevent the mortality this is a highly sat down rated area sentinel requires for opiates were encouraging people to use more than one dose if necessary. One question you were with dr. Coveers information i wanted to thank you it was relevant to any clinic a drug abuse clinic that helps with the community with relevant to the oxycodone has the Police Department been trained and adapted the ox deny protocol. It is rolled out through the San FranciscoPolice Department and i will say that that is wonderful and also encourage people in the community to have it at well, theyre the people that are onsite they can be one step ahead of objection done. I assume it is the Police Department that policy another typo on the third paragraph; right . I was going to ask dr. Katie it seems to me if hundred and 20 deaths annually to 10 deaths annually is really quite significant we were quite concerned about the deaths with the idea of having necessarily objection available to the public in the changed program for surface do you believe this is the success it is. Yes. Ive been in contact with dr. Koffman in my cabinet and reviewed the research it is of the that the more question implement the longer than we implement necessarily objection a great coraegs regulation and getting the news out but this is very fluid this is a wave that is not quite clear what the market analyze it would be easier to cut necessarily objection but the dealers can get more money it is driven by the dynamics and underground market im happy we have an excellent surveillance unit this is complicated the use patterns around civic center is different from cap street and the avenues so it is a micro compliment kind of issue with regards to where it is floating about but have an excellent surveillance and the word get necessarily objection on the streets and it saves lives. It is a very nice report for the awareness day it looks like were certainly at least on the right track wear a National Leader very is policy in conjunction with the state legislation that is National Standard im not sure were the first with the Needle Exchange and perhaps necessarily objection but this is really standard throughout the country so many great things that start here in San Francisco with our department so well, thank you. Any further comments if not well proceeded to the next item. General Public Comment ive not received any general Public Comment requests so well move on from the Community Health community. This will be brief we heard today with dr. And leslie shes the director the Response Team known as b e f f e r and leslie the Action Committee for women in prison try care Response Team the bottom line we apartment the question were thinking there are commissions will ask in terms of the Emergency Response are we prepared quantifyly were prepared as evidenced by the response to the louisiana country and ebola the Department Route reviews capacities that are nationally required in terms of Emergency Response were providing and meeting all of those and probably beyond when you look at what theyre doing within the department with regards to training all the departments Public Health staff for the Emergency Response workers and working with the hospital counseled and assistance that is very much in presence today, the spearheaded approach to emergency prepares is through dim insurance through training and exercises and multiply scenarios that are continually going on are we prepared and ho do we know well hear a more fully presentation on the boards level in october and they promise to give us that respond in a more descent way but quantifyly we feel there is great depth and the exactly part of the presentation was in regard to the patient under care in the network occurring an emergency can we take care of patients in the Health Network and direct response providers the answer is one 26 into 3 parts looking at the preparation of the San Francisco general and laguna honda that is not put in this but preparedness in the ambulatory there shutting down a clinic and okay do we know where all the patients are and coming into staff that day and practicing those disaster scenarios we have the structure and processes that are being implemented in terms of the question are we prepared their planning on coming back in the october meeting to answer that more fully so again at the Community Level weve felt there was Good Progress and satisfied with those citywide preparedness and health wise preparedness. Any questions. I have one in the sense that in a citywide emergency question would be whether our clinics are prepared not just for our own network but for others. We can ask dr. Babe babe to speak those are part of the scenario training and id like to underscore the department of training all the department of Public Health staff to be ready both for citywide emergencies and a Health Network emergency were at 50 percent the ducht has been trained hopefully to hundred percent so a full system capacity to deal with both levels im going to turn it over to dr. Bubba. I was going to everybody else all the Health Care Partners understand they can train anyone actual one the cabinets it the medical sunday morning for the entire community not only in the ambulatory network but garner all their resources to be able to serve whatever the disaster is. Is that part of where your review going to go in terms of your review. Were trying to look at the Community Health care were looking at the Health Network and the citywide capacities well hear both those in the october meeting; is that correct. It would be up to the commission which parts of the meeting to highlight youll get information on all the Services Provided within the population and bans that information choose to highlight ones for the october meeting. Okay. It so you would if we are having it prepared this is what youre talking about also that if that became part of an expansion and the area so we can understand how the precipitation program is coordinated here does that make sense and there are two levels one is taking care of our own patients part of our network your responsibility and taking care of the citywide folks the way i think the way the department has designed the flexibility of the staff to address both is really amazing not there yet i think were still training 50 percent more of the staff but the goal is there. Any further questions. Okay. Thank you very much and ive not received Public Comment for this item. Yes. Please. I have an urgent comment can i does that relate to the item were on. What. Does it relate to the item were on. No, it would be general Public Comment and oh, sure you just got here are we finished with this particular item why not take here comment at this point. I hope youll find is ms. Cross ill put 3 minutes on the buzzer. Do i have a half minute warning and i will do that. My name is are last name is nancy cross anybody that reports what is going in the city that might be an emergency takes a risk the grand jury said no whistle law for reporting things that need to be recorded but i am as a a resident of a shelter which is subject to not good Health Environment in terms of noise and smoking it violates the law to smoking and also i was hard of hearing all day today because having to listen to a leaf blower sound all night long churning air into the blast you know, we have all the hotness we have it night and day because people think that is a nice game to play on women residents in the first floor they hear it we have no benefit of anybody evaluating whats going on all day long ive had problems that leaf blower was running all night long and continued now the person responsible it the Episcopal Services community and within a week as i remember in the carpenter examiner to showed two sros he is the they were found dead bodies most in those hotels and what was his response . He shrugged his shoulders things happen i think we need an overview of Things Health related in relation to this health and not other primary urgent care and hospitals for patients that get sick and ill and abused by nonoverview of the environmental conditions including the loud noise of the leaf blower all night and day long for a week or 10 days you have ten seconds. I hope you can do something about it. Our department will take into account that weve had interests in the serves of the sros. Thank you for allowing me to speak. Thank you. Item 67 commissioners is the fiscal year 20132014 charity report. Good afternoon commissioners Deputy Director im mabus im the new assistant director for the department of Public Health im pleased pleased to present the 20132014 charity care report as many of you may know the 2013 information has been detailed cue to staff changes in the office but the decisions to combine the information from 20132014 to present post analyze and we believe it made for a better report first thank you all 234reb89 well discuss the presentation will take 3 parts the first 20 to go over the charity ordinance ill provide brief information and the second part will go into the Charity Landscape with the Affordable Health care act and the third part of the presentation the part well spend most of the time based on the finding of that track fiscal year 20132014 report and so first, the charity care owners its been here since 2001 the first of its kind in the in addition the purpose to provide transparency around the charity care levels that we are seeing in the city and county and to allow the did you want and the Community Partners including the hospital to plan for different charity care needs were noticing through the report it is defined charity care emergency in and outpatient medical care for those who cant afford to pay along those lines to requirements the first having to do specifically with the hospital and the second a joint requirement between the department of Public Health and the hospitals themselves so the first requirement has to do with with maurnt patients to be notified and they do so first verbally and also a requirement to have notifications in various areas of the hospital novelist the parnlt of the eligibility requirements for them the second requirement has nothing to do with with reporting every year the hospitals in San Francisco provide charity care data to us and the department of Public Health then in turn analysiss the data with a report for the charity care trends reporting purposes 78 reporting hospitals for the Charity Care Ordinance and they fall into 2 main categories mandatory health 360 are required by ordinance to provide information to the department of Public Health and volunteer hospitals those would do so volunteering on the slide the volunteer hospitals are notified after kaiser and sf g h and another one providing the analysis for the charity care report oh, and one important thing to note all the hospitals whether mandatory of volunteer provide the same information no difference between the information and the mandatory volunteer is simply for reporting the next thing that is important to know the actual charity care reports that the hospitals have within tare buildings so as you can see the state law delineated by the red line the hospitals provide information below 50 percent of the hospitals the hospitals meet or exceed this requirement against it back drop weve talked about the Charity Care Ordinance and the reporting hospitals i wanted to also all the Main Findings that will go go depth were talking about the first has nothing to do with with the decline in the number of Charity Care Patients the next healthy San Francisco and traditional paperwork the next findings with the variations among the reporting hospital the next has nothing to do with with the medical shawls with the city and county and the last has to do with charity care paperwork and the residential paners that remain thinking chaunld i changed from 20132014. This slide notes the number of Charity Patient from fiscal year 2009 to 20142009 was the first year the data was separated from healthy San Francisco patients and traditional Charity Care Patients just to be clear the healthy San Francisco patients are within the program whereas the Charity Patients back in the Charity Care Programs run by the hospitals themselves as you can see that with and an theres in the healthy San Francisco patient the blue line a decrease in the Charity Patients that soifz a shift between traditional care and healthy San Francisco as the healthy San Francisco were gaining momentum and popularity among the insureds the number of patients seeking the care increased over time the timeline you notice has nothing to do with with ac a related information as you may know the ac a was signed into law in 2010 so 2013 San Francisco engaged in a rigorous effort to enroll as many folks as possible into the new Health Care Programs as possible as you can see the circle delineates the shift from 2013 to 2014 and with the healthy San Francisco patients the blue line as you can see a significant decrease the first time in the history of the report if 61 thousand to 51 thousand 10 thousand less patients for the traditional charity skewer patients the decrease is much less significant 3 thousand patient and the decrease was note before the Affordable Health care act taken together ann and overall a decrease in the total number of schirt care patient if 20132014 from hundred 10 charity care painter in fiscal year all in favor . I. To 97 thousand in fiscal year 2014 that prediction that the city and county had for the successful enrollment to decrease the demand for charity care actually rang true this graph shows fiscal year 2009 to 2014 but it tracks the Actual Expenditures and so for the blue line the healthy San Francisco patient as you can see that the expenditures kind of track the number of patients weve been noticing over time with an increase in the fabulous number of patient a steady increase in the expenditures associated with that group if 2013 to 2014 a shafrp decline this San Francisco patient a sharp decline in the expenditures associated with that group thats what youll expect to happen as many uninsured patients frathd i anything congratulated away from 2013 we saw a coresponding interests in the amateur expenditures the history is not clear if youll notice in the previous slide in terms of the number Charity Care Patients the overall number was decreasing over time the impact of the ac a on the Charity Group is less attributable to the Affordable Health care act as you can see here the expenditures as commissioner chow rightly appointment have remained flat over time the considers in the amount of expenditures in 2014 and an increase in 2014 but the increase button them compatible to previous years it is unclear with the trends actually represents at first, we thought perhaps the understated line with regards to expenditures along with the decrease if the number of patients said something about the patient less health needs or status worsened commissioner chow asked us to understand the relationship with between the expenditures and patient no evidence that alluded to the Health Status worsening or their health needs more complex more information is needed to understand what the trends are but the future charity care reports will note that now weve talked about a little bit about the overall Charity Care Patients and he expenditures i thought ill provide information about the actual patients themselves as you can see in terms of the expenditures for Charity Care Patients adjusting for inflation the Charity Patients has remained flat and decreased in fiscal year 2012 to 2014 and in terms of the Charity Care Patients how their assessing the Charity Care System as you can see the overwhelming number of patients assess the system throw out Patient ServicesEmergency Care patients have a sixth role to play as you might expect charity care reports outlines the data across 3 points the first is the overall what was the experience for 20132014 overall and the next data point has nothing to do with with healthy San Francisco and traditional charity care and then the last has nothing to do with with the hospital specific trends that we saw after analyzing the data provided to us what we saw there was really not a clear hospital specific trend in 2013 to 2014 that applies to all the hospitals nonuniform changes from fiscal year 20132014 i had a hospital meeting with many of the hospital representatives in attendance today it was noted the city and county excuse me. Very unique transition period that transition period and how unique for every hospital b will lead to the results were seeing some of the factors that might lead to the result would be the geographic location of the hospital, patient migration patterns and the various insurance Enrollment Programs that each hospital has one of the measures that we looked at was expenditures by hospital as you can see you know this tracks from fiscal year 2010 to 2014 as you can see before the arching a a slight variance for hospitals in terms of their Actual Expenditures from 2013 to 20145 hospitals got a st. Lukes oar st. Francis and as far as i am concerned and sf g h kaiser and chinese and ucsf actually experienced increases in charity care expenditures that is the kind of various in the data and one thing to note weve decided in the Community Meeting worth noting the hospital reporting periods are not uniform some hospitals report to us on a fiscal year from july to june and some hospitals report on a calendar year into january to december as you can see in the slide the hospitals with the asterisk they denote the actual hospitals that are reporting on a fiscal year so the hospital timelines in terms of the fiscal year years dont exactly match up as you can see within that group the calendar hospitals at the top and the fiscal year hospitals at the bottom there is variance variation as well could lead to that is not necessarily the reporting period but the specific hospital characters that will effect the type of charity care expenditures that a hospital mit see from year to year. This graph shows the actual medical shortfall and the charity care expenditures one thing that is very important for all the hospitals in the city and county are medical shortfalls maine the difference between the cost of providing a particular service for a medical patient and the actual reimbursement as you can see there is also variation in terms of the hospitals experiences the report as requested by commissioner king details from 2010 to 2014 but for read ability purposes cutdown it down for 20132014 for that substantive so you can see the trends taken together across the 8 hospitals as you can see that there was a decrease in the amount of charity care expenditures to the tune of about 21 million but an increase in the medical shortfall over that by about 3 times 63 Million Dollars looking back in time those changes were the most significant weve seen in the data. Is that for all the calendar year for suffusions over and over the bryan graph. Im sorry, i should have denoted the fiscal year the four hospitals on the bottom are reporting fiscal year sorry about that. The charity care owners requires the hospitals to provide zip code information an important measure it allows us to track the traditional charity care trends over time and what we saw in looking at the information the residential patterns of the traditional charity care patient doesnt change 6, 9, 10 and 11 contribute to the landscape in the city and county and those districts are areas we might focus our efforts with regards to the uninsured and loovktd the data we found the traditional Charity Care Pool may consist of in the new health era new san franciscans 20 percent to 76 in 2014 a disinterests performers of out of the county due to other counties robust ac a enrollments efforts as well less of out of Community Residents and a consistent population of homeless 10 to 12 percent and out of state 12 percent consistent over time so taken together in terms of the Data Analysis we had looked at 0 for the charity report a few conclusions and important points stand out the first one the a. Ac a has an important change with the Great Success in intraoral folks in covered california the proposition of the uninsured has decreased we expect a less of a demand in charity care we say this overall the second point it the general it continues to provide and likely continues to provide if the Health Care Era the significant moumg of charity care and significant amount of expenditures 70 percent is the General Number that we have notice over time and expect that to continue the third is maybe the most important point in the whole presentation that is to say that there is going to be a continued need for Charity Care Programs and the Safety Net Services in the studied the first thing the doctor and demand for charity sincere a testament to the ac a enrollments were seeing over that time but also a significant pocket continue 35 and 40 thousand people in San Francisco who will continue to remain uninsure