Allegiance to the flag. I pledge allegiance to the flag of the United States of america. And to the republic for which it stands, one nation, under god, indivisible with liberty and justice for all. Thank you. Our secretary will call the roll. Roll call. President scott. Present. Vice president lim, excused. Commissioner follansbee, excused. Commission sass expected. We dont have a quorum but we will by the time we get to an action item ive been assured by those expected commissioners. We do have some opening remarks so if youd call on discussion item 1 please. Item one opening remarks, Health Service board president and acting director. Mitchell, ill take the privilege of going first, if i may. Thank you. This forum is designed to do several things. Not only to provide more in depth information on certain tommics and issues that topics and issues that will bear on the work and policies in part as well as the issues as we work win providers. Some of these are not unique to the system but theres changes year to year well be addressing today. We began to do this three years ago. The premise was we werent going to try to cover everything. The landscape has changed dramatically with the election of this new president and this administration. Exactly where were headed strategically from a health care standpoint is at this point in my view anyones guess. We know some things are still in play this board has a fundamental responsibility to understand the current environment to make the judgments necessary on behalf of the members of the system and thats the intent of this forum today. At this point ill turn it over to commissioner breslin with bad news. In june 2005 bart was appointed as the first director of the Health Services department create proposition c at the november 2004 election to protect our benefits. He resigned in october 2009. A resolution in 208 commanding bart mentioned some of these accomplishments. He transported the Health Service system from the edge of failure to unprecedented success in Customer Service and satisfaction. Inspired staff and raised performance to a new level. He reorganized the rates for more open enrollment practices for members completed on schedule. He improved Financial Reporting practices, financial forecasting capabilities, retrospective reviews and errorfree audits. I think anybody around will remember the day we never had errorfree audits until bart came on the scene. He had a policy and funding policy to assist the board he established the website. The adopted the Health ServiceBoard Governance policies and procedures and established the hhs health fair and created the dashboard project, he developed a Strategic Plan. Bart was brilliant and had many accomplishments. He was also one of the most ethical people i have ever known. A quote from a letter the staff sent to the hhs board dated january said bart has instilled the importance of doing the right thing for all Health Service system members even when faced with strong opposition. He left us too soon and he will be sorely missed. Commissioner thank you commissioner breslin. Id like everybody to stand in a moment of silence honoring his service. Commissioner thank you. Acting director i want to say thank you commissioner breslin for your words. Many worked with him and his work is remembered in the Health Service system and their feeling remorseful about his early passing so thank you for mentioning him today. I wanted to say in addition this is an Education Forum well have a full open enrollment before. You know it closed october 31 but the work is still going. To stay it was an epic large open enrollment is an accurate statement. The whole staff worked hard. It was all hands on deck. We will have a full report in december as well as a continuing update of the blue shield implementation. Thats the conclusion of my comments. Commissioner do you want to make a comment about your pending vacation . Commissioner so yes, ill be out of the office. Ill be available by phone and remotely. Ill be out of town. We know pamela and others will be in good stead to manage the office. And for Office Members listening this is not vacation for you. Continue your good work. Now well go to Public Comment. Is there any Public Comment on discussion item one . Hearing and seeing none well go to discussion item two. Item two, discussion item. Aon Hewitt Service plan. Great. Good afternoon. Im Wanda Anderson from aon and will present the service plan. We appreciate please speak in the microphone more . We appreciate the opportunity to rearticulate our commitment to the board given recent staff changes on the aon team and to reassure the board we have a proven process of transferring knowledge to ensure nothing gets dropped or false through the crack. We wanted to give you visibility in the way we work with clients and a specific plan with hhs and hhs board as we move forward. I know have some limited time. Push me along if you want me to move a little bit faster. Page two is the framework of how we work with our clients. This is how we work with clients across the globe and as leaders much aon we are measured on the satisfaction and results we deliver on behalf of our clients. So youll see on page two there are key areas that were focussed on, partnership, innovation, excellence, expertise and results. What weve done in the subsequent pages is to articulate our commitment in those key areas to the board and to hhs as it relates to our benefit consulting services. Would you like me to hit the highlights of each page . Commissioner i would because this is going to be a point of continuing discussion as we go forward this year and so it would be good to lay a framework today. Sure. So i think one key area is around stakeholders and the constituents and board and staff and we will have interactions with board, staff and vendors to have ongoing dialogue with the president and well make sure those activities occur. And we have ongoing ways of Building Partnership with developeders that support the initiatives you deliver to your membership. We want this to be and while we have a change in the lead actuary the way were staff is teamed oriented. There are people that have behind us that have been involved in the work we deliver to the board for many years and that has remained consistent nep Knowledge Base is there and we have a process of transferring that knowledge. Then as we had spoken maybe a month ago we do have Senior Leadership from aon hewitt very much concerned and wanting to be involved in the progress of our relationship. You had a chance to speak with our ceo. She will continue to be an executive sponsor and be proactive in contacting the board and staff for feedback. In addition our u. S. Practice leader is an actuary by training so another appropriate level of executive sponsorship especially with the change of our Actuarial Team leader. In page four we have done great work with te board and staff. This is where we want to make sure we bring the depth and breadth of resources to bear. I think you have seen some of the new resources that we brought to bear so for the aco trio we have a medical director involved in our conversation. We have pharmacists. We know thats a huge point as trends continue to increase. We have expertise there. So youll continue to see the depth and breadth of resources we bring to bear. In the meanwhile well have the team before you. In term of measurements, feedback from the board and the staff and obviously any Public Comment is appreciated. But also i think the results like supporting the implementation of trio is another way to measure the success of that component. In terms of excellence, you talked about error free. We know how important that is especially in the Technical Work on behalf of the board. We have all the right expertise and peerreview process to deliver with all the deliverables to you. We also have a very disciplined project management process in place that will help us be proactive and really understand and look ahead of the curve in terms of any considerations or issues we may be facing and put a mitigation plan together. Again, ongoing feedback from the board and staff and regular checkins with executives and mitchell and myself will be the measurement component. Lastly, results. We want to make sure we deliver value to our clients whether its measured in quantitative and qualitative ways. I think the board has done some phenomenal things in the past and obviously your trends have been below the National Average so we want to continue to deliver those results working in partnership with the board, staff and vendors. Again, this is from a measurement perspective ongoing feedback. We do as part of our client promise have not only ongoing dialogue but we do a survey at the end of the year. I believe the hhs staff has received the survey and again folks like myself are measured by those results and thats another way we improve our process of delivering to our clients. With that, if we can turn to page eight an org chart of the Consulting Team at aon. I serve as your account executive with overall responsibility for making sure that we deliver the strategy and the results that you desire. Then we have the team mike is leading and youll see names below him and those have been consistent actuaries over the past years on hhs and so they are deep in the details and understand whats been happening. Then youll see from a nonactuarial ann and she has a team below her to help deliver on the work we do on your behalf. Then you obviously know scott helfan. He knows the board very well and has been crucial in helping us navigate some of the changes. Then youll see the subject Matter Experts that bring in as appropriate the work we deliver to you. Commissioner in my mind the functionality of this chart would be as follows, the subject Matter Experts would be directly under the two branches that you have. Scotts role as Relationship Manager would be parallel to you or under the subject Matter Experts, if you get my drift. I think the way this process has been working over these past several years, we have had the subject Matter Experts on call, directly through you or the lead actuary so scotts role is not one of filtered to the subject Matter Experts but of assisting the process at some level. I think its probably been more in consultation to yourself than being directly involved in any work flow matters. And he should be at the top because hes the Relationship Manager and making sure the broad resources at aon hewitt are brought to beari. Commissioner i wanted to make sure that impression is made to the process. Commissioner breslin. Scott is employed by aon . Yes. Commissioner how long has he been employed big aon . A number of years. Really . Want me to follow up on the service . Commissioner all right. As long as were clear about that. Thank you very much. Is there anything else. I want to note, how we support you every month and theres activities behind the scene and wanted to make sure theres visibility that theres a process we know to be proactive in our relationship. Commissioner this is a good explanation in what you plan to do and i appreciate it. As you know, we had a meeting about a month ago where this news was brought to my tension and i gave you my fullthroated reaction at that meeting. Relative to the process not the decision itself. The task ahead of us is to figure out how were going to work Going Forward. You introduced several key members of your team at the last meeting but id like you again to reintroduce the lead actuary working with us and key members of the team. Mike is with us today. Hes been with aon hewitt. Come on up. He say great actuary. Weve worked together a number of years and im so happy hes on this team. Commissioner mike. Mike clark with aon hewitt. Commissioner you can pull that up to almost your height. Ive been spending the months getting immersed with the data and working with the hhs staff to understand financials even start early thoughts around looking ahead to 2019. So its been a great two months Getting Started and i look forward to continuing the process. Thank you. Commissioner commissioner breslin do you have comments . I want to make it clear i expect full transparency to the board. I know youre not appointed by the board but youre approved by the board. And ive often thought the reports were designed to get a result whatever was advising him wanted instead of a clear transparent report sometimes. I was especially concerned about a violation of our reserve policies in the last year. I dont care about what anybody said i would expect all reports to be transparent, independent, not influenced by anybody, hopefully. So thats my concern. Im not blaming the past actuary too because he was between a rock and hard place. Commissioner and one question i dont want unanswered is that we were in violation of a policy. We voted on it so that wouldnt make it a violation. I think we need to be careful with our language particularly in this day and age. Go ahead, mike. Thank you for your commentary. Im transparent and ethical and worked in a collaborative fashion and i will bring that with my work to the board and members of the system. Commissioner thank you for those assurances. Well looking forward to continuing a working relationship as we go forward. The expertise thats been provided is critical in meeting our fiduciary obligations. I think we should add that to our plan of being fully transparent and objective and that is always our goal as an Advisory Firm and team. Thats what were expected to do and will put that as a plan with the transparency and openness well be proactive in identifying the pros and cons of any situation so you have full visibility before making decisions. Commissioner appreciate it. Thank you, again. Commissioner is there any Public Comment . Hearing and seeing none well go to item three. The clerk discussion item Internal Revenue code cafeteria plans director. Fr i want to give a background on what we included this. Every year usually in the august meeting or september meeting we bring in front of the board the membership rules for approval. We also bring the cafeteria document for approval. We wanted an opportunity to share with the board why we do some of the things we do operationally and the decisions we make about requests from members outside of open enrollment. Commissioner i thought you did it by throwing darts. I noticed during tenure with hr directors and analysts why do we have some of the rules. Were not just being mean. We do have to follow guidelines and this involves things like new hire and they have to enroll in 30 days as a new hire or if theres a newborn and you want to add them to the plan it has to be within 30 days of that particular date of birth. The reason we do that is because of federally governed rules and theres tax consequences if we do not fully follow the rules. When we talk with members and cant enroll them 90 days after the child or birth, theres an appeal process. With that said aon will give a brief summary of what the code means. Commissioner thank you. Section 125. Todays agenda what wed like to cover is what a cafeteria plan is, section 125. The key requirements of the plan. And whats allowable within the section 125 and highlight the discrimination rules and then consequences of non compliance. And this comprise with the tax code. So most of the health and welfare programs are delivered via cafeteria plans. What it does is generally allows an employee to choose between a cash salary reduction or a benefit on a taxadvantage basis. Its both to the employee and employer. Pretax dollars are used to pay for benefits. Employee payroll reduction are pretaxed and players do not pay payroll tax. Theres a few so youre not subject to fica tax and in some cases income taxes withholdings. Because theyre pretax theres limits on what you can do within the plan. So well go into a lot more detail on the following pages of whats allowable changes. The section 125 of the tax code applies even if its not applied because its a private sector. Arisa doesnt apply in your particular situation, however the tax code does apply for your plan. So what are the key requirements of the cafeteria plan . It includes a Plan Document. This is a legal document that states how the plan works and define the section 125 plan and it has to be available to employees at their request. Its reviewed by the board every year and updated and as rules change the Plan Document is updated. You need to have an annual Enrollment Plan and i know youre going through this now and it can be painful but its allowed every year and gives employees the opportunity to choose their benefits. The benefit decision has to be made prior to the starting of the new year. The plan is why your having the enrollment in october and most are on a calendar plan year and the open enrollment happens in the october november time frame. So after the annual enrollment, your generally not allowed to make changes but there are certain situations where you can have changes during mid year and well go into the provisions on the following pages. There are specific provisions that are required and they include three categories. So you can make a midyear election change if you have loss of other health plan or acquire a dependent via marriage, birth, adoption or become eligible for medicaid or another federally funded program. So those provisions are part of your plan. If a change in status occurs, the election changes and this another rule that has to be consistent with that event. For example, if an employee divorces the employee may dop drop the coverage for the hou spouse. I want to note many employer have a verification process in place to make sure theyre following the rules as it relates to dependent coverage and a qualifying event. And the next page are actionable changes. In general youre not allowed to make changes unless they fall into these categories. If you do allow changes, they normally happen within 30 days mitchell indicated for the qualifying event. It could include gain or loss of a dependent, marriage, birth, death, divorce, gain or loss of other covering others and it could be change like full time to parttime or you may stop working. Those are employee status changes or significant change in cost or coverage. A scenario like that will happen with the spouse. For example, now the spouse is eligible for coverage under their plan so it may create a midyear change for that employee with that spouse. Theres a change of marriage, divorce, legal separation, annulment, beginning or ending of domestic relationships would be allowable midyear changes. We talked about the dependent we talked about domestic partner changes and Employment Status and dependent coverage. Ill stop there because theres a laundry list commissioner there are and i think we can read those through at our leisure. Lets move on to the non discrimination rules. Okay. Within the tax code theres non discrimination rules so employees benefit equally and youll see the def anything of highly comp and the following page identifies the testing associated with the rules. Do you want me to go into detail . Commissioner its not needed. I wish we had our compliance attorney. This is a fun page. Consequence of noncompliance. Failure of 125 requirements will make the plan disqualified for the preferential tax treatment and calls that scorched earth because it basically means the employees will be taxed on the pretax benefits and employer paying taxes on the taxes commissioner how are those determinations made whether a plan is compliant or not . The rules i just outlined. The plan articulates what scenarios would be allowed and in terms of having those up to date, generally employers do testing to make sure theyre compliant with the program. Commissioner that is what im getting at. Who would come in and say, okay being youre either in or out of compliance . The auditor and weve seen an escalation of audits. Commissioner can we do a selfaudit . We do continual discrimination testing with our fsas and because theyre paying out back to the member on a regular basis. All of our other health plans are negotiated under the bargaining unit. The only time we could do and have looked at possibly doing discrimination testing is with the high compensation earners but thats a bargaining unit so that compliance contained under the mous. Commissioner do we have a general type of review of compliance around the plan and internal assessment . It would be the eligibility audit because we have to follow the rules on the definitions of our dependents. As far as other audits are concerned, we dont currently have an audit looking at the 30 days or not. We look at that as an operational metric that the paper work came in on a particular day and we did it within a certain days but for the most part were compliant because i hear all the time we follow the event rules. Those mechanisms are generally what other Plan Sponsors do it make sure the document is up to date and do regular testing and many have dependent verification as an ongoing process. Commissioner all right. Thank you. I think that was the end of my section. Commissioner if i may add, for the public and our membership, what this means and this is how we explain it when they complain its 90 days after theyve been hired and why cant they enroll and that type of think, we explain to them 30 you may be spending as the ploy jae part of your preme your employee part of your premium is pretaxed and if were not in compliance we lose that and anything you pay for your benefits would be included in your taxable earnings and that usually resonates. And all the midyear changes within the document is me comprehensive and that is the full breadth. Commissioner is interest any Public Comment . Hearing and seeing no Public Comment well move on to discussion item four. Item four, health care costs, risk sharing aon hewitt. Mike clark, aon hewitt. Several months ago at a meeting the discussion of risk sharing came up and it was requested we address the topic in todays forum. Ill spend a few minutes talking what health care financial risk is and the Methods Health plans utilize to address the component of health risk. The advantages and the considerations of those methods are and then talk specifically about how they apply among the various health plans and dental and vision plans offered by the Health Service system today. And then very specific information about some of the areas on plans that you have in place today. So what is health plan financial risk . Its created by a variation of plan experience. Theres many plans. We captured six on the page. How members use the plan in terms of going to doctors and using Prescription Drugs and variations of provider pricing which can vary from provider to provider. New technologies in pharmaceuticals including the topic well talk later in the forum. Large claim experience can be a health risk. Member demographics. Looking at the age of populations and finally the Member Health status. Claim experience can deviate one way or another. It can help health plans or work against them. Commissioner how does Health Care Policy impact this part of the analysis . Health care policy has an impact. I would say its more of a longer view as it influences the longterm direction of the administration of health plans. That plays into it as well. Commissioner thank you. So weve outlined three box of the methods. Starting with full insurance, where youre essentially transferring the risk to a health plan and premiums include claims, fees and risk charges. On the other end on the full right side, the employer takes the full risk for the claims being experienced by the plan as well as covering the fees. And the middle, you can have a position in between with risk sharing. You can see at the bottom of the page that could include stoploss insurance, capitation, which is a fixed cost for certain portions of care that are delivered to members and also can have a capping of employer claim liability by the health plan. Commissioner can you explain what stoploss means . Absolutely. I talked earlier large claim experience and how that can have influence on the experience of a plan. So stoploss insurance may look at anybody who goes over a certain amount of claims in the course of a year. For instance, 1 million. And well talk about a 1 million protection on the plan through blue shield. So if a member goes over 1 million in a year, the plan will assume the responsibility at the point at which the member exceeds 1 million. After that the loss stops. Commissioner thank you. Some of the terms are always around us. Everybody assumes that Everybody Knows exactly what they mean. I frequently say during our deliberations were playing a lot of inside baseball here. Id like periodly, though we all know what it means, for people to understand the more common terms so thank you. I appreciate it so please stop me for clarification of terms. Well talk about the advantages and concerns from employer perspective. The ability to budget is very stable and the insurer assumes the role of the hippa covered liability and Health Insurance portability and accountability act, hippa, has requirements related to what organizations have to do from a compliance standpoint. However, there are additional costs built into the price of insurance. Like you purchasing individual insurance yourself for automobiles theres a price the Insurance Company charges to take on that risk in the form of state premium taxes, Profit Margins for the Insurance Company and also in the world of the affordable air act, insurer fees charged for that insurance. If you have a favorable claim experience and it works in reverse. If have you a bad experience there could be more limited supporting which can support decision making. Less flexibility and plan design because you have state mandates that can apply to fans that dont apply if youre selffunding and cost measures may take longer to play out in recognizing that in your premium. The next page touches on selffunding. Youll see some reversal and advantages and concerns in some ways. Lowered administrative cost and improved cash flow because your not earning interest on the monies held exempt from the insurance laws. Greater flexibility in control and plan design. Perhaps better access to reporting as the employer owns the claim daughter data and the benefits can benefit the employer. Theres less flex act and exposure if they exceed levels the employer establishes reserves for the plan termination and Public Sector also has reserves for the system and the employer plays the role under the fiduciary responsibility. And a couple pages touching on sidebyside comparison. I touched on a lot of them but it may help see within an element a sidebyside comparison on pages 7 and 8. Commissioner this is a very good summary and something we may be referencing as we go through our discussions during the renewal cycle. Remind us youve done this. I will. Commissioner well take our attention back to this because i havent seen this type of layout and its very readable. Thank you. Well refer to it as time goes by. Lastly, the two slides i want to touch on is the application to the health plan. Theres no i would folks will often asked me should we be fully insured, selffunded. Theres not a write right or wrong answer. Theres a various approach for risk sharing depending on the plan. You can see on the left side the kaiser plans across the plan are fully insured. Your medicare retirees with the new city plan. Several dental mans are fully insured and so is dsp. With selffunded and risk sharing, and well talk with those, with the blue shield plans and for actives and early retirees and which applies to the city plan for actives and early retirees and delta ppo dental plan for the actives. We wanted to touch on the program for active employees and early employees. This was adopted in 2012 by the Health Service board and they include several elements i touched on early. The 1 million planning and theres agreements in place and theres a maximum liability cap and trio comes into play in 2018 with savings projected relative to access plus based on exclusions listed here. Commissioner thank you. Are there questions for the board on risk sharing at this point . Is there any Public Comment . Thank you, mike. Appreciate it. Knowing the next topic may induce the very thing were talking about, im going to take a recess at this time for about ten minutes. Thank you. [board in recess]. 78 commissioner discussion five. Opioid crisis overview. Id like to make a brief comment. This issue has very recently become front and center for a variety of reasons. Want it noted here today this board has had either an update or a review of pharmacy issue. Its tragic the impact this is having on the lives of thousands of people and may be attributable to several reasons. No one, no one be there age, gender, ethnicity, is free from the impact of this issue across the country today. Its my hope this afternoon we can gain a better understanding not only of the overall issue but what the experience has been and is with our health plans as they are providing services to our members. Hence, we are not only asking paige to do the National Trends and all that stuff, we wanted to go deep this time and ask the health plans to also provide their perspectives on this issue and its my hope well understand what to do Going Forward from a policy and services standpoint and benefits design standpoint for members of the system. Paige, welcome. Thank you. Mr. President , im with aon hewitt. Id lake to set the stage for where we are today with the Opioid Crisis and i will be followed by each of the Health Carriers and as they discuss the procedures in place. Fact. In 2012, 282 million prescriptions were written for opioids. Now, today in 2017, that has decreased to 236 million. Commissioner excuse me. Can you alert them we have a presentation. We have a presentation. Commissioner im sorry i interrupted you. We need this part of the public record. Over 2. 2 Million People are addicted to legally written prescriptions. Over 5 Million People are addicted to prescription pain medications, not illegal. Of those prescribed prescription opioids, about a quarter of them abuse their prescription. An additional 8 to 12 will become addicted and when times become tough 4 to 6 will transition to heroin from opioids. And though im clinician i have a hard time remembering what and medications are derived from the poppy plant. Theres heroin and morphine and theres been development in my career of semi synthetic opioids such as hydrocodone which is vicodin and percocet. Most of us know what a percocet and vicodin is. You may or may not know what the generic name is. Along that line, an Additional Development has been the synthetic opioid. It started out be used as anesthesia which is fentanyl. It is hypothesized that 60 of the overdoses are related to fentanyl use not necessarily opioid. Now methadone is used for the withdrawal from heroin and can be used for the withdrawal from opioids but typically from heroin. Theres a couple things i want to say about opioids, first of all is that overtime youre dependence means you need higher and higher dosage of the opioid and if you stop, typically you may have withdrawal symptoms which would send you back it using again. Lastly, whenever the prescriptions become less available or too expensive people did turn to the street and go after a method of achieving it through heroin. What i want to do quickly is highlight federal actions. In 2016 the 21st century cures act allocated 1 billion for Opioid Crisis the first round was distributed in april, 2017. The new administration established a commission on combatting drug addiction. They recommended a state of emergency to be declared. At the time i wrote this it had not been declared but from the last two days of october it was declared as an emergency. What that does is releases funds and federal resources to address that. Now, it should be noted that in waiting for federal action, first of all, we have the private sector coming to the forefront. Cvs pharmacy has new requirements for people that receive their pharmacy benefit through cvs. They limit it to seven days. This is for people receiving new prescriptions. As of today, 49 states have Prescription Drug monitoring programs and state legislatures are beginning to take ac because theyre realizing the crisis cant wait for federal activity. Whats california doing . California has a Strategic Plan to address that. First, they want to increase treatment availability for people dependent on opioids. Second, they want to make sure theres no access problems. Third, they want to reduce the opioid overdose related deaths and theyre through that and ive highlighted one section of that is learning collaboratives. They target the primary care offices and target the emergency room. Really teaching. The fourth aim is to i am preliminary medicationassisted treatment. That is recommended to help people through their withdrawal symptoms and i may not pronounce the drug names correctly so forgive me, bupeophrin and viatrol and lastly they want to make sure working so of course theyre going to track the progress. And most recently in august as you said you have had pharmacy updates in every forum, youve been keeping on top of the Opioid Crisis. And so marina presented in august 11 of your population has received an opioid proscription. She also noted 2 of the rx spend is for opioids. Lastly, retirees tend to use them as a higher rate than actives. Id like to start with blue shield to identify wa actions they have taken for your population. Commissioner thank you. Before you step away, is there any questions from members of the board . Id like to ask a question. You said retirees are more users but are more trades more users like with injuries like police depend, plumbers clearly anyone injured on the job can use it but some is the result of our inactivity, in other words, were sitting and then go out and try to be weekend warriors on the sports field and you hurt your knee, injury your back. So it isnt necessarily i can look at what professionals tend to see a higher use of opioids than others. Commissioner marina, in your review of the data did you find concentrations in any Job Description areas. Not the departments but particular Job Description areas . In the previous analysis we did not