With musculoskeletal injuries but what cause we dont know and we looked at it by not job code but department and not necessarily the trades. Well share that with you. The other thing is if its coming from an active injury and i think paige alluded to this it would be under workmans comp and wouldnt be in our numbers. A lot of the questions you ask will come back. Commissioner very good. Thank you. Thank you, paige. We have blue shield, is it . Yes, it is blue shield. Good afternoon. Commissioner good afternoon. Im the director of clinical pharmaceutical programs at blue shield. Im a pharmacist by profession. So you can answer some of the questions. And i want to, today, for having a chance to talk about our narcotic safety initiative. Its a passion project for us, a Passion Program for us. Basically in 2014 we started observing a lot the clerk we have a presentation. Thank you. We starting getting a growing voice of members telling us the prescription. Yesterday opioids were becoming a major concern and being perpetuated. In our efforts what we wanted to do was to evaluate how to reduce overuse for those with nonchronic cancer pain. Our goal is to reduce that amount by 50 by the end of 2018 compared to our baseline 2014. Nord this is quite an aggressive goal. When we first started out we werent sure if wed achieve this but what we decided to do at that time was to implement evidenc evidencebased interventions, helping prescribers, prescription members who were on them to lower and safer doses or maybe to discontinue opioid therapy altogether. Also important is to identify and stop fraud, waste and abuse. And to identify problematic use and deploy resources to help members get to more effective treatments and effect state and National Policies that really impact the crisis. Thank you. Our initiative began with the evaluation of what was happening amongst their members and families who were very much impacted by Substance Use disorder. They were telling us that often times what they were observing is that a prescription was with what started the cascade of events. And then perpetuated by continuing refills for the prescription opioids. We have recently had data shown that a lot of Substance Use disorders started with street drugs. Now were seeing more and more that is starting with a prescription thats prescribed by a physician and filled and dispensed by pharmacies. We believe health plans have an Important Role in helping mitigate the crisis. Not just from the perspective of fulfilling a treatment but understanding our option. With the board approval in 2014 we launched our enterprisewide initiative. What we decided at that time to do was to launch the impactful interventions we felt would make the most difference. Frankly, our approach was to first turn off the tap, so to speak and prevent people from starting prescription opioids if there was other options they could use. And then also to help those people on the other end of the spectrum on the highest doses at the highest risk for imminent harm. Youll see in the presentation over the past three years, our approach has been aligned to those activities. So in 2015 we primarily applied more stringent review of new prescription opioids especially longacting opioids which have the highest risk of chronic use. We also started looking at te data and found most the opioid is with hydrocodone which is a common opioid ingredient found in cough and cold medicine. When you ask the question, what type of person is most likely to be impacted by Substance Use disorder, its any and all and children are very much affected by cough and cold. Teenagers get the cough and cold with the hydrocodone in it and something they can use illicitly at parties and such. In 2016 we narrowed our focus on the analysis and we helped to assess and stratisfy the risk and between last year and this year we completed an analysis of emergency room prescribing of opioids in the l. A. County area. The good news that we found is that over the last three years, the prescribing has been coming down. More importantly, prescribing as come down primarily for prescriptions written for more than a threeday supply. Thats very important because most of peoples chronic use is when they get a chronic prescription that can last a long time. In 2017 this year, we increased our focus on what i call the middle group. Those are the people who have been chronically using opioids in moderate doses. And what were really trying to do is work to address as mentioned earlier access to evidencebased Substance Use disorder programs, alternate Pain Management and to help members manage pain and reduce risk through Pain Management programs and other alternate treatments. Were also continuing those analytic efforts i mentioned earlier. Were partnering with the California HealthCare Foundation and Harvard University in an analysis and hope to vie publication within the next hope to have a publication within the next nine to ten months if not sooner. Were trying to understand the impact of the program or efforts both at a plan level and as well as at a general level, population level. So the good news is for our total book of business at blue shield california medicare and commercial, as of the First Quarter weve observed a 32 reduction in the consumption of opioids. Its not just the number of prescriptions. Thats one thing but you have to take in consideration all the dosing going on. To fentanyl is much more potent than morphine. For every fentanyl prescription you can multiply that and thats your consumption. Were looking at it from a consumption standpoint. Were very much pleased to see not only the 32 reduction but the fact that were tracking to our 50 goal by the end of the next year. To, you know, make improvements, and those partnerships have also been able to help us identify some really unusual outilizization, so what we are starting to see are some really compounded opioi opioids that are questionable in untwebdintended uses, and s were identifying them, were going after those pharmacies. Were also, you know, making sure were employing the right restrictions and levels of protection in place to limit that liability. In 2018, our plan includes continuing to evaluate and expand access to Substance Use disorder and alternate pain treatments and also to medical assisted treatments, so buprenorphine, which is also known as sebaxone, that medication is very important for people who are needing to transition off of opioid therapy, and weve improved access to that. Vivitrol is another one that is helped to commonly control cravings, and methadone, and naloxone is the one if you get into an acute overdose situation, you can use that one to help reverse the effects of that. So were really working to make sure that access is available to all of these treatments and to Pain Management programs. Weve also launched a very successful and well attended provider education series, and were addressing topics such as opioid tapering, concurrent use with other high risk medications, benzodiazepines, muscle relaxers or sleepers, and also locking down unapproved uses with the compounds. We continue to work on policy strategies that have high likelihood of impact. There are a lot of policy proposals, but quite frankly, a lot of them are just you know, thats the existing state today. Its really not impactful. We want to make sure were driving impactful legislation, and finally, but not last, is we continue to partner and collaborate with key stakeholders. We view this as a plan, this is one area where everybody agrees that we really need to partner together to fight the crisis. So im really pleased that i was able to provide a report today of the very positive results for the hss population. We believe so strongly in the efforts here that weve actually incorporated performance guarantees into your 20172018 contract, and we expect to continue to see improvements over time, so with that, ill open it up for questions. Are there questions from members of the board . Yeah, i have one. Yes. When you go to suppose somebody breaks their finger or whatever, and they go to a doctor. So is there a set something set now where theres how much of this drug that they should give to the patient or how do you control that . Well, the cdc has published guidelines for how much and how long anybody should be prescribing an opioid, and what weve been doing is really working with providers to get them to be aware of the guide lines and start prescribing in accordance with the guidelines, so there are a number of ways. Education is the easy passive way, and then, the more physical way, the one that has some impact to members is that you employ restrictions on formulary and benefits, so those are usual ways of dealing with how long, how much. I think probably the more important way is really to plant the seeds with the prescriber because once they really understand and are educated, then, youre not impacting just one person, youre impacting everybody that that person that prescribers taking care of, and weve seen that, you know, with some of our Case Management efforts. As we start to educate the most difficult prescribers, people who have been very entrenched about thinking how you manage pain for people with opioids, once they understand and they know we want to get people to safer space, theyre much more open of doing a different way for managing for pain with other, you know, members. And i is my impression correct that kind of the typical pattern was that youve had an injury that required these types of medications, youve kind of got a ten day supply, and you might be taking it two or three times a day, Something Like that, that was kind of the standard, much more being said. No matter what it was, you got a ten day supply of whatever yes, except that it wasnt a ten day supply, it was a 30day supply. 30day. Exactly, and you know when you are planning a surgery, most surgeons are just automatically prescribing an opioid not every surgery requires an opioid after surgery. You really have to look at the ability for pain tolerance and what the injury or the surgery was, and many nonopioid medications can effectively manage pain. And the cdc guidelines, are they recent, and how recent . The cdc guidelines were, i think, updated last year, and maybe again earlier this year. Theyre very recent. Okay. Thank you. So there isnt anything to say that the physician cant prescribe more, though . No, and thats one of the things that i personally would like to see in other states, theyve enacted legislation and policies to limit the number of days that an opioid prescription can be prescribed for a first time. I personally dont think thats a bad thing, but you know, theres a lot of politics involved in that, but short of that, i think all of the health plans have been working on limiting those the coverage limits for opioids. And we have to be really careful, you know, especially with not i think its easier to do that with new prescriptions, people who have not been on opioids before, but for people who have been, you have to be much more careful because you dont want to create a situation where they decompensate or then, they go to street drugs. Commissioner ferrigno. I know theres some a couple years back with the police department, they had the behavioral science unit, and theres people that have some problems with opioids, and theres some Pain Management medications that you use. Is that hard to get approved, or is that. If youre referring to seboxone, or buprenorphine is one of those other treatments. It acts somewhat like an opioid, but it doesnt have some of the risks that are associated with it, and they use it to help people detox off of opioids, but more recently, the way that practice has been evolving is that theyre starting to use it as maintenance therapy now, so people who used to be on opioids may, instead, be switched to a seboxone drug and maintained on that over time until they can get their Substance Abuse disorder under control, and it may be that they never really get it under control, so you may have to maintain for a long period of time. I just have one more point. Yes, please. I know that you if go and get your teeth pulled, you get a 30day supply, and you dont even need it, you can just take ibuprofen. I think people keep this stuff in their medicine cabinets, and kids take it and take it to parties. Yeah. Thats one of the reasons why we have an opioid epidemic. Yeah, stock piling is one of the things that we addressed, but 30day supplies, if youre giving people 90 day supplies through mail service, thats where you can easily stock pile, and thats where we put a stop to that, as have many other plans, as well. Page, im not sure how were doing that. Is this every plan thats coming in next, on you how are we doing that. United health plan. Good afternoon. Good afternoon, you can raise that microphone slightly. Just there you go, but do talk into it. Thank you. Michael terhare. Im with optimal x under United Health care, and ill be speaking to you about the city plan and the programs that we have in place. I am a registered pharmacist. My role or title is clinical consultant. Ive been a retail pharmacist, and i have been involved with the pbm industry, pharmacy ben fit manager for over 15 years or so. The first slide, weve got a couple of stratistics up there as youve kind of alluded to, you can heavy about this almost every other day. Week nav ago, we heard President Trump speak about it on national television. Last night, on ktvu, there was a little segment about state suing pharma, so we know its there. And heres some of the metrics str statistics every 16 minutes, there can be a death due to overdose from these medications. Its very expensive 78. 5 billion. I think this was, if im not mistaken, 2013. Most of the expenses are because the treatment is so expensive and going up. And 4. 5 million americans, piage already alluded to that number. And heres a big number the u. S. Consumes 80 of the opioids, so. The next slide, what i wanted to do is on the left, we see theres some other statistics. We already covered those. I want to first go over the opioid utilization for the city plan. Weve got some data there. This is for january through september 2017. The plan paid 113,000. That was actually down dramatically from the same period 2016. Now i attribute that a lot to the programs we have in place. Theres a huge awareness out there, too. Were working with physicians, so what were trying to do is bend the trend that Everybody Knows has been going up for frankly, its been two decade does. Thats severe the problem is. The prescription count, 1692, year to date, and member utilization, 491. Tylenol, hydrocodone, fentanyl, youve heard percocet, vicodin. The good news on the top five, theres no long acting opioids, as that was brought out earlier. That is whats killing people. Oxycontin is the top drug in the United States that everybodys taking and having problems with. Lets go to the next slide and see what our program does for the city plan. We have a real wide range of programs here and touch a lot of points. Its a multitiered approach. On the left, ill talk about these programs, what they do is they reduce unnecessary and inappropriate use of these medications, so for instance, we prior off long acting opioids. Thats the oxycontins. Thats whats really driving this. And what we did was we built in those cdc guidelines, and so somebodys wanting to get one of those, per the guidelines, it makes sense. Well maybe you dont need maybe even drug therapy. Maybe theres another modality to try. Okay. That doesnt work. Try it lets try a medication, but maybe not an opioid. Many atlas v. A. Health care system in april came out with a controlled study that said compared opioids versus nonopioids, and back pain and rheumatoid arthritis, so its about the same. It makes sense. If youve really got to go further, lets use a short acting opioid to start out with before you get to the long acting. That is he thats a very important piece we have in here. Other things we have is we limit the fentanyl patch because that is appropriate. There is appropriate times to use this, and thats the key here the appropriate times to use these medications, but have the safeguards in place so you startup above, before you get into the very powerful long acting drugs. In addition, a longacting one, weve put a limit on the daily dose, per cdc guidelines. Now in some cases, cancer, etcetera, thatt makes sense okay. You need more than that . No problem. The other thing we do, weve got it in there for not only the longacting one per day, but were going to add up all the opioids, and if that hits a certain ceiling, were going to reach out to the doctor and make sure thats appropriate. Over on the right side, these programs are mainly we monitor the claims and then identify situations where we can make an impact. So for instance, the high utilizer narcotic program, here, we look at 30days of claims, and if we see a members getting way too many narcotics, numerous pharmacies, numerous physicians, thats a real big red flag. Were going to reach out to those physicians, and they appreciate that, too. They dont know sometimes that the member is going to other physicians. Now, if we see a pattern there, we can even lock in the member to one pharmacy, which makes sense. That pharmacist will have nice monitoring for that member. Im happy to report, also good news on this front, with your plan, the last four quarters, i havent seen any members that have hit this flag, so good news on that. We can identify prescribers that are out liers, so if theyre prescribing way up here, higher doses, longer lasting medication, we reach out to them. We also for high claim cost memo members, somebody thats spending a lot of money on these narcotics, well go ahead and get Case Management involved with them and see how we can help out. Weve got edits in place where sometimes these medications are interacting with other medications, that it should not happen for more than a month or so. Were going to go ahead and then reach out to that physician. We also have a program here, fraught waste abuse. We can look at programs here and say boy, theres a lot of claims coming in from this doctor, and this pharmacist with this doctor, and these people here, it looks like drug trafficking, so we go ahead and turn that over to the authorities. Over on the right side of this slide, we see some if somebody needs treatment, weve got a benefit for it. We also dont prior off naloxone. We brought that up earlier. If somebody needs to be saved, overdosed. And then, we also have an 800 number for substance treatment. In anybo anybody can call that the member, friend, family, theyll help them out. So thats what we have in the city plan, some really good, positive results. Paragra now, we are always continuing to update our criteria and our programs based off of cdc and other evidencebased guidelines. The accounting now, knowing that this is an important subject, well keep you up to date on our updates both as the city plan utilization. Im sure theres some literature out there, but i will say anecdotally, i do see this in other words, somebody thats got a job all day, driving a truck, and im on the same account. Mike is on that. Were going to see more back pain, and use of those, but the key is, do you have the right programs in place so they use the right ones first . Ill go ahead and turn it over now to michelle, and shell talk about the retiree program. Okay. Thank you. Are there questions any other questions . Okay. Please. Go right ahead. Good afternoon. Michelle la 1 sics. So what youll hear from me is very similar themes to what you have heard from the previous speakers, but when youre dealing with a retiree population, as page mentioned, sometimes, the utilization is higher. There is more cancer. Sometimes, you do have some members in hospice, and its appropriate for them to receive that. When i talk about some of these programs, similar to the other plans, as well, you know hospice is cancer, those are very appropriate, so we do exclude those, but you will see that more in a retiree population. So on the righthand side, we have for your retiree proposition, your utilization, we have about 3600 retirees that have had at least one opioid medication year to date. That is about 24 a of your population. If you recall what page said, in the teens, is it about 14 or 15 . It is more of the retiree population, just because of their age and their illnesses and their disease burden. And then, if you look at that, what does that translate into in prescriptions . Its about over 13,000 prescriptions year to date, and that equates to lets see. Im sorry. For in terms of the percentage, but what i wanted to get at that you talked about long acting and short acting, so what were finding is about 14 of those prescriptions it for long acting opioids, and then, youll see at the bottom, the table there, theyre mostly short acting, so your population is retirees is also using more short acting than they are using long acting. And so next, i will go into the different programs that we have in place for your retiree population. Very similarly, we do prior authorization and quantity limits to make sure that opioids are being used appropriately and safely. If you look at your top medications here, youll see acetaminophen thats in the percocet and rvicodin. Make sure that we have appropriate quantity limits, and also prior authorizations. Certain opioid medications are only approved for use for cancer pain, so we want to make sure that we are evaluating that and making sure that theyre being used appropriately. And then, also, in terms of you heard this throughout is we call it the morphine equivalent dose, as people have talked about there is different opioids have different potencies, so we want to get to where we can evaluate whats the total number of dosage of opioids a person is getting, so we calculate everything down to a morphine equivalent, what you really want to do is take the whole picture of the patient and what theyre taking, and make sure that its appropriate. And if it seems that its not appropriate, were going to reach out to that fizz and talk to them and make sure they get an attestation from them, a medical necessity, to make sure that it is appropriate to be used in those situations. And then, in terms of Case Management, as well, we want to bring in all of the providers as a community to help help retirees when we may detect that there may be a problem, so were not just going to immediately, you know, shutdown. We can put restrictions in place when we detect a problem, but first, what were going to do is were going to retroactively look at the claim, see if we can detect a prab based on the number of pharmacy and examine pursuers and the dose theyre getting, and then, were going to have a conversation with their providers, and all of their providers that are prescribing these medications to get to a better place with that retiree, and then, if we need to, we can implement restrictions in terms of the quantity or we can also reject, you know, not cover. And all of this in the background of Medicare Part d has to be within the framework of the cms guidelines, so cms also has these programs in place, so many of your Medicare Part d programs will have these Medication Management type programs in place, as well. We can go to the next slide. And then, we also have another program, in terms of outreaching to providers, in terms of sending out targeting communications. Again, when we detect that they are getting an abundance of opioid medication, multiple providers, multiple, you know, pharmacies, outreaching to those providers, making sure they have a full profile and comprehensive view of that retire rea retiree and what theyre taking, and helping them identify there might be a problem or issue here by outreach. We are, as michael mentioned, going to have a program when we detect fraud waste and abuse, so when we detect that, we will send that off to the dea and supporting them, as well as the oid, so were supporting all of those those avenues. And then, lastly, as mentioned, so we talked about making sure that theres appropriate utilization, safe utilization, and then, if theres fraud waste and abuse, trying to cut that off, but we also want to make sure that people are getting access to the treatment that they need, and if they need help from medication assisted therapy for a dependence, that we have removed what barriers we can for them to access those medications, as well as naloxone are inform for an ove thats all i did. Questions. Questions from the board . All right. How long have you been engaged in this, for both the act of cityplan, and what youre doing . Specifically, how long have you structured these types of interventions . These interventions have been in place i can tell you the prior authorization and quantity limits have always been in place. Ive been kind of in the background of the retiree plans since you moved to a Medicare Part d, and so we have always had prior authorizations and quantity limits in the Case Management, but we always adjust them each year to make sure that were staying in tune with new developments. I think more recently, you know, the morphine equivalent dose in those kind of guidelines are more recent, and i think youve heard from multiple folks here that that is kind of the new trend to make sure that were not just targeting thank you for allowing us to describe our Opioid Program in california. Ill show the first stage and i wouldnt take a lot of time because paige spoke of this but United States consumes 99 of the worlds vicodin and norco, hydrocodone. 99 . Thats more than another astounding fact and paige and the others have talked about the rest. So our initiative was really to insure that we provide safe and appropriate care to our appreciates across north america and we give our patients and physicians the tools and support they need for consistent opioid prescribing, monitoring and documentation. We didnt say oh, that bad patient is a drug addict. The doctor writes the prescription. The pendulum can swish switch the other way. It is appropriate to write for the medications for certain types of things and when you do that you need to follow the patient, make sure theyre Getting Better and youre doing it in a safe manner so thats how we focussed it. Our next slide talks about how we focussed on the initiative. So we looked and saw and said whole who proscribes most of the medications and its people like me in Family Medicine and theyre our number one prescribers. I think you heard from previous speakers about Emergency Room Physicians being high prescribers and those are our number two and lo and behold, its othrthopedics who are numb three and you ask why more retirees get more opioids. They have problems with their joints and get neese knees replaced and thats often where they get them after surgery. Well continue to work on our lower proscribing lines. As we Pay Attention to people from the city we look at our 4 million members. Im the executive sponsor for the Opioid Initiative and we have folks from physician education who then work with almost 21 of our hospitals and Medical Centers and 200 offices so that everybodys speaking the same language. Whether in primary care we are all doing the same thing that was important to do that. So we used a fourpronged approach concentrated on patient education and options for our patients. Physician and prescriber education. When i say physician i include Nurse Practitioners and pas and anybody who prescribes and Patient Safety and the last is community safety. Heard from the last speaker 60 of people who end up on heroin find the drug in grandmas medicine cabinet or mine because i had knee surgery and i need to find a safe way to dispose that. Let me talk about what we did for our physician education and support and ms. Breslin talked about restrictions for physician on the equities of opioids. Reflecting back 10 or 12 years ago, there were mandates from the medical board to take cme programs. We were taught to treat pain at any cost and a lot of that education was funded by pharma who said most of these drugs are no problems. You can give it. Nobody will get addicted and nobody will die and now you know what the statistics are. Theres no blame. We had a decade of education that taught us Something Different and its going to take us time to reeducate our physicians and patients. So i never learned anything about this in medical school or residency. Fortunately for us we have Electronic Medical records did you want to ask a question. Commissioner how are you keeping big pharma out of it now . How can we be sure theyre not behind this commissioner well, theyre in our audience. Were happy to have them here but we try to make sure we have evidencebased education so people like myself and others are looking at the education and making sure thats how we give it to our physicians. We dont allow pharmaceutical reps to be in our campuses and thats how we keep pharma out of our place. We put in tools and medical records to prompt them to ask the patient, if its only going to hurt for three days, write ten pills. Theres no reason to write it for 200 as it used to be in the old days. It tells you to monitor or go to and you need to know whether theyre take them because they may not be taking them. Somebody else may be taking them or they might be selling them. The trainings we did had to be customized for our physician and getting the people to do the training and involved in the training and get their attention. Rather than making it mandatory involving them in their training made a lot of sense. My internal medicine colleague said we want six of the training and two hours of it was communication. How do you have that tough conversation with the patient. Ive seen the patients that had their car accident in 1982 and have had six doctors and theyve been on these medications forever. All of a sudden i have to tell them, hey, this is not safe for you and you take a sleeping pill and muscle relaxant you may stop breathing. Theyll look at me like whats wrong with you. Our physicians felt they needed the communication tools. Our e. R. Doctors you cant find in the same room at the same time and we designed a threehour virtual and thats what they took and other colleagues wanted a oneour version and im happy to report though we didnt make it mandatory over 99 of our physicians took it and did pay them for it so making sure the time was given was critical for us. And we all have lots of tough prnts and we hahprnts and we hp patients and we can come up with a plan thats going to work for my patient so making sure we have that was important. So after the education was done, we really needed to have some awareness. Did i know how many patients i had on opioids and what doses were they on . We produced a list for each physician to give them the names of their patients, what opioids they were on and what doses they were on. Had you seen them this year . Are they on a sleeping pill or muscle relaxant did you do a urine drug screen and sent it to their chief as well to look at it with you and in a collegial fashion we discussed that to see how youre doing in that area. We have authorities colleagues to pick up a phone. Someone will say did you mean to write for 200 tablets of percocet and that awareness and check and balance has helped us. For patients we worked on its informed consent. I dont think weve done a great job explaining to patients these medications generally do not work well for noncancer pain. And if were going to use it for accidents and surgeries, using it for a limited time makes sense and there needs to be an end point for this treatment. Its not just something youll take for 10 and 15 and 20 years. Making sure you have the time to discuss that and even watching online and printout an agreement letter if its going to be appropriate for longterm therapy is fantastic. 20 of patients said dont give me this stuff it sounds dangerous. That was very good. Again, our pharmacists were great in educating patients and if they were to be on medicines they had at least two visits a year which is what the california medical board recommends. Patients on high doses, the cdc talks about 19 morphine milligram equivalent. That increases your risk for death and overdose. And looking at the patients indications and can we taper then because they can go through withdrawal. You cant suddenly turn off their pills because then theyre off to heroin. If you dont give them alternatives youre in trouble because one in three patients today has chronic pain of some sort and if you arent going to give them this make sure they have access to therapy or tai chi or yoga and if you dont give those alternatives theyre in a hard spot. Short of cancer, why do so many people have chronic pain issues . Is there a big increase . We have all sorts of things. I look fairly okay but i played lots of sports and i have almost no cartilage in my knees. It hurts every day but i dont need opioids. I keep exercising or ive modified my exercise. I dont play too much tennis but maybe ill bake bike or swim or play only an hour. Like im a yogi now, is it a practice where people with knee injuries were prescribed stuff forever . One study talked about pain for noncancer addictions that got extrapolated for any kind of pain and they were giving it out for almost anything. There was an article that came out in the literature this week that talked about giving an ibuprofen working better than an opioid. They come to e. R. And paid 100 and the doctor gives them a motrin or ibuprofen and they say i got this at home. We went way on one side in prescribing to one side but not eliminate for Cancer Patients and postsurgery. Again on the Patient Safety, these issues are brought up giving smaller quantities. Making sure patients are on multiple meds. Making sure people who need nal naloxone get it and you want to make sure these are the people who are going to be taking that. Then we talked about the alternatives to opioids. And then Community Protection is really important. Ill give you something to add to the Patient Safety is physical therapy. Yes. I said it but i forgot to add it on the slide. I dont think theres enough emphasis on it. No, we have good access to fisc fiscal physical therapy and that works. Again, decreasing the amount of opioids out there makes sense. Its unfortunate, ive had a knee procedure myself and told my surgeon i cant take these. They give me nausea. Ill use ice and motrin and next thing you know, 30 vicodin were in my bag and i said whyd you do that and he said you might have pain over the weekend and may not be able to get hold of me. I said, i know how to get hold of you. I didnt take any of those some having some place to dispose them off. Fortunately our pharmacies now have the bins to put them away. Commissioner i thank you for that. Lots of places have them, police stations, fire stations. That is really great to take those back. We already talked about the urine drug screens. Well, we talked about a lot things. The other thing is engage community partners. In Santa Clara County and others we reached out to all the emergency rooms. Because if were doing something in Kaiser Permanente whats to stop our patient going to another hospital. Having the coverings how well handle patients in the e. R. Were critical for us. These initiatives started two years ago because you asked how many years did you start back. This is i believe, october of 2013 or early part of 2014 and since then we have seen a 42 reduction in opioids, totally and 30 of patients on high doses. The cdc calls the 19morphine milligram equivalence and today 85 of our patients have an opioid agreement letter and over 75 have had a urine drug screen to look for diversion. Our emergency Room Initiative started last year. We have seen a 44 reduction in opioids compared to last year. This year thats an article in the new england journal of medicine talking about highintensity prescribers in the emergency room. They define those as people getting prescriptions one of four patients leaving the emergency room in this hospital room were getting those and our number was 12 and now its 6. 6 out of 100 now will get a pain medication. And again a very appropriate amount because they can always be followed up by their primary care physician so theres no reason to give 30 pills. 10 or 12 is fine. Thats again great. And two slides you shared with us we are happy to say for the opioid recipient overview our kp members have the lowest number of recipients per thousand for opioid prescriptions. The next one has the supply overview. Again, our kp patients have the lowest both in the active and early retirees and medicare eligible ones. So we talked a little bit about why was this successful. Why was this Program Successful . I think there were a few things that stood out. One was strong Leadership Support from the top and down through every Medical Center and every medical office that we have. Having a clear and consistent message whether youre a physician, nurse, pharmacist, administrator and having the interdisciplinary option to consult on tough patient was great and having locking coaching and support was fantastic. Having that physician, specific data, ive never seen a list of all my patients on opioids. Now when i see it every month i know what progress im making and if i need some help. Then i think the collaboration with our number pharmacy is fantastic. They can call us we have some chronic pain pharmacists who can taper patients because thats tough and with my practice maybe two or three patients is all i can manage because it generates phone calls and emails and its hard for a primary care doctor to do that. So if you have someone else helping you with that it makes it easier. Thats all i have to present to you. Id be happy to take any questions that you might have. Commissioner other questions from the board at this point . Commissioner this is very informative. It seems it would be easier to be more successful than the other plans. I t