Commissioner lim. Required Financial Reporting during the audit when we do the financial report, required with the audit, and also reviewed by aon and reviewed by independent auditor. Ok. So, further certification we are using the funds properly and for the purposes intended. Correct. So, we provide the calculations but you are correct in that is audited and i know that was reported on last month. Ok, thank you. Commissioner lim. Ibnr for the city plan was substantially reduced 2008, because pretty much all of the city plan is fully funded now. For the medicare retirees. So it would go down, expect it to go down in 2018. All right. Thank you. Any questions, other questions from the board . Any Public Comments . Hearing and seeing none, thank you. We will now return to our regular board meeting. We are no longer the committee of the whole on rates and benefits. Have we changed . No. Madam secretary. Thank you. Item 10, discussion item, update on blue shield trio hmo implementation and provider partners. Jeanette moen, blue shield of california. Hi there, thank you. Jeanette moen with blue shield. I just wanted to give the board an update on the trio implementations and some other provider relationships that have changed in the product. I always have to remind myself why we are doing this because it is herculian project and undertaking, and again its to leverage those relationships that we have already forged with provider partners en the community who are doing an outstanding job for the city and county of San Francisco delivering high quality care and reducing costs. Its to reduce costs and make the plans sustainable for h. H. S. Members longterm. Its an attempt to transform Health Care Delivery by disrupting competition nuances in our marketplace. And its to ensure that longterm all members of actually california, part of our mission, have access to high quality affordable Sustainable Health care. I just wanted to give an update to the board to amend some numbers i had provided last month, we have final numbers in. Based on the january 1st trio enrollment, 14,500 members, approximately enrolled, equivalent to 13. 5 million in 2018 savings. Continued enrollment of that number, 2019 and 20, and beyond, will only be compounded. Meaning that 13. 5 million for the same cohort or of members will only increase in savings. If you add more membership, it will compound even further. So, updating this pie chart, 62 of all h. S. S. Members are using trio providers, and of that 62 , 40 of those 22,500 members enrolled in trio ultimately. Excuse me, why arent the rest of them automatically enrolled . You know, so we used a logic to automatically enroll members only if every Family Member in a family unit was using a trio provider. And some have 5, 6, 10 different doctors sometimes in a family. Right. If nine of the doctors were trooi trio and the tenth wasnt, they were not a candidate for auto enrolling. We did not want to prompt any relationship changes with physicians. Ok, thank you. So, we have some really exciting updates. We have we will continue having bumps along the road and changes. Fortunately today i have mostly very positive things to report. I will get the hard message out first. With meritage, if you look at the pie chart, it does not constitute a large portion of the h. S. S. Membership but what we did learn, we did auto enrollment based on people having meritage providers. That is actually divided into three divisions. Marin, and two sonoma divisions. The two sonoma divisions would not be part of trio. We enrolled 32 that we should have not done, we moved them back to access plus, we want full disclosure of our learnings along the way. Any questions about that . Ok. This is the interesting news. As you know, big change for h. S. S. , for access plus versus trio, is that the cpmc hospitals or any Center Facilities are included in trio at all. And met with resistance from suter, even though they were unwilling to partner with us for trio. Once the numbers were in, we had a new dialogue, and it is our hope, always keep in mind, suter is our partner as well, whether you are blue shield or h. S. S. , suter is the partner as well. But it does not mean you are going to partner on everything. So, they have, they came back to the table and we have added a variety of sutter facilities to the trio network as a result. And that is effective january 1, 2018. Those included the ambulatory Surgical Centers sutter in San Francisco, i have a list here. And a list of the Surgical Centers in alameda, a little bit of a Health Care Delivery desert, where 580 and 880 intersect, and one ambulatory Surgical Center in costa costa. We did not really have a need there, im not sure why we added that, but its added. It will not hurt anyone, only an enhancement. What is very notable is alta bates, and the Eden Medical Center are add, and thats 3, 4 hospital campuses added, also where we had from what we perceived, even though the department of managed Health Care Found it to meet all standards of a robust network, we did not like the way the network looked in that 58080 corridor, we filled that entirely. I thought sutter facilities were out, but now they are in. Because a deal was made with them or a better because a deal was made with them. Yes. Yes. And they were open to talking to us about it. Jeanette, if i might add, open to it after the numbers were in. Ok. So, i mean i think that is important to realize its also important to, when you look at the 13. 5 million that we are saving next year, as well as this change, you know, this is a market change that we worked really hard on, even though i know last month we sounded a little whiny and a big open enrollment and heavy lift, but these numbers and happenings make it well worth it. And that was the intention of this, to really talk about market competition, and if we were able to leverage that. Dr. Follansbee. Part of the problem was sutter insisted you could not deal with each campus separately, you accept one, they all had to be part of the network and you have managed now to either carve out or whatever term you want to do, some Sutter Centers without forced to use all of them. That is correct, that is correct. 100 of sutter is access plus. 100 in the p. P. O. As well, two name Brand Networks we have, that is correct. This is an exception. And if we think back to my first slide, it is disrupting the marketplace, it is creating competition, and it is creating change, and at the same time, its improving outcomes and making plans sustainable and affordable. So, there will be bumps. This is really positive news. Its a difficult balancing act. I understand. Thank you. Along that line, to continue along with the provider partner update, moving on to slide five. Oh, we did have our utilization management, we had a series of very indepth meetings around claims, basically, and how the risk and the claims are performing. And i wanted to go over a couple highlights. The meetings are actually two hours long, and i pulled out one slide to share. So, its really important for everyone to understand that the risk has increased and that means its a higher risk to finance. Its costing more to finance, and thats because a term called dxcg, commonly used term in Health Care Risk assessment, and basically what it does, describes a value of risk to a patient, and we all are born with a one, or we are all introduced into a plan with a one, and then based on claims and combined with demographics, our risk score alters. And so the medicare was really notable is h. S. S. Has a very, very, very high risk score, and they continue to get higher. And this is why it is very difficult to negotiate with our partners to take down that risk. I would like to ask, is this profile similar to other employers in your book of business . Unique to us . I find it hard to believe to be unique to us. Well that, is exactly what the slide will tell you. So, if you see the dark blue line, and you see it creep up, that represents blue shields book of business. So the highest risk employer is at the top of that blue line at the 100 and the lowest risk employer at the 0 . The nonmedicare retiree risk is the Golden Diamonds. The gold diamond. Almost at the 100 level. So, i think there are 3 or 4 other accounts that are higher risk. Than we are. Than h. S. S. For early, for nonmedicare retirees. Thats early retirees. Correct. Compared to other early retirees. The average age of early retirees for h. S. S. Is 60 versus 48 for other Employer Groups. The other notable score is your active score, which continues to deteriorate and part of the result of slight, and its been very well managed and this is not uncommon, especially municipal accounts, but the shift of membership out of a network h. M. O. Into kaiser, it continues to deteriorate the risk score and we saw that, we saw reduction in membership, a slight, and also saw a slight reduction or worsening of the risk score. This is another reason of, for doing trio. We need to partner with the providers to get the cohort healthier and cared for. So, you can see where h. S. S. Active employees compare. And you can see that it slightly, went from 1. 47 to 1. 59. Say to director griggs, publicly and to incoming director, each time ive ever seen a slide like this it is a prelude to increased premium rates in the ensuing year. And so i understand you are just giving us the facts today. Actually i think you will be happy about this. Trio has a cap on this. I understand. But each time, the precursor of whats to come. Hold on to your wallet, saving money in medicare. So as we look at this, and there will be ample time for discussion, so i actually did it because i wanted to talk to you about your results as far as costs. And i would yes, so, lets talk about while your risk is where it is, lets talk about where your claims dollars are, relative to the prior year period. So, moving on to the next slide, h. S. S. Medical trend, 1. 3 , im going to use rough numbers here, but National Trend is 7. 5. So, somehow with the worsening risk score, we are at 1. 3. Im sorry, im confused. What does the medical trend refer to, what is that . Medical trend is the inflation for medical delivery. So, its not just your rents going up here in San Francisco, for cpmc, its improvements in medicine technology, cost of health care, higher litigation rates, the list just goes on. There is so much pressure on this particular sector of the industry. So, medical trend always outdoes inflation. Why is ours so low . Because we are doing good things. Because we are doing really good things is right. Thats exactly what it is. It is unbelievable that we are getting these trends. And ill finish it out, for prescription, it was 3. 5 . For active, negative 1. 7 for early retirees, and the national r. X. Trend roughly at 12 . So testament to the partnerships. I really did show you that prior slide for this. I did not it was not a prelude to opening your wallet. Ok. Im sorry, just to make sure im clear. So, what interval is this trend, is it a monitoring, is it a month, two months, a year, trio year over year. Calendar year over calendar year. 1. 3 is what, calendar year 2016 over 15 i dont think its no, goodness. I did not bring the snapshot of the time frame. It must be 7 1 to 6 1, 17 over 16. We cant produce these until we have three months of runouts and then present on them. So probably mid year to mid year, 17 over 16. Really nothing to do with trio, but all the rest of the things happening in terms of looking at services and accountability. A. C. O. Well, you are correct, it does not have to do with the labelling trio but what is trio. 62 of your members are using trio today, and have been now we are refining that and focussing on the partnerships and calling it a product, trio. So, it is trio. And thats produced, just those trends alone, 22 million in savings. All right. Commissioner lim. So, assuming the rest call for early retirees, way higher, but as far as medical trend and drug prescription which means our early retirees are more healthier probably because we didnt have that much medical claims and prescription claims. Well, i will say that the risk trend for the early retirees went down slightly. It went from 2. 84 to 2. 74. Its still that Golden Diamond at the top of that 100 curve. And i always like to point out when i see fabulous numbers, i dont care if they are fabulous. You you already overcharged me x amount and given me 1. 3 discount, its meaningless to me. I want you to charge me the right amount. We know we are being charged the right amount because we exercise so much Due Diligence partnering with the providers that we look at everything and we have carrots and sticks that they do charge the right amount. What it is saying, director lim, is that its being held at bay. Those trends are completely counter intuitive to the risk and counterintuitive to national and bay area trends. Maybe i could say this, part of that probably is attributable to our wellness program. I cannot say it would be attributable to the wellness program. And im happy, we have an opportunity next month to talk about prescription, and you can see all the various stealth prescription programs in play to manage the high cost drugs. At risk, have some created for the wellness program. On the page five presentation, early retirees 60, versus 48. How did you arrive at 48 . Thats too for the whole you could not have early retirees most employers nationwide or book of business. Workers retire at age 48, that early, i could not i could see for 60 for the City Employees, because of the incentives when you become 60 you have more the present age of your retirement is going higher. But 48 for early retirees . I asked the same question at the meeting, i think its driven by dependents. So, when you are an early retiree, we take into account the dependents as well. So, other groups are having more dependents who are bringing down that age in that early retiree category. Accounting for dependents for the city, it cannot just be 60, it could be lower. Most of the City Employees retire at age 60 but the dependents are way, way younger and i cant believe its 60 then, if you accounting for dependents. I would ask, rather than trying to unravel this, we come back to this point. If you are talking about the age of early retirees, i dont know what their dependents would have to do with it. I would like to have a little broader explanation about your methodology for arriving at that number. You only become an early retiree when you are, its nothing to do with the fact my grandmother im taking care of or my two stepchildren. H. S. S. Transmits early retirees along with their dependents and we have to bucket them all in the same bucket together. So we do take into account the ages of the dependents and the more children that are in there, thousands, it will mix up the ages. I understand youre explaining what you do. Im asking a broader question. Why do you do it that way and that would mean that you would have to get into explaining your methodology a little bit more as to why you do it that way. Its not intuitive to me, if im counting early retirees, those are belly buttons. Thats an early retiree, it has nothing to do with the fact, you know, where they come from and how many kids they have. But i would like to have a clearer explanation of your methodology at a later point. Later point, yes, of course. I have one comment and then a question. Because the city offers a defined benefit pension plan that doubles in Service Value when you reach age 60, theres a tendency for Public Employees to stay until they are 60 years old. I think many other employers dont offer a defined benefit plan at all, they have a 401k or some other deferred compensation plans. There is no benefit to waiting until a particular time. If you have a, the ability to retire, lets say you know, you can sell your house for Million Dollars for less than that you bought it for, and look at the overall financial package and the money in your 401ks, then you make a decision based upon your assets and your forecast. For City Employees, age 60 is a critical date for just about everyone. My question is, are we the only Employer Group in trio right now . How many Employer Groups are there, and is it pers is not in it right now, they are in a similar version of their own and have been for some time. I can get back to you with the exact numbers. We have had a significant uptick january 1st. It was hard for me to imagine any sutter facility coming back to the table if the only Employer Group were us. Its you. Even in the east bay, we have that big impact on some of the providers in the east bay . I will say that ulta bates facilities are not heavily used by h. S. S. And access plus. Those were added in. I was not involved in the negotiations, but they were added in. Right. So you are correct. There is not a huge use there. But they were added in. Okay. Thank you. Thank you. Any other questions . Any Public Comment on this item . Thank you very much, we look forward to your next update. Thank you. Next item. Item 11, discussion item, update on best doctors, Second Opinion vendor, best doctors representative. Hi, good afternoon. My name is nancy oh, im with best doctors. Nice to be here. What is your responsibility with best doctors, please . Account executive to Health Service systems. And you have been with us for how long . I have been with h. S. S. Since may of last year. All right. Thank you. So, what im here to do today is, im sorry, struggling to get this down near my face. What im here to do today is to provide an update in terms of utilization. So, the first time in may when best doctors representative john fisher, Vice President of development was here, he went through two months of utilization and it was very premature and today what well be doing is looking at the actual closed activity, so the actual closed cases for three full quarters. One of the things i wanted to cover before we dived into your actual utilization was i wanted to address a very common question that we are getting, im sure you have seen the news, best doctors and teledoc is one organization and one of the questions im frequently hearing from a lot of clients is basically what kind of enhancements are you providing for members, do you have any technological developments. So i wanted to address that. Because best doctors is offered to all of your population, i wanted to make sure to be very clear to say all of our communications that are going directly to all the members speak specifically and only to best doctors because we dont want to confuse any membership. Teledoc is a service that is offered, its the telemedicine through video and phone visits that you can access, if you are a blue shield of california enrollee. Its one of the benefits that are included inside the blue shield of california plans. So, blue shield of california is driving all of the communications about teledoc access, but the nice thing is that on the back end of behind the scenes, we have been able to turn on a seamless member experience. So, a member who is enrolled in blue shield of California Health plans get communications about accessing teledoc, the telemedicine service, and when they download the app or register on the web portal, then they can access all of the teledoc Services Offered through blue shield of california that in addition to that, theyll be able to initiate a Second Opinion service through best doctors. So, its one stop shopping and thats from the teledoc side. So you can see here a snapshot of a general overview of your activity for the first threequarters, again going all the way back to january of last year. Right here we can see the total number of member contacts and that can be in the form of a phone call, an email, a member portal inquiry. So thats total. And from that, we were able to open 509 cases and at the time that we closed this report, we had a total of 413 cases. In terms of the difference between 509 open cases and 413 cases that were closed, it could be that they were still in progress at the time that we had pulled the report. Again, this is just for closed cases we are trying to show you. Of those 413 closed cases, you can see that there were 44 of the cases that had an adjustment and diagnosis, and of those 413 closed cases, 87 had exhibited a change in treatment plan. At the bottom of this slide, you can see that we usually like to gather data from the members asking them how they had heard about the best Doctor Services and we typically only collect the top three or top four ways that members collectively state how they heard of the benefit, so you can here the mailers, we had actually sent out several mailers, so we sent out two mailers this year, in addition to the letter with the magnet, and you can see what an impact that has. We have also been very fortunate to be able to piggy back on one of the e newsletters available, so another avenue to get in front of members. On this slide you can see how your 731 contacts flowed over into the Different Service lines. So, from contacts you can see that you had 299 closed cases for find the best Doctor Services. Ill go over a very quick recap of all the Service Lines just to refresh everyones memory. Find the best doctor is a physician search and match program. So, say for example someone is looking for a specialist and they want to see the type of best doctors that are available in their area. So, thats one of the Service Lines that we have available to h. S. S. Members. Then you can see here, we had a total of two, ask the expert cases that were closed. And ask the expert is basically a compilation of evidencebased data, providing answers to members questions. So, the member provides some detail about their background, theres no medical records collection, and then we provide some information in the form of a report. Its sort of like doing a Google Search except you are not doing a million or 6 million hits of data. You are asking a physician to provide the report to you. The next one is the interconsultation. That is our brand name for what is the virtual Second Opinion service and you can see that we had actually hit what best doctors had identified as a target, so we had targeted 102 closed cases for quarter three, and we had just hit that number, so thats spectacular. And the last one is medical records e summary. Basically that service is collecting a persons medical records, it goes back between 2 to 5 years. We want to make sure that everything is current. We put all of the data into a secure flash drive and then fedex it to the members. That way if they are travelling overseas, or if they are travelling across state lines, o if they are looking for a new physician, all of their current and relevant medical records are in one place. This slide is basically showing you how exactly we are getting contacted by members. So you can see a lot of the interconsultations, thats the virtual Second Opinion is initiated through the phone, and i think that thats very usual because theres a lot of questions that typically people want to share, you know, how is your visit, did your doctor say anything specifically or you know, did you have another visit in between the last time we spoke. So, a lot of those cases are typically opened through the phone. Again, here is a deeper dive into the Second Opinion service, interconsultations. In order to provide a good explanation of what the service is, ill just run through the steps of what happens when a member initiates a service. They authorize best doctors to collect medical records. Once we collect all the medical records, we then reach out to a best doctors in our database to review all of the clinical notes, the pathology, see if we need to retest the blood, and then see if we have missed or omitted or skipped over any medical records. They might be missing. And then we have the expert review everything and write out a report with their findings. They would clearly state whether or not they are confirming the diagnosis, or if theres an adjustment, and the same applies to the treatment as well. Expert does the review, writes out a report and the report is shared confidentially only with the member unless the member specifies otherwise. All right. I would like to pause, i think some of the slides here are selfexplanatory about how you have engaged the population, and that sort of thing. I would like for you to go to the section of presentation that talks about clinical integration for just a moment. Sure. That would be slide 14. Yes. Whatever you were going to tell us about that aspect. Sure. So on slide number 14, you can see that we capture the inbound to best doctors and out bound to your benefit partners. So, what we do is we capture each time that we refer out a member to, for example, the h. S. S. Wellness team, if a member has any questions about did you know that you have this program available, and the member says no, i didnt know we had that. And then we would provide the information to the member. We also offer to do a warm transfer, because we do realize that if you sometimes just hand it to the member, they are not going to follow through. So we make sure to offer to do the warm transfer for them. And the same thing holds true with any of the other vendor programs that you have. We dont have everything displayed here, for example. One of the things that we are not displaying on this slide is any of the Tobacco Cessation programs than could be we didnt do outbound programs. They dont have a case that related to the Smoking Cessation or referrals. So these are in bound to best doctors or out bound to one of the benefit partners. Im sure that sometimes it might be a little surprising to see that we have a little bit of lower numbers from particular vendor partners or even from the h. S. S. Wellness team, and one of the great things we do is integrative projects or discussions and that we revisit any opportunities for referral and integration. And so thats ongoing right now. I have a question. Commissioner breslin. You have blue shield of california referred to best doctors 0, referred to benefit partners. Are you saying that, what are you saying . They didnt refer anybody . Correct. Blue shield wouldnt refer anybody, right . At the time that we had only just the regular access plus h. M. O. Plan, there was not a capability for blue shield to refer to best doctors. However, we are in we are having a discussion and process to speak to any opportunities with trio for best, for blue shield to refer members to best doctors. So previously there was not an opportunity for blue shield to do so. But it sounds as if we are looking into opportunities Going Forward. So, it wouldnt be the doctor thats making the referral, it would be blue shield. Yes. Its when blue shield is speaking to the member. At what point would that happen . Usually if you call blue shield, you call they call h. S. S. Or might call, you know sure. It could be any number of folks. For example, typically when members are talking to clinical staff about their care or they are trying to get some guidance in terms of the direction of their care or next steps, and its typically when registered nurse or another clinical staff member from blue shield of california is speaking to the member that you would be able to ask them did you know you have the service through h. S. S. That is free and confidential, typically how the referrals work. Wouldnt be the doctor, obviously. No, it would not be the doctor. As im reading this chart, at this point, we have blue shield, kaiser, and u. H. C. As major benefit Plan Partners with us. So, there has not been an active program to look at provider referrals to you, is that what im hearing, or you are just beginning to do that . We have done outreach in order to kick start conversations to look at opportunities for referrals and as you can see here, the only provider that was effective in terms of carrying out a Referral Program was United Health care. All right. Then united refer best doctors, and then you say referred to benefit partners. So, what does that mean, the seven people went back to u. H. C. . No, these are all unique users. So, if we are taking a look benefit partners. Looking at the second line, the u. H. C. , the first column shows referred to best doctors, 19 cases. That means u. H. C. Referred over members to best doctors and out of all the members they referred, we had actually seen through cases through closed status from 19 members. 19 unique users. It says referred to benefit partner seven, what does that mean . That means from best doctors we sent out Seven Members back to u. H. C. And its not the same members that were referred in. It was members that obviously didnt know that u. H. C. Had a particular program or could help support them or clarify their questions about their claim or their physician or innetwork status. Looks like it should be 12. Seven from 19, 12. Unique users. 19 people that completed cases with best doctors, and then best doctors sent seven different members to u. H. C. Because they needed Additional Support from u. H. C. So this is best doctors referring to the health plan. Yes. All right. Thats what the second column is. So the first one is in to best doctors from the benefit partners. Dont really know what happens to the 19, necessarily . Im sorry . Dont really know what happened to the 19 . The 19 members that were referred from u. H. C. To best doctors had completed an interConsultation Service. Thats the Second Opinion service. All right. Are there other members, other questions from members of the board . Regarding this . Yeah, i have some questions. So, appreciate this presentation. Its different than the presentation we had at month two. And in some ways. This focusses, i think, in terms of outcomes, focusses on Member Satisfaction with your three cases, which is encouraging, anecdotes of members being satisfied with this. It doesnt refer at all to any cost savings or additional costs, which i had some concerns about when i saw some of the initial cases. Are you abandoning cost savings, dont really have access to that . We are spending a fair amount of money and the way it was sold, not only for Member Satisfaction but also to try to improve our overcharges and our over utilization. And get to that, ill get to son of the cases. Sure. To answer the first part of your question, commissioner, we are not moving away from still looking at potential and projected cost savings for cases. We do actually include that in a supplemental report. Its called a clinical impact summary that we dont typically put out for members to look at. Its aggregate data and deidentified, but has a lot of clinical information, thats why it was not submitted for the public viewing. But, so we are not moving away from that. We still do do that and its part of our contract with Health Service systems in order to project and calculate the savings for each case. Well, i understand that you may not want to do that on an individual level but some aggregate summary of cost savings impact due to these services being provided is going to be to me essential as we look at Going Forward with contract renewal of the service in the coming year. Yes, we understood that it was a new service, it was being applied in different way. We are obviously very large population, but we did bake it into the cost, if you will, to our members, and we need to know what is the benefit side for those who have utilized the service. Its good to know the total aggregate numbers of cases that you have addressed and so forth, but attached to all of that at the end of the day is a cost impact. And we need to see that. Yes. So, that will be included at the annual report. And you know, the other supplemental report that i had mentioned, clinical impact summary has the projected savings per each case, deidentified, annual when we calculate on aggregate basis. Well, i would like to request that we have an interim report regarding cost savings, just as you are able to go through three quarters, give us this level of detail about what happened. There should be some, again summary that relates to cost savings. Estimated, known, or something. Uhhuh. Yes. Very helpful. I can get that to you. And again, just to reiterate my previous concern, we dont have any cost information here, was that i was a little concerned the data we were presented was not very robust. That that projection for the one case, as i recall, was based on surgery was averted because some tests were ordered, but there was no six month or one year or two year followup and we cant really expect you to have one year or two year followup in some of the reports, even at one year, because you have just started. But the methodology would be very important, not just project the cost if everything goes perfectly well based on one interconsultation, but what the ultimate cost was. Do we just delay procedures or cost. So the methodology is very important in that. So i have another point. So, on slide two in the upper righthand corner you talk about clinical impact. You said 44 change in refinement and diagnosis. This is change and diagnosis. At least from a medical side, refinement and change are actually quite different terms. Refinement means there was a nuance that was added as part of a review that wasnt really a change. They didnt go from leukemia to Prostate Cancer or diabetes to something else. And so im a little concerned about what, how you used the term change or refinement. What does that refer to exactly, in terms of the significance. Grade those refinements in terms of serious or minor or something, you have a scale . We dont grade adjustments in diagnosis or treatment plan changes. What it is is basically as you touched on, it might be a lab test or imaging that was missed or overlooked. And that typically when you see a lot of the cases that we do, it can contribute to why a person cant get a unifying diagnosis or why its been diagnosed a certain way or graded in terms of staging a different way. So, when we are talking about an adjustment in diagnosis or treatment plan, it could be just as you said, misstep they are calling out. But if its something dramatic, like you mentioned, your example of leukemia to Prostate Cancer, that would be a very distinct change in diagnosis and that would be called out on the report. Right. About you this is 44 change in diagnosis. Which implies to me the diagnosis was in fact changed. And thats a different term than refinement. Refinement has a different impact, at least in my mind and maybe im just being overly sensitive to this, but as someone who for my practice often refined diagnoses and some cases changed, i know the difference. Likewise, 87 change in treatment, that change in treatment or refinement in treatment . You know, we had a case in, at the twomonth interval, recommendation was for followup scans at a certain interval that was within the same guidelines as the original doctors recommendations, just three months versus six, but the guidelines said 3 to 6 months. So, i dont know if it was coded as a change because even in the range of all the, you know, subspecialist consensus statements. So, change in treatment and refinement are important terms, and i think for us to judge on the impact, 87 changes to me is in treatment is actually, would put every Health Plan Partner that we have on notice here that we are really missing the boat, and ill when i go to the cases, ill reiterate that. This is reconcerning to me, that we see when you go from the first case on page, whatever it is, six, the, no change. Page seven, you mean. I think six is the case the one with the heart attack, coronary artery disease. Thats page seven. Ok. Im sorry, the slides ok, page seven. It says that the treatment clarification, confirmed the diagnosis, how different was the plan compared to what the member understood from the previous, you know, from his own, or her own provider. If it was a significant change, that means that that first provider needs some counseling, if they were not providing adequate recommendations, if this is some tweaking, maybe have the cholesterol done every three months instead of every six or something, that is, would not put any health plan in this room on notice that they have messed up. I have the same concern about the third, the second case. Which was the neck pain. Case basically they recommended additional images. Well, you know, who, was this member not really referred to a specialist . And thats why they went to best doctors, and that would put that health plan on notice that that physician is not utilizing their available services. If it takes this kind of a consultation to recommend some more imaging because of chronic neck pain. Thats a concern of quality that we are, our Health Partners are missing. Same with the last case. Apparently this member provided all kinds of data, and in the absence of any diagnosis or treatment according to this scenario, just the doctor ordered a bunch of stuff, i dont know what it means and what to tell you to do with it, go to best doctors to figure out what all the stuff i ordered really means and what you should do about it, and so the member was very satisfied because they got a diagnosis and treatment plan that doesnt involve really anything other than selfcare which is important, which is clearly important. And so if the doctor was saying no, i dont know what this is, i dont know how to treat it, im going to give you a pill, then there was a cost savings to us and to the health plan. But this is this case really strikes me as sort of like, what doctor would order tests and then not provide any guidelines to what the tests mean so the poor member has to go to you know, Consultation Service to interpret. That is terrible communication from the Health Plan Partner. Whatever communication for this specific members case was broken down, i cant speak to. What i can tell you is that the member was the one that initiated the service of best doctors because the member could not get a unifying diagnosis. And the reality, im sure that everybody has seen this because its been really big news for a number of years is the staggering statistic about misdiagnosis. And misdiagnosis is, you know, we were using this case as an example of the physician who orders a bunch of tests and then you know, doesnt really help the member identify exactly what the issue is. I think the reality is, is that physicians are typically very overburdened with the number of patients they are required to see, and we are trying to get everyone in the medical industry and the health care industry, to get in front of quality and so all of these measures are there, and you know, theres a lot of different programs to improve quality of care but times human error can happen and i think thats why we see what happens with misdiagnosis, and its not because we believe that any physician doesnt really care about the patients care or the delivery of care, it could just be an error in ernest. I appreciate all that, im a retired physician, i appreciate all the stresses and demands and the issues you say. What im trying to say is we spend a lot of time working with our health care, you know, provider partners to actually show that they can do quality, you know, prove to us that they can do quality work, screening, mammogram, all the whole shebang. And so you know, so this service to some extent, the more you advertise it, by the way you just advertise it to me, is that there are just mistakes being made all the time and we are the ones who can save you, ok . Doesnt help to have you advertise that to me or our members saying dont trust the health plans that the Health Service system of simi county or San Francisco will contract with, they are going to screw up and we can save you are what your Health System is doing or monitoring. I think that is a completely valid point. If you look at any of our mailers, we do not use hyperbole like that. With me, you just used hyperbole with me, you did. I did not say that misdiagnosis happens every time. I said that it is a staggering statistic that we are seeing. But the reality is that all of the material is not there to scare people into thinking that every single physician is going to make that mistake. We do have material that is memberfacing, thats shows that its going to be a third of the cases across the entire United States that has misdiagnosis, and thats not a statistic, thats actually made up by best doctors, its something thats shared. But we also urge people to get a Second Opinion because it is a free and Confidential Service and it can provide peace of mind. We also share the statistic of members who have had services with best doctors out of the cases that we have seen, we have seen an adjustment in diagnosis and treatment plans of this percentage, and best doctors most recent book of business. So, obviously its not going to be 100 changes all the time, and its not trying to trick the member thinking if they bring in the case they can always expect to see a change in their diagnosis or treatment plan. One more comment then ill be quiet. I apologize for my fervor over this. But, and i appreciate what you are saying. To me this part of the presentation looks like an advertisement in a magazine i pick up off the rack at my supermarket. And when you say not 100 of the time, you are right. You dont say that, you say 44 of the time. Our case, when we review cases we got a change in diagnosis, 44. Almost half. And 87 of the time we change, we recommend changes in the treatment. Thats not 100 , but thats pretty high. And so if i were naive and thought oh, my god, i need some peace of mind because theres an 87 chance my clinician has not provided the appropriate treatment plan, i would be pretty alarmed and, i like the peace of mind. That part i think is great and may be worth that if thats what you are doing but these slides dont tell me thats what you are trying to do. You are trying to advertise your service, 44 change in diagnosis and 87 change in treatment plan. Well, the clinical impact summaries line by line actually calls out if it was changed or if there was an adjustment. We are not seeing so thats the problem, all right. Thats ok. Points taken, commissioner breslin. I do have just i wanted to just say what i what this, the way this was sold to me, not that it was going to be cost savings in fairness. The reason for this, i think the overriding reason was that sometimes someone gets a diagnosis that requires surgery or requires maybe radiation therapy, serious diagnosis, they are concerned about, is that the right thing for me to do and they want a Second Opinion. So, that to me is a value to the members. Whether it costs more, whether they wind up doing something that costs more or costs less as an out come is secondary totally, but that peace of mind is the critical reason for the program. What worries me is on the very last slide when i see, when you talk about having 700 contacts and i see so many being referred right back into our system for, to get the answer to the question they are asking, im kind of worried that many of our members are just calling the wrong person with their concern, that they are picking up because of that mailer or magnet, they are calling you about something that needs to be taken by u. H. C. Or kaiser, their own provider. I want to know what percentage of your calls are significant in, around the Second Opinion sort of service, and how many of them are just misdirected calls that shouldnt even be counted in your end. Ok, because, or i want to see that n, for that number of misdirected calls. That is not efficient, that is really not a useful service if all it does is cause confusion among our members. So, Second Opinion, yes. I think we really need to emphasize the value of that, and every communication to every person. Second opinion. You know, not call me because you know, somebody did not pay my bill right or somebody you know, im not quite sure what to do about this problem, what should i do. I just dont see that as being your role. Sure. I can tell you that im using bigger numbers, statistically speaking. We are not getting a majority of callers that should be talking to their medical provider because of some billing inquiry or mixup. A lot of the questions come from not quite understanding what the service is, so they think of it as like if i call in and i have a sore throat, can somebody tell me what i need to be doing, so its its that one. But so we try to emphasize that its the Second Opinion, its, as if you would get a Second Opinion from an actual physician in person. So need to get those statistics as to which is which. When i see 744 contacts, i want a breakdown of what those are about. How many are Second Opinion calls and how many are something that is not, you know, your primary function. Sure. You can see on slide number five three, i think this is. Four. Four, sorry. That is three, yes. Slide number four, you can see from the total contacts, the correct number of folks that had contacted us for a Second Opinion or that we could help them with a Second Opinion was 509 cases, so 509 unique cases. And then also, sometimes when members call us, they do want a Second Opinion but its not appropriate to get a Second Opinion because many of the folks that are turned away and we cant really help them with the Second Opinion services because its no longer relevant, sometimes people want this Second Opinion to be done postmortem, so that they can go back and make a case for mistreatment, and so we don