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 dont provide that because what best doctors intends to do is try to provide the right treatment Going Forward and not after the fact. So, sometimes people may want to get a Second Opinion, but its after they have already had a procedure done. Other questions. I have a lot of comments about this. First of all, its not free, its 1. 40 per member per month, adds over 1 million to the rates. Talking about a looming excise tax and i dont understand how you know your diagnosis is better than the other doctor diagnosis. 509 cases open, 413 closed. Unless you follow the case for a long time down the road you wont know whether your diagnosis was better than the other persons diagnosis. And we already have this Service Available to us. If a member has a certain problem, they can get a Second Opinion and a facetoface opinion with another doctor. As far as i know. I know people that do it. And if they dont, i know that h. S. S. Would probably help them facilitate that, and those particular cases. So, and these are not facetoface visits, and you are looking at the same stuff that the other doctor looked at. And i just, i just think that this is a duplication of services and i have a few other things, but its getting late. I just dont also dont see why you think these are the best doctors. The bay area has the best doctors, really, some of the best doctors. Yes. So, they can already go to them. They dont have to go through you. And anyway one of the thing best doctors focusses on, two things. The virtual part of it, people dont have to go anywhere and repeat another visit with another physician if they already have their medical records and the clinical notes. Theres nothing like a facetoface from everyone you talk to, to look at the patient. Sure. And that makes a huge difference rather than just looking at a bunch of papers and stuff. Thats missing here. Sure. Of course its going to be missing from a virtual visit, yes. The other part of a virtual visit is you are taking away any kind of geographic limitations, so if somebody, you are right. We have a lot of physicians from the bay area that are in the best doctors experts database. I have seen them because ive seen a lot of the requests come through. But also there are other specialists who are considered, you know, the premier, most knowledgeable or working on some research or, you know, on the clinical edge of whatever they are doing, im not a clinical person, i cant really express this. But they might have access to more knowledge in certain circles and they might be located in the southeast, and it takes away that limitation is basically what it is. All right. Are there other questions from the board, director griggs. I would like to make a statement for the purpose of the minutes, h. S. S. Will go back and look at savings and costs reporting. It is one of the performance guarantees that we have with best doctors for february, i believe. So that is coming and we will work heavily getting it appropriate to present to the board. Second thing, go through the reporting, too, and look at refining some of the labels on whats on the report to further clarify for some of the things brought up. But it is and what i have heard and the member interaction ive had, it is at this particular point in the existence with h. S. S. , one of the peace of mind things that people feel confident, more information or different, you know, from a different source, or some networks or some integrated h. M. O. S limit where the Second Opinion can come from, too. So, you know, this is an area where i see its benefitting. We will go back, the department will go back and provide this additional information. Thank you. Public comment on this topic . Public comment . All right. Yes, hi, i realize this is atypical, speaking as an h. S. S. Member, not as an employee of the Health Service system. Im speaking because i am somebody who recently utilized the best doctor Second Opinion service. I heard a few comments here and as somebody firsthand experience the service what it meant for me. I did get a somewhat serious diagnosis for me, cardiology related, and there was, im with kaiser, so my Second Opinion options were all in the network of kaiser or my mother did want me to go to see her cardiologist. And that was going to be completely out of pocket, and very expensive. So i thought i would avail myself of the services that we provide to our members. And i did open up a case. I ended up with an hour telephone call with a cardiology specialist at the cleaveland clinic. I dont know when in my life im going to get an hour with a cleaveland clinic cardiologist, and that conversation was very helpful to me. When we talk about risk factors, when we talked about how do you define success, that was not a conversation i had had with my kaiser doctor, they are like giving me percentage of success rate and even my service system, we talk about how, you know, people have to advocate for themself, ask the right questions and its so difficult. And so to commissioner sass, or commissioner follansbee, its not cost and peace of mind. I have to tell you, i got peace of mind out of my experience and i did go through the procedure and it was costly, so if you are going gonna look for cost savings you are not going to find it on my particular claim. But what im hoping is i will continue to be a productive and effective member, employee of the city and county of San Francisco, and Health Services system and that service to me meant the world. All right, thank you for your comment. Any other Public Comment . My name is diane erlick, i used the best drs. , im a kaiser member and also cardiology. In kaiser you are limited. You can go do any kaiser doctor but its the kaiser line that you hear when you go to a kaiser doctor. And i used best doctors and i found it extremely helpful and it did result in a change of medication that i am much more pleased with. So i think it is very valuable. Thank you for your comment. Any other Public Comment . Hearing and seeing none, we are now ready to go to our next item. Item 12, discussion item, presentation of q3 express dashboard, marina coleridge. Oh, sure, now i have to collect myself and play this other person. I understand. I started to say we could defer this to the next meeting, but i dared not without permission from director griggs chlth. The first time we have presented marina coleridge, back in august of this year, was the first presentation of our new express dashboard where we are really trying to, on a repeatable, recurring timely basis bring integrated dashboard that looks performance across all three of our health plans. In last month board materials we did provide the dashboard through q2 of 2017. That was a very packed agenda. So, we did not actually list it as an agenda topic, as well as i knew we would have the q3 one available by the january meeting to be more timely. We have a present station, gov tv. A presentation. Knowing that this is a late hour. Yes. And that the material is dense in terms of how its presented, i would ask that you provide thematically the information on the succeeding slides or key points. You have done a great job of putting down kind of some key footnotes and so forth, but i think that in order for us to get the best understanding of what youve taken time to collect here, we need some highlig highlight guidance. Certainly, i will not read the dashboard notes, they are the same notations we provide each time. There are two dashboards in the deck, one looks at the nonmedicare population, so active and early retirees, and then we repeat some of the dashboard components for the medicare population, and that does not have the financials in it. Looking at page 2 of 9 for the nonmedicare population, these members are all trending pretty consistently, when we look at previous period for your med and rx spend, while that is down over the dashboard that you saw in december, we are slightly trending upwards, and i dont think thats really any surprise. I think weve gone from a spend of 599 million, up to 606 million, high claim costs also very consistent, if you go back over the last couple dashboards and look at those numbers. Slight uptick from q1, but otherwise all these members are holding steady. Our cost per employee per year, which is found on page three, this, over the course of 2017, has also been increasing. A total allowed amount of 12 thousand 9 hundred 0. 82 per employee per year. Thats trending up about 1. 7 as we look at slide four ask one im sorry, make sure im clear. The total, is that sort of, you know, in each of these graphs, is that the, like under high cost claimants overview, so the h. C. C. Allow amount per patient, the total is higher than any one of the three components. So that means that we allow into the contracting more than any of the claimants . Im confused what the totals are supposed to be. Please be clear as to which slide. Slide two, under high cost claimants overview. For example, a number of high cost claimants. The total, its close but not exactly the number, the three components. But allowed amount per patient med and rx, and blue shield, 128,759, city plan, 106,000, kaiser 126,000, but the total 129,137 which is higher than any of these three Component Health plans. So, im just i dont know what the total actually means. Yeah. Im going to have to go back and look specifically at the code behind that. I believe its going back out and recalculating without putting a plan on there. And so we have additional dollars that end up showing up for some cobra and other utilization, and i believe it ends up in the total, but its not ending up in the blue shield city plan on kaiser, because now this gets technical silly, but we the Health Service system owns the eligibility feeds into this. The claim feeds from the health plans and they can marry up to our eligibility, we dont have the cobra people. And because of that, some of the dollars drop off. But when you go to total, you are not restricting the data and doing other things, so it will pull it back in. I suspect its that piece making numbers like this look a little odd, ill confirm that to you by the next board meeting. Thank you. I guess my question, somewhat similar, when i see a number like 129, is that an average . Versus a total number . Its an average, its a per patient. Im just wondering if total is the right. Total column, i see what you mean. Yeah. Cant be i think, it cant be an average when you add 128, 106, 126 and weight it for the number of enrollees per plan. Cant be any greater than any one of the three columns. I understand. I thought you were talking about the specific measure, the per patient, averaging out over population. I see where you are going. Thats just a question. With the terminology there. We will clean that up. You were on page three. I believe i was shifting to page four. Fine, thank you. I was done, wasnt i . Cost and utilization trends. Yep. Cost and utilization trends. What youll notice on here, kaiser is the only plan thats below the western norm and significantly so, but what i want to call out for you is that western norm which is whats available to us in the apcd, is compiled by really looking at p. P. O. Data, and so its not an ideal norm to use, because its somewhat misrepresenting, but we have struggled and in ernest are constant sly trying to find a proper benchmark so that we can really see how our plans are performing based on what our reality is. We are looking at some other modifications that might actually make us sort of create our own norm, all things cost money, though, its a decision where you are spending your budget dollars. I did want to call that out. So, more than anything, i look at the west norm to get some general idea, but looking longitudinally whats going on with the numbers. And of course, the plan performance in the middle of this page, my personal favorite. Done as an annual update. This tries to do a ratio by the average by looking at the risk score, which again, still the dxcg methodology other people have mentioned instead of list being it in the they scale it to 100, thats why they see 106 for blue shield, normally read it as 1. 06 risk score. And then a note as you read through and absorb the data, premium contributions, because they are based on the medical premium and as you know from other budget conversations that happen today, embedded in the medical premium, you have, for example, the 3 p. M. P. Under sustainability and doctors and other items embedded in there. Chronic condition prevalence on slide 5 of 9. Really important to us in continuing to look at what sort of information can we use to look at both the quality and also help provide some information into our Wellness Programs. These, im pleased to report, trending downward. In the shortterm, up ticks, hypertension, diabetes, low back. But where we were at the end of 2016, dropping down in terms of our per 1,000. And preventive screenings, the next one. And what i would like to call out on the next slide, six again, we dont necessarily have perfect data, but always said if we waited for perfect data, we would never have anything to look at and evaluate and inform where we needed to go. And so on these, for example, you know, if we look at kaiser screening weights, around 90 on the cervical and the mammogram and the colon cancer. Those in here are not set to the measure which exists in the engine we have to pay for to make happen, it should be every two years versus one year, just a look at the year and where we are looking at, get a sense of are our members taking advantage of the preventive screenings, do we see variability by plan, just a caution how we are consuming this information. And lastly, i know stephanie presented last month in terms of where shes at with her Wellness Programs and i loved that piece about the score of 75 on the overall wellbeing, the number of population, drives to a lot of other good things. The bottom left, 72. 4 of our population are sitting in healthy and stable, and thats where we want to keep them. No news to any of you, 1. 9 of our members are driving 40. 1 of our costs. So, we want to stop our members from getting over to further right along the risk band profiles, and point of note on the top ten summary groups, hepatitis has dropped off of that, and looking at some episodes and some costs, and so and other than that, no other specific notes on your commercial population moving quickly, since it is late in the day, to the medicare dashboard, page 2 of 6, once you get into the medicare section of this document, i would like to say this is one of the first ones ive had a chance to look at since we have incurred data now moving into the 2017 year. It is it is rolling 12 months, so when jeanette from blue shield was talking to you about the early retirees with blue shield and the average age, if you are trying to crosswalk to this and you see 72 years on this, and wondering why, 12month rolling, so i still have six months of those medicare blue shield members in here. So, just so you are not thrown off by that. And also maybe some of the six months, the risk scores are looking really kind of whacky here, both blue shield and city plans spiked significantly. So, well bring back, some further analysis, positing possibly some of the healthier blue shield medical retirees have moved out to the p. P. O. Product and what was left in blue shield was some of our sicker individuals which is driving up the risk score, but also the city plan score spiked from 315 at the end of incurred december 2016, up to 497. We did not have time to get into that level of analysis before the board meeting. Well bring back and see what we are noticing there with our medicare population in those particular categories. And just some notes on chronic conditions. Same thing we are seeing in our nonmedicare population, a lot of these are dropping down. I do need to do some similar analysis to your question, commissioner, about why the total was higher. We see that here with the hypertension patients per 1,000, each of our plans, the numbers have dropped on our patients per thousand on the prevalence but the total is higher than what it was previously, well look at that and bring that back to you as well. And those are primarily the big callouts and are there any other questions that i can attempt to answer for you . All right. Any questions from the board . Any Public Comments . I i appreciate very much your, appreciate all this very much. Particularly the preventive screening rates, to put that into perspective. I was taken aback by how low they are. But when you clarify they are not linked to the guidelines, not Everyone Needs a colon Cancer Screening every year, maybe every five years, so i dont know if there needs to be an anecdote, you know, to say these are not these are just overall. Looks like we should be, we shouldnt be comparing one health plan to another because the populations are different. Particularly above, you know, in the premedicare. If i understand that correctly. Yeah. Because, and so not so discouraged. Pay a lot of money to have such a low mammography rate, so but if its not is and also looking at trying to actually incorporate the measure in there. Thank you commissioner. Mike, do you have something to add here . Mike clark. This data does cross plan years, so one member could represent in multiple columns. So for instance on page 2 of 9 of the nonmedicare data, if you add up the sum of high cost claimants, 58 people may be in multiple columns, because of this spreading across two plan years. Ok. All right. Thank you for that point. Any Public Comment . Hearing and seeing none, now going to come to our end game very quickly. Yes. Item 13, discussion item, report on health and network plans, if any. All right. Please, any plan representatives that have something that they wish to share. Kay kiepler, kaiser permanente. We are in height of the flu season and still encouraging all of our members to get flu shots. We have updated our website with flu information and continue to offer our flu shots at no cost and no appointment necessary, so, wanted to make sure that you knew that we are in the height of all of it, but there is still time for members to be able to go in and get the flu shots. Thank you, i think thats very good given whats ahead of us. We know the flu shot did not accurately predict whats circulating in the influenza a. In the past, kaiser had protocol, diagnosis of influenza over the phone and in a certain period of time, i think 48 hours, prescription is sent directly to the pharmacy so they can get started on treatment. Are these kinds of protocols still in existence . And whats your supply of medications, also seeing reports that flu drugs are in short supply. Ive seen different reports on the news as well. I would have to check to see what the protocol is this year for i dont know if we are releasing prescriptions over the phone without a visit. But i can certainly find out if we, what the protocol is this year. Seems like your education should be known with the flu vaccine, and what to do if you think you have the flu, not to expose everyone at the Medical Center at the same time adequately treated and rapidly. Absolutely. Each Medical Center is addressing it in an appropriate way, depending on the volume. So, in those urgent cares and emergency that are seeing high volume and there are some, its quite overwhelming in the community, they are setting up locations for just patients with flu symptoms to be seen to keep them away for patients there for a sprained ankle. The next thing you want to do is infect everyone if they are not coming with it. They are through phone services, through other communications, we have a call center, outbound calls, where appropriate able to prescribe medication, they are doing that. I have not gotten notice we are out but there are certainly limits and what we have received more is that others are out ab starting to send those nonmembers into our emergency rooms, which as you know, we cant turn away anybody who comes to an emergency room because they are out of medication. So, its one of the things we do really well, we are a very large system and can move things around quickly. But it is a command Center Activity and each one of those Medical Centers that are close to capacity or have significant. Last week in Southern California specifically, where i think its been a bit of a bigger hit so far, they we were close to capacity last week. Its gotten slightly better this week. And so what we also do in that situation is we look at nonurgent scheduled surgeries, for example, and postpone those by a week or two, to make, to ensure that we have enough beds and enough staff to cover those urgent needs that come in. All right. Thank you. Thank you. Any other plan representatives . I just want to make a comment. Commissioner breslin. To United Health care, i wanted to say complaints from members about harassing phone calls still, and, we just received this nice mailer, and then addition i got another letter and i called the number, will you please call us, we are trying to reach you, i called and they took about ten minutes, they could not figure out why they sent whoever was on the phone sent out the mailer and i had to go by then. Its ridiculous. I really would like you to come back and say how much is it costing to do this. We would be happy to do a presentation to the board. And you know, its like we want to come into your house so you can prepare for your doctor visit. Yep. All right. But its over and over again. Shannon with United Health care. Well be happy to bring something back. Coordinate that through director griggs and director in terms of timing. All right. Is there anything else on this item, Public Comment . Hearing and seeing none. Next. Item 14, discussion item opportunity to place items on future agenda. Items for future agendas. Hearing and seeing commissioner breslin. United health care, copay for Urgent Health care is 35, Medicare Advantage plan. 10 more than blue shield and kaiser is only 20. So, i think for next month, you know, and well have this for an ongoing question about why this is more than everybody else, especially when you can afford to send out all the mailers, you can bring down the cost. We are just beginning the renewal cycle. I was going to bring a couple items to director mitchells, or acting director Mitchell Griggs attention. Recommended changes where we are seeing some complaints. Add that one to the list and definitely price a lower copay into and another thing, physical therapy copay is so much more than acupuncture and a chiropractor, i dont understand, especially since physical therapy is covered by medicare and the other two are not. Not only your plan, but others. And i dont understand that. And you know, chiropractic and acupuncture are passive service, i mean therapy. Compared to physical therapists. I dont understand why the difference in the price. Thats just for the future, its not just for your plan. All right. Well take those two points under advisement. United health care has made a commitment to have a discussion during the regular rates renewal process. Thank you. Any other items for future agenda, hearing and seeing none, no Public Comment, well now move to item 15. Discussion item, opportunity for the Public Comment on any matters in the boards jurisdiction. Any comment on any matter the boards jurisdiction, by anyone. Hearing and seeing none i see we do have all right. What we have noticed and actually gayle bloom brought up the issue of her bills, we have noticed a problem with sutter billing and have a number of retirees that have bills that are several years old now, and they have been trying to get them resolved. They have been sent to collections for like 20 or 25. And they have gone back to United Health care, back to blue shield, then they have been referred back directly to sutter and sutter says yeah, we see you paid that, but theres nothing we can do about it. We cant fix it, cant change it and the member is saying but im being taken to collections, you need to tell your Collections Agency that thats resolve and take that out of there. We cant really do that, so we have members being penalized and its really gone back to sutter billing. Its not United Health care, they have done whatever they can do. Ive spoken to our staff a number of times at Health Service and they are limited in what they can do, and members are saying, im still sitting here with a collection notice of a payment that im not obligated to pay because it was paid two years ago, and its not relevant to anything. And so i dont know what can be done, but maybe we can make some kind of inquiries, but sutter seems unwilling to adjust some of their practices in the Billing Units to clear up accounts and members are then Going Forward with ultimately collection notices and i think this is not acceptable for our members. So, whatever we can do to try to mitigate that. To try to get this on a path for correction or inquiry, it would be helpful, i think, to try to get some specifics and it may we know who they are, and so does the staff. All right. So, i think we need to take those that we have and then use that as the means to begin a conversation and partnership about the health plans around these issues as a way to unravel this, ok. Absolutely. Thank you very much. Thank you. Any other Public Comment . Hearing and seeing none, we stand adjourned until next month. Thank you. Were here to raise awareness and money and fork for a good accuse. We have this incredible gift probably the widest range of restaurant and count ii destines in any district in the city right here in the mission intricate why dont we capture that to support the mission youths going to college thats for the food for thought. We didnt have a signature font for our orientation thats a 40yearold organization. Mission graduates have helped me to develop special as an individual theyve helped me figure out and provide the tools for me that i need i feel successful in life their core above emission and goal is in line with our values. The ferraris yes, we made 48 thousand they were on top of that its a nobrainer for us. Were in and fifth year and be able to expand out and tonight is your ungrammatical truck food for thought. Food truck for thought is an opportunity to eat from a variety of different vendor that are supporting the mission graduates by coming and representing at the parks were giving a prude of our to give people the opportunity to get an education. People come back and can you tell me and enjoy our food. All the vendor are xooment a portion of their precedes the money is going back in whats the best thing to do in terms of moving the needle for the folks we thought Higher Education is the tool to move young people. Im also a College Student i go to berkley and 90 percent of our folks are staying in college thats 40 percent hire than the afternoon. Im politically to clemdz and ucla. Just knowing were giving back to the community. Especially the Spanish Speaking population it hits home. People get hungry why not eat and give in 2017 weve had the lowest number of fatalities on our streets in our history. We still have a lot of work to do. And doing this work is a team effort. It is of course working with the department of public works and the sfmta to discuss infrastructure issues to make it safer for pedestrians and bicyclists who are vulnerable to vehicles often times sadly going too fast. Were working with the San Francisco police department,