Comment on that item. All those in favor say aye. Aye. Opposed . Hearing then, the moments the minutes are adopted. Item three is directors report. That afternoon, commissioners you have the directors report for june 4th in front of you. I will just highlight a few items. One key piece is that last friday, london breed unveiled her Budget Proposal for fiscal year 2019 to 2021, and really focused on important investments and programs to create more housing, prevent homelessness, and transition people into services and housing to clean the city streets and to expand Behavioral Health treatment services. In continuing in her commitment to help people with Behavioral Health and Substance Use issues, the budget contains over 50 million in new investments to support this expansion of Behavioral Health. Behavioral Health Treatment, and other health services. This includes funding that will support 102 additional Health Treatment beds, and of the hundred and two beds, 52 will be made for residential treatment, and 50 will be proposed for Behavioral Health respite. These are in addition to the 100 that have been opened in the last year. This total of 200 is a very significant, in one of the most significant investments when expanding our Behavioral Health. The nearest budget also adds capacity hours and outreach to the Behavioral Health system and supports increased funding for boards, which have needed that in order to stay in business in the city, case management, medical respite, and the healthy streets operation centre. Centre again, very important investments to this priority, as well as for the people of San Francisco. With regards to the budget, Going Forward now in terms of the budget going through the board, our c. F. O. Will provide you with a written document which shows some of the shifts have happened since you have approved our budget, and i remember now, with supervisors taking hold of the document and revising it and it is an iterative process. After that process has happened, we will update you, which we hope will be ready on july 1st in a breaking news, i just want to give you an update that supervisors ronan and haney are introducing legislation called Mental Health San Francisco, which is being introduced today at the board. This is a proposal that will increase Behavioral Health services for san franciscans, through increasing investments in the d. P. H. System. The proposal has just been released, and we are reviewing it and looking at it very carefully with regards to costs in programming, and we will report to the commission as soon as we are able to do so. Additional investments in the Health System since we have asked, the mayor announced 22. 4 million in soda tax revenue to improve Childrens Health and wellness programs, and of these investments in public health, it includes sixpoint 6 million to support community and schoolbased grants first health education, physical activity, Health Eating and Food Security promoting better water consumption and communitybased participatory research, school food improvement, the expansion of oral health, the Community Task force an oral health program, which is so crucial to overall health, and increased Community Engagement so that communities most communities most affected will be informed about choices that they make. There is also substantial investment in increasing nutrition and water access through this tax. The so really a key example of how policy is helping us make better investments in improving public and community health. Switching now from budget to some of the negotiations with labor, i am proud to say that we have reached a tentative deal with our nurses after lots of work with the union, with the department of human resources, and our team, we reached a tentative agreement that will be voted on this week. We voted on soon, i dont think it is this week, but very soon. I want to say that d. P. H. Values our nurses and the key role in their system, and recognizes that it is the foundation of patient care. Nurses are the Largest Employee group with, with 2,000 dedicated professionals. It is our priority. We cannot deliver on that promise without the nursing staff and per diem nurses who care for patients every day. We are excited about reaching that tentative agreement and hoping that the union votes affirmatively to approve it so that people can get the pay increases that they work so hard for and deserve. I want to highlight one of our medical staff, some of you may know her, i have worked with her for many years. She is a medical director of the Transitions Division and she was recognized with an award. The award recognizes one clinician in the homeless healthcare for healthcare for the homeless shield annually who provides culturally appropriate, highquality care for people experiencing homelessness, and they have spent nearly 30 years working. I can say from engaging with her , she represents the best of the department in terms of dedication and the commitment to serving the most underserved populations, and it really makes she really makes amazing connections with the patients she serves. She is really deserving of this award. I just wanted to honor her at this event. And then you have the other pieces in the report as well, which you are welcome to review at your leisure. I am here for any additional questions. Public comment . I have not received any Public Comment requests for this item. Commissioners, do you have any questions . I think under the mayors proposed distribution of the soda tax, while you separate it into these parts, are these blocks in a broad category that the department will then be able to help shape what will be, for example, is it a grant to this edo, or will they go by way of the department, or will they do it at a different level from the soda Tax Commission . Our director a population has more details on that that i can provide. Im not sure if theres anyone here today who can provide more insight, but my insight is that the commission the advisory plays some role, but they are not necessarily prescriptive in terms of the direct programming side of the peace. The money is allocated in specific blocks, and then we would put it through our r. F. P. System in order to be a little more directed in terms of how the resources can be used, but we can give you a more more detail and we can talk about it in the next meeting. I think the issue is it needs to be coordinated with what we are already potentially doing. Thats right. We have one program that was able to add the soda tax into the program. I think we might have a better answer than i was able to give to your question. We can follow up on additional details, but there is i want to get the title right , there is an Advisory Group about how the city allocates the Spending Authority , so the Mayors Office is working with the Advisory Group to make its allocation. They did move money around in various buckets, but overall, it represents growth in our portion of the soda tax, the largest portion being four kids in the schools, which is consistent with the spirit of the tax, plus additional dollars for evaluation. The recommendations have been made for the proposed budget. In general, we should be working under the recommendations to implement and not to move around was that your question . I understood your question. These are buckets of money that had been allocated by the commission, but the question was , how do we execute it and integrate it into our work overall, how much can we shave actual programming within these categories. Yeah. In some cases, it is quite prospective prescriptive. There are only some instances where you can do that. There is a largest portion, i dont have the number in front of me, but it is 2 million. There is a whole r. F. P. Process in place. We have gotten the recommendation. I was going to mention that we have an example of how the funds augment existing programs as well, so maybe when i do the reporting for the committee i kin mentioned that more in detail. May i ask, if it interests the commission, we can provide an overview of the soda tax and the policy, and what programming is being used, and to the extent that we have the results of those programs. There seems to be questions, and this is an exciting policy piece i wanted to show how were doing using the dollars to benefit the communities. We can certainly work with you all to put this on an agenda as a broader presentation. That is definitely something that we have been planning and have been interested in. We are going to have some other presentations. Thank you. Thank you. Item four, general Public Comment. I have not received any requests anyone . All right. We can move on to item five, which is report back from the finance and Planning Committee meeting. This is the report back from the committee meeting. Okay. The finance and Planning Committee met right before the commission meeting, and lets see if i can do this justice. We had revealed the contract report, of which we want to bring this to the attention of two of the items on the contract the first one is, you know, the one time added money into the ymca s. F. Hope program, and the ymca s. F. Hope is to serve the homeless and the money that added to the program is 400,000 , you know, from the sugar sweet and beverage tax, and it is for the period of two years from october 1st 2016, to december 31st 2018, and the contract also had been extended for another year to june 30th, 2021. The other one that i wanted to mention is the contract for strategies. You will see that there is an annual difference in terms of the increase, which was 8. 6 4 . We were wondering why it was 8. 64, and we were able to learn that this is an increase in hours for the service. It did not increase in rate, but increased in the units of services. Other then the contract report, we had also reviewed several contracts, including a contract from let me fix this. They will be in charge of the billing and corrections. What we learned is that this is to close out the old system as we continue to transition and we will have a new, a different billing system that we will be running, and the next new contract that we would use was a contract with kpmg, and kpmg i forget, it is to support Emergency Data services to make sure that, you know, we safeguard the s. F. D. B. H. Information system, and then one more contract. The contract with Family Service agencies, which includes two programs. The one is the beam up, and the other is the acute language. This program is to target youth from 16 to 24, and in addition, we also have reviewed the drafts San Francisco have put together for the report no, ive got the wrong one, sorry. Okay, we will review the annual contract report for submission to the board of supervisors under chapter 57. We also have approved a current contract list under chapter 21 of the administrative code, and we also have discussions about the annual contingency report for submission to the board of supervisor, and lastly, we heard some great news from mr. Wegner that on the Third Quarter of our revenue and expenditure projection report, we are still in the green, so that has come through with the meeting. Thank you. Commissioners, comments or questions . Yes, thank you. I just wanted to commend all the commissioners who were not with us, especially in regards to this sole source that the department has really made very clear what the sole source process is here, and the reports that they go to both the board of supervisors, both reports go to the board of supervisors mandating either by the sunshine ordinance, which describes what they all are, and also from the board itself, and i wanted to know how we were using the contingencies, and i commend all the commissioners to take a look at the powerpoint carefully because it is one of the best explanations of the process and our contingency process that i have seen for many years. Thank you. Any other comments or questions. Thank you. I did not receive Public Comment requests. Item six is a consent calendar. Commissioners, i have given you instructions on the complex procedures that you will walk through today, and i missed one of the steps. We will talk about this. Lets go slowly, and im sure we will get through it. There are number of conflicts regards to the consent calendar. I will go through the conflicts that i have and i will ask that of the commissioners, please,. [indiscernible] i will start out. I am requesting that we extract contracts from the university of california, the ucsf group. I am also asking that we extract the sole surf item 21point for two. Those items will be extracted from the consent calendar before we vote. I am requesting that in item be moved. It should be extracted from the report. I am requesting on the solesource 2142 report, that the item 15120 and 121 related to the San Francisco Aid Foundation be extracted. And for clarity, i am asking on item 21point for two that one on one be removed as part of the extraction. I will now call for a motion to vote on the consent calendar. So moved. The extractions. I am getting a whole bunch of good advice. Everyone is an attorney. Second. All those in favor say im at aye. Now we will vote on those items which were extracted. Mr. Secretary, do we need to rewrote reread those items before we vote . Yes. Lets start on the item that was extracted. Also, item 21point for two. Actually, just stop there. Those items from the contracts report, you vote on that. And then each of these separately. I am going to call for a motion to accept these. Is there a second . Second. Motioned and seconded. There has been a motion and seconded. All those in favor say aye. Aye. I am recused from that item. Yes. Lets move on to the item 2142, item 34. We need to do one, we didnt vote on that, we voted on the first two. Im sorry, i apologize. It is concluded confusing. On the second item that i asked to be extracted, item 21, number 101, university of california calls for a motion. So moved. Is there a second . All those in favor say aye. Aye. It should be noted that i am recused from that aye. And then, for item 2142, item 34 , st. Marys medical centre, commissioners will be voting. She was shown as recused on that item but i need a motion. Second. All those in favor say aye. Aye. And then other commissioners . Item 15, 120, 121 of the San Francisco aids foundation. I need a motion to approve, and a second. The commissioner will be shown as recusing himself. So moved. Seconded. All those in favor say aye. Deep breath, everyone. That was great. Item seven, i will note all those recusal his. Item seven is a draft charity care report. It is the left, the top left. Good afternoon, commissioners i am the Senior Health Senior Health Program Planner with the office of policy and planning. I will be presenting the 2017 charity care report. It was first presented to the finance and Planning Committee on may 7th, and i would like to thank members of the committee and other commissioners who provided feedback and comments on the report. For this presentation, i will provide important Background Information related to the charity care ordinance, and the charity care landscaping San Francisco, then i will go ahead and go into the annual report and provide information on citywide charity care trends, as well as hospital specific data. Next slide, the ordinance in San Francisco was passed by the board of supervisors in 2001. At the time, this law was the first kind of its nation, and in support and the spirit of Public Disclosure to increase transparency construct transparency and accountability. The ordinance requires hospitals to report charity care data to us annually and to notify patients of free and discounted services. There are eight hospitals that report their data to d. B. H. Annually. Five of the hospitals are required to report further ordinances. These are, st. Marys, st. Francis, the Chinese Hospital and st. Lukes. Three hospitals report voluntarily, and these are kaiser, ucsf and zuckerberg San Francisco general. With these eight hospitals together, d. B. H. Hasnt is more accurately able to capture citywide trends. Before i start on the report, i wanted to highlight some significant events that have occurred since the passage of the charity care ordinance. In 2007, the healthy San Francisco program launched. This is San Franciscos Health Access program that provides uninsured residents access to Healthcare Services and we are able to capture healthy a San Francisco patient Cost Services data in our annual report separately from traditional charity care. After the passage of the Affordable Care act in 2010, the next few years were spent preparing for aca implementation in 2014. They implemented and began we saw an increase in healthcare Insurance Coverage through medical expansion and this is something that we have highlighted in previous reports. As we moved into 2017 and 2018, it is important to note there has been uncertainty at the federal level around healthcare and the Affordable Care act. Policy changes such as the repeal of the individual mandate penalty, proposed changes to rules, and recently provider rights to religious refusal, may Impact Charity care and how people speak seek or receive Healthcare Services. We think we will be able to capture the impacts of these policy changes in future reports moving on to the reports, the annual report compiles and analyse is and identifies trends and data across all of our eight hospitals. It captures healthy San Francisco and traditional Charity Care Patients separately we do want to know that the report captures one year of data either on the fiscal year, july to june, or a calendar year, january to december, depending on the hospitals fiscal year. Overall, this report should give you a high level of overview of charity care in the era of health reform, and it also showcases how trends are experienced differently by hospitals. We engaged representatives from all eight hospitals to discuss the draft prior to presenting to the commission. Now this slide highlights the three charity care trends that we found this year. Many of them are related to the Affordable Care act, and i will go through each trend and provide data for each of these. So the first trend, as expected, with continued implementation of the Affordable Care act, charity care has clients in San Francisco. And the figure to the left, you will see the number of unduplicated patients from the last five years. We have been seeing a significant decline in Charity Care Patients. The figure to the right provides an overview of charity care utilization by type, Emergency Services, outpatient and Inpatient Services. There has been a decrease in emergency and Outpatient Services by volume between fiscal year 2016 and 2017, and a slight increase in inpatient utilization. Continuing with the first citywide trend, charity care expenditures declined significantly in fiscal year 2015 and have now stabilized around 89 million in fiscal year 2017. There is a slight increase in the last two years, and this increase can be due to a variety of factors such as medical insulation, or seeing a higher acuity patients. Overall, there has been a shift from charity care to medical. Medical is a difference between medical expenditures for services and reimbursement for those services, and hospitals typically absorb that cost. With the expansion under the Affordable Care act, it has become important and we included in the report to capture all of the uncompensated care that it is provided that is provided in the city. Moving on to the second trend, healthy San Francisco continues to be an important Healthcare Access option for uninsured san franciscans and eligible for sponsored health coverage. In these slides we are going to dive deeper into charity care for healthy San Francisco compared to traditional Charity Care Patients. Healthy San Francisco patients have greater access to an organized system of care, stronger connections to primary and Preventive Care, and they have supports of transition into initiated coverage if a patient qualifies. For these reasons, you will know that between fiscal year 2014 and 2016, we see a significant double decline in the number of Charity Care Patients. To the left, expenditures and to the right, healthy San Francisco population. In 2017, we started to see these numbers level off or stabilize. This suggests there are populations who continue to rely on healthy San Francisco for access to Healthcare Services, and this is likely due to ineligibility for aca initiated health coverage. And commissioner chow, at the committee presentation, you asked why the number of traditional care charity care and if there might be more Information Available to understand this population, and because we are the largest provider of charity care, we looked more closely at the charity care population, we found a majority of their traditional Charity Care Patients actually did have governmentsponsored insurance, however, there were gaps in coverage, so many of those folks were under insured, and qualified for charity carriers cares through the Financial Assistance programs. A few examples of instances where this might occur, for example, perhaps the patient has medical and they have a tenday acute bed stay, medical may only cover six stays, and the remaining four days are not covered. Those costs might be covered if the patient qualifies under the Financial Assistance program. It could also be used as a supplement for patients who have medicare or medical and have a cost share for those programs. Moving on to our third city wide trend, traditional charity care will continue to be essential for the hardtoreach population and for those who cannot access insurance. So even in the era of health reform, we see that traditional charity care continues to be necessary, especially for populations who may not be able to Access Health insurance for a variety of reasons such as homelessness or immigration status. In this slide, you will see a proportion of all services by tights. Emergency, inpatient, or Outpatient Services, and on the left, you will see the proportion of Services Utilized by the healthy San Francisco population and to the right, utilization for traditional Charity Care Patients. What you will notice is that for the proportion of emergency and Inpatient Services, compared to other service types, they have increased each year for the traditional charity care population. We do not see the same trend in the healthy San Francisco population. We think that traditional Charity Care Patients may only be accessing the system when absolutely necessary, so this population may not have access to the primary and Preventive Care that the healthy San Francisco population may have. And also, commissioner chow, as you mentioned in the committee meeting, you noted that although there was a decrease in the total amount of traditional Charity Care Patients, the costs or expenditures for traditional charity care had increased. So one thought is that perhaps because traditional Charity Care Patients are seeking care when they are sicker, there might be higher costs associated with it. So on this table, it shows the zip codes for each of the ten hospital campuses, in every hospital sees a large number of patients from within the corresponding zip code. This indicates that hospitals are generally serving the local communities where they are located. So for example, in the zip code 94109, that is where st. Francis Memorial Hospital is located. And patients who reside in that area may choose to Seek Services at st. Francis. It is important to note that since they are a county safety net hospital, it serves a majority of traditional Charity Care Patients across the represented hospital campus zip codes, and many Charity Care Patients travel within San Francisco to their hospital of choice. So continuing with residents and zip code data data, here are two graphs that show reporter residences of traditional Charity Care Patients. To the left, you will see that San Francisco residents have and continue to be the majority of Hospital Charity care recipients we saw a large number at 16 . Hospitals had also seen 9 of Charity Care Patients from bay area residents outside of San Francisco, about 6 of these patients were california residents, and 1 were outofstate. These numbers are relatively consistent over the past five years, except for an increase in the percentage of california residents. This increase maybe due to the intake of patients from wildfire affected counties. The figure on the right has a breakdown by supervisorial district. Consistently, we see the largest number of Charity Care Patients from districts that have lower average household incomes. Particularly from district six, district ten, district nine, and district 11, and we also have a complete zip code analysis in the full report. So that concludes the city wide trend. Now we will focus a bit on the hospital specific data. This section provides a little bit more descriptive information about each hospital itself, such as the number of Charity Care Patients, service utilization, expenditures, and medical shortfall for each hospital, it is important to note that there are a variety of factors that can influence charity care across the hospital such as patient preference. To give you an example, this slide displays a number of Charity Care Patients across all eight reporting hospitals for the last five years. Overall, the San Francisco trend is that Charity Care Patients are declining, however, we do see that this may not be the case for all hospitals and hospitals may be experiencing trends differently. It shows tables from each hospitals ratio for fiscal years 2016 and 2017 compared to the same coverage. The ratio for four hospitals of the eight reporting hospitals are at or higher then the state average. The sfd is a larger provider of charity care in the city and it hides the highest ratio of costs at 9. 6 2 for fiscal year 2017. St. Lukes, st. Francis, and str above the state average. To conclude, they believe that you should be able to analyse trends that are applicable to charity care moving forward. As noted earlier, there are potential policy changes, such as efforts to dismantle the affordability care act, and although you dont know what those impacts might be, they could Impact Charity care moving forward, and we hope that future reports are able to capture any potential impact. Additionally, i would like to acknowledge that there have been recent discussions regarding the billing practices, particularly balanced billing. Charity care policies play an Important Role in protecting patients from Financial Hardship you learn more about the revised charity care policies, which have been strengthened to protect patients. We anticipate we will see in facts of these policies on the charity care data as early as the 2019 report. Lastly, i would like to acknowledge all of our hospital representatives that have worked with as on the work group and we thank them for their continued support and partnership. I am available to answer any questions you may have. Public comment . I did not receive any Public Comment. Thank you for this report. I was wondering if you could delve more deeply into that 70 of the San Francisco residents, i think it is 60 9 this year for the traditional charity care there are so many programs. I am wondering if you can detail more of the demographic that youre talking about. I know you know where they live, but could you give more detail about the demographic and other cofactors like these patients who are food insecure, and i wonder if you could also comment more on how the new immigration policies and the concerns that families who are undocumented have and play into all of this, because it crosses my mind that maybe some of the higher inpatient costs relate to people delaying out of fear, and what we had as a sanctuary city, might be able to do. Thank you for your question. I will touch first on the first one. Regarding demographic for our Charity Care Patients, at this time i dont have additional information, that it is something i can look into. However, related to the integration policies, during the work group meetings, we did have a lengthy conversation about how to address fears and concerns from patients who may or may not be taking services because of propose public charge policies or changes to these policies. It is something that absolutely is of concern to the hospital, and something we hear very clearly. At this time, it is something we can continue to explore and there will be additional conversations to see how we can address the concerns of the communities as well as the hospital. Thank you. Thank you for this report. It is very enlightening. I was looking at the graphs on page 10 and 12, and wondering whether there was correlation between i know you drew some conclusions on the increase in Emergency Rooms into 2016 and 27 for traditional charity care, and looking at page 12, the increase in the charity care for homeless in california. Theres a correlation between population that is not San Francisco, and those going to the emergency room so that they dont have another place. You do have maybe they dont have access to primary care, but also because they are coming from outside of either San Francisco neighborhoods, or they are newly homeless, or newly here homeless, that that might be a correlation to the increased emergency room, im thinking about if that would be the case, what are the solutions for San Francisco in terms of addressing that potential correlation. Thank you, commissioners. I do not believe we have a date breakdown of data for the zip codes of patients and the type of service utilization. I think that is an important question that we can pose to our hospital workers to see if there is a correlation between residents or zip codes and the utilization to see if there is more individuals out of county, or people who are homeless who are presenting at Emergency Services or utilizing Inpatient Services. I think it is something we can look into, but i do not have additional data. Are potentially those who are San Francisco residents and newly homeless. Okay. Thank you for trying to respond to some of the questions that came up. The data is really intriguing. I just wanted to note that on slide eight, that while headline talks about that charity Click Charity care may be reclining , it highlights what the total is. The total cost for both charity and medical shortfall for this population is continuing to increase, and that that also is part of the totality that we are receiving from our private and public hospitals, and providers. So it is just that it would be highlighting another part of the message there that this is really increasing, continuing thing continuing also on slide 12, i think that if you go all the way back to fiscal year 13, versus 17, it looks like some of those blocks really do have some increase, which probably needs to have a little better understanding. Twelve , 16 , in terms of the reported residents and likewise, i think from going from 1 , to 6 as was pointed out, why is that happening . It would be something that certainly has been of concern in the past, sort of ignored or tried to deny that people see us as a magnet county because of our generous programs, but as we are looking to this, one wonders if that is totally true, and perhaps now that we have this data, it might be something to be mindful of. Lastly, only to go back to one of the historical reasons for the charity report, was report on page 14, and only to acknowledge that the hospitals continue to demonstrate how much is being spent on charity care and that the ratio to this date is that it is something that the commission has been quite interested in, and has a position that hospitals should try to reach the state ratios as a goal, and that this is something to that continues to be monitored from the commission side. That is my comments. Thank you. First of all, thank you. A great presentation. I thank you for recognizing the importance and value of showing how this individual case impacts individual folks. I did have two questions for you , and you may have already touched on this. Slide number 7, we see the increase in inpatients utilization, what would you attribute that to. It is higher in 2017. That is a great question. We are not clear as to why that number has changed. I think, perhaps, if you go back several years, additional years to see how that has changed, it might be more illuminating. It is something we can look into , but i think that is a good question. Thank you. The second question on you moving forward slide when you look at actions by the current federal administration and the department of health and Human Services issued guidance that would allow states to skirt some of the rules and take away protections for people with preexisting conditions, or making it much more expensive, even though the state of california would create protections at the state level. Would you see that as is something that would also increase the charity care expenditures across the board . Potentially, yes. It might increase the charity care expenditures if individuals arent able to access care. I think it is something that we would have to look at with specific policies as a state, or how the state may skirt certain provisions and see how that might impact San Francisco. It may increase or decrease charity care. Hopefully they will not prevail. Thank you. I had one more observation. On slide ten, i think you are right on point about the fact that charity care is costing more because more intense services are probably being rendered. There really is more Inpatient Services than previously, and Emergency Services are very expensive, and clearly it is a population that we should try to understand to see if we can actually move them more into a managed program, and i think your opposite slide is really in stark contrast, probably a similar population, a healthy San Francisco, and in that case, and this was where even when we began healthy San Francisco the first two or three years showed, and this seems to be continuing, that this population, once they are put into a program that has a primary care system, has a home for their health, actually uses less acute care type services, which is really startling to see the difference between that and the charity care portion, along with less hospitalization. It might be that this is a population that we should look at as a very vulnerable one that we might certainly have some of the frequent flyers and all, and i know that in trying to do this , we take another look at what that block is, and we have an opportunity to outreach into that. Other questions from commissioners . Thank you very much for this report. Thank you to the eight hospitals that were involved. This question may be to another one, or it may lead to a statement. That has to do with a connection collection through populations that are being served through charity care. Do you have that kind of information . No, commissioner. That is not data that we are currently connectors collecting is part of the reporting process that is not what we are collecting. It seems their comments about the homeless population, and if we have that kind of level data, then when we look at what the department is doing, in terms of black africanamerican health, and the disparities that are there, as well as the Transgender Community and other community, it might be helpful to understand what the impact of the charity is here on those populations that are negatively impacted and have negative outcomes in terms of their health status. I am not sure that is work that can be done, but its something im looking at in terms of what the department needs. I am not quite sure. So we had these discussions before. We do believe there are a lot of the same things that might be going from hospital to hospital. A lot of the information his are not shared. We have never actually identified or triangulated who they are, and where they normally have those services. I just think that it is still a mixed opportunity for us to do some really important work because from the numbers themselves, it speaks to me that it hasnt changed that much in terms of the type of services being used, even though 41point 5 used to be a lot larger then the other two that we also have to consider the decrease in the number of patients seeking charity care. I am not quite sure where the rest of the committee stands on this. I think that it is really something that we have to work on and know we are trying to work with other counties because when we talk about homeless, a lot of them are transient, they might be here sometimes, but they might be across the bridge sometimes, but they all come back here for services. I think that the more we can find out those details, the better we can identify what we need to determine to focus on in order to improve the health outlook. Thank you. You have comments . You may not be possible to match the data sets, but we have the high utilization data set that was mentioned and worked on for many years. Im wondering if there is some way to cross this data with the high utilizers in our system to see if theres something there that the commissioner was alluding to. We can certainly take a look at that. I just dont know how granular this data is that just a very small sample size that will be helpful in terms of the impact of charity care in terms of the vulnerable populations in San Francisco. Yes. We are speaking about this and clearly we have some data because there is 32,000, for example. I think the question is, and a former commissioner brought this up lots of times in terms of how we might be, not looking clearly at this. This maybe, where the zuckerberg numbers in here may actually be the majority of these, and that they are groups that we could do something about. Part of this is to fragment and find out how many within that really is within our own ballpark from our own hospitals that we do have the influence, that then we could work on that and that the other hospitals, they may also want to take a look. And im sure all hospital staff have some idea of where they are impacted by their usual frequent flyers. If we are looking, and this may be an area of removing while looking at this process, we need to know where the real issues are. Where is that population . That would be a good place to start. Thank you. Thank you, commissioners. [please stand by] the community centers. In march, we had indicated we might go to for a sale in the fall, but it didnt look like that was going to work out in terms of other measures, so were pushing to the last quarter of 2019. There is slight increases in expenditures, about 2 at zuckerberg, but at the clinics, there is about 16 jump, primarily because we had Maxine Hall Health Center with a bid that came within budget. That is why its jumping from 20 in march to 36 currently. I hope you can see some of this detail. Sorry. I was going
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