I think we would have to think about, you know, how the interoperability, the Data Integration and how that would work under the various models. I think that would be different under the hmo plans today versus the ppo plans. Page 30, the consolidated scenarios, this is where we would consolidate down to three plans. At open enrollment you would have choice of kaiser, and hmo potentially in this model and a ppo plan. However, the difference here is the hmo and the ppo plan would be provided by a single carrier. A carrier or insurer, or health plan, so at night, cigna, blue shield, United Healthcare would have both of these plans. They would manage both of these plans. Does that make sense . You are saying one of the Healthcare Providers would be providing us with an hmo . Correct. Today we have that split by health plans, this would say we are bringing those together under one health plan. Retaining and hmo plan design choice for the member at enrollments on a ppo plan at open enrollment. It is my understanding, i was in Service Practice for half of my career, these already exist. There are lots of ppo and hmo plans. All of the carriers do not have just one template. We would set out the criteria that we want and then find a plan that probably already exists. They would not be writing new plans out of the blue. Correct. In this example we have kept that Third Party Support service for advocacy and navigation. On page 31 some considerations. There will be some level member disruptions for plans if we consolidate them to one hmo. Additionally if there is a carrier change, there will be a carrier change for one of the other, the hmo or the ppo potentially. There would be a change there. That second bullet, i think is what becomes key here is it creates a single risk whole along the non kaiser plans. Today we have our blue shield bucket and our healthcare bucket. In this model we would say these are one bucket of claims we can manage. It is self underrated or funded and spread that risk. It helps with the longterm sustainability of the ppo. That is one of the primary reasons we have this scenario forward. It can enable contract provisions if we are negotiating with one larger stick. To use our phrase earlier. And then carrier programs and care coordination can be consistently delivered which can be different from today having the two health plans. It will one be be one single set of care coordination programs. The scenario we propose. We propose one hmo and ppo design. It is just the employee contribution varies. The design is the same. From that aspect he would have the same Design Choices for copays and coinsurance. It is meant for members to have choices. It is written in the charter. I think if we consolidate too much, were back to the competition thing and choices. Again, just. Out, lots of physicians belong to multiple groups. We looked at this before when we looked at trio, and where would the disruption be . Member still had a choice. If they switched it to trio, it wasnt a huge choice and providers within that it wasnt as if they were assigned to one or two primary care providers. They could stay with their old providers may be under this scenario they couldnt do that. Obviously if we were to look at this what would this disruption be. Would it affected 50 of our members or. 05 of our members because of the way our providers are already members of multiple groups. They would still have the ppo plan design option it shows that they may have a different carrier than they have today. In your second bullet. For the non kaiser vendor, it would just create single risk. [inaudible] all of the populations on the hmo and the ppo would be considered one risk . [inaudible] correct. [inaudible] it is creating a shared risk pool. Actuary should really answer this question. The way we would view it is looking at the concept of the entire experience that is coming through under both the hmo and ppo, and then do more to look at the differences between the plans as a foundation for setting rates, rather than the specific experience, and again i point back to the uhc ppo today, it is 2800 people is a Large Population within the broader framework of sfhss. It is a high risk population. Today, the rating methodology looks strictly at the experience of that group and designs rates based on that that ultimately result in higher premiums granted there are differences in rating methodologies that i think construct the difference that president breslin talked about earlier. From our framework, what we are trying to do is create a more level Playing Field in how we would rate the hmo plan versus the ppo plan. The other aspect of this is, today, trying to communicate to members. If you have a particular condition, here is what each health plan can offer in terms of support, as you work with your physicians. Here is some incremental support that can be offered. It is different today across all of the carriers. The other aspect of bringing things together under an umbrella over the framework of these plans is to be able to do communicate consistent messaging on how to access benefits. You know social Health Related benefits or how to access resources within specific programs. That is a lot of what this consolidated scenario was trying to accomplish from a pure rate setting again risk pool standpoint as well as just consistency and messaging the members about Resources Available from the plan. Just to clarify, im assuming you have United Healthcare as hmo and United Healthcare as ppo. On the ppo you have 2800, on the hmo you have 45,000. For risk polling you just combine the 45,000 in it doesnt take into account each one, so. Using more actuarial values to determine rate differences between the hmo and the ppo rather than relying on the absolute experience of each particular plan. Premium wise. In aggregate it will equate to the same as it does under todays methodology. Page 32 we have the next option. Our scenarios for consideration that we named the stem competition scenario. This is where we would focus more at open enrollment for a member to pick the Health System that they want to receive their care within that framework. We are saying potentially retaining that ppo on the right hand side. And then you would pick like you do today, and a trio youre picking with him, i guess thats not a good example. The acos could include but not limited to blue shield canopy, see chp and or sutter. You would have broader choices. Youre picking your Health System at open enrollments. Again, these would be hmo plan designs similar to the access plus plans today. And then with the coordination of care with your primary care provider without ppo remaining on the righthand side. This would be one provider. What this recognizes is that the Health Systems in the bay area are consolidating and integrating. You can make your choice about which system to enter. That is what this is considering. It is similar to Health Access to you, its more similar that they are adding one more aco. Potentially. As far as the health plan that we didnt go into that, that is where you could come by some of these scenarios is just say we want one carrier, multiple carriers, some of these, they have a Health Delivery system. To be want to solidify that. There is a lot of variables within that scenario. On 33 it creates Competition Among the Health Delivery system to engage in management members. The Provider Network choices in the hands of the member at open enrollment when they select the Health System that they want to take care of. Member instructions is a possibility. This may be a viable option for 2022. Something that is in our lands for the future. As a potential future states. It really warrants further research and studies. We talked about this earlier. Studies that show increased costs under system competition scenarios. Really wanting to think about that. It was on our radar is something we wanted to throw out there. Any other questions on that . Just to make sure i am clear, because this is more of a system driven, although blue shield its different then see chp, canopy is what used to be Catholic Healthcare west. Canopy is and they have added there in general, sequoia, they do have some dignity hospitals between them. I think united is there carrier and they are currently filing, right. Those are ones that i think it is useful, they wouldnt be even eligible canopy has a product. And now they have aetna as their carrier. Dignity has joined up with anthem. The changes are very real and very dynamic. I want our board and membership to be fully informed about what is going on. To make sure im clear. Say a member is used to getting her care through ucsf and they might choose canopy with the idea that they would not be able to go to see someone at any of the other hospitals, and other hospital systems. They would continue with what they identified and then they would be restricted to that. Right now, we discussed this further health plans. Yes restricted and more open. Canopy designed to compete with kaiser. If you lived in the east bay and you were working a 12 hour shift for the Police Department and had that book ended for our commute or whatever grade you could go to a physician at ucsf in your Canopy Network during the day. And then, you know, use john deere for your Emergency Services or your elective surgery or whatever. That is what is going on. In the marketplace. I was going to ask one question. Im absorbing the content. It seems our preferences of the partnership. Im not aware, correct me if im wrong if theres been any sort of comprehensive surveys of our memberships as it would help and guide our decisionmaking. Not yet. You are stealing my thunder on the next step. Yeah, we have spoken to this at a high level and we describe that we are doing a roadshow and a listening show, surveys as a whole. Listening to members input into much of what we presented here today. I know it is a ton of information and we wont necessarily be repeating that. Thats why it is great that it is recorded. We will have this conversation and dialogue for membership over the next several months. Please do hold that thought, because we will get to it after i complete the last model description which is called private exchange. Part of the concept is, you know, if were all familiar with public exchanges, you know, for instance californias exchange has gone out, contracted with Certain Health plans and they have put their plan designs on an open marketplace and then i, as a californian can go out and choose whatever plan is best for me, whatever carrier is best for me. The idea of a private exchange is to bring a marketplace to the employer and the plan sponsor. They can be done and fully insured frameworks where the experience of that employer is given to the marketplace of plans and they have designed their rates to compete for members, or it could also be done on a soul funded basis. The idea is put an array of choice. These are just examples. Certainly, examples. I can choose from among any of those particular plans, the Provider Networks, their framework for care management, et cetera. As well as variations of plan designs. We say how much do i pay varies by metallic plan. Aetna may put four plans on the spectrum in blue. This really maximizes choice, to me, as a member. What it does is pulls a lot of the control that you have as an employer to, lets say, from sfhss standpoint, its done and a very different way. On page 35, again, just defining what a private exchange is using a thirdparty administrator, create that exchange like shopping experience, broad array of plants. Its not a public exchange. It may look like a public exchange, it is not. There is not a relationship between those two. Its also not eliminating employer sponsored an offense. It is eliminating what they provide to their members in a different way. It is still done with all of the underlying financing delivered by the plans based on the pool of experience of sfhss members. Not any other employer, not any other person outside of sfhss. Considerations on 36, a lot of choice. Member disruption could happen depending on the choices a given member makes. It does add complexity. People now need to understand both carrier choice as well as plan design choice. It certainly dilutes your ability to look at data for the population, as a whole. It really puts pressure on all party claim database to bring information to look at information as a whole. Its somewhat limit your control. In a sense this is, youre almost outsourcing the financial control to the health plans and telling the health plans, dont compete for my members. We do see, as you can see here at the end of the day, probably not viable for 2022. We will see how this evolves. Its been around for several years. There are concepts out there that some employers have latched onto. It will certainly be a viable opportunity for the future. We will certainly get inputs on this along with the other models we have looked at. I just wanted to state here. We may not see this as completely viable among the five models that we have. You say some employers have latched onto this. Corporate employers for the most part. Which i think is another reason why we dont see this as viable. Thank you. A couple of questions. Are we limited because we are public from engaging in this right now im taking a change in our charter or anything . Yeah. Is all part the problem. We shouldnt be discussing anything if there is not a. I think we wanted to mention this today, because this is a session where we want to say these are all models that are out there. Yes there would have to be a lot of work through i think. I dont want to speak for the legal team i dont want to speak for the contracting team. There are complexities in this. I think he would face if you decided to move forward with this model as opposed to the other four for 2022. Where a concept like this warrants some discernment is, as the market does consolidate, and public providers throughout the bay area are grappling with the highest insurance rates, in the country, is there an opportunity for us to at least begin a dialogue, with the public providers around the bay area about how a concept like this could benefit all of us, as far as, you know, again, i havent sat down with eric and talked through all of this. There is obviously as many challenges as there are opportunities to really think about whether or not if we pooled our membership as far as a buyer goes, could we have more weight in purchasing. And then it would make sense if that were a Bay Area Council kind of way of approaching this. Would it then make sense to think about having an exchange like a vehicle for delivering those choices around the bay . It is an out there idea and that can redo do it tomorrow, but should we be thinking about this . Do we have a responsibility to be thinking into the future. That is why we have introduced it, because i havent yet had the opportunity to meet with my counterparts in the other counties. It is on my to do list to see if others are thinking this way. We certainly have gotten the squeeze here. Calpers just redid their entire way that they approach their benefits carving out Northern California because it is so expensive. I think we just have to be forward thinking and are there good ideas out there for the future that we should be exploring now. These kinds of things would take several years to consider even if everybody agreed. There would be a lot to consider and talk about. Not all counties have a charter. Most counties do not have a charter and we have a charter. That is important. Am certain they all have rules and regulations whether its a charter government are not. Their membership has their involvement, i mean. Im not sure who else has a charter in the ten counties. I doubt it. Can i make a couple of other small points. To me that might be some variation based on metallic plant whether youre in a silver, gold or premium. That may be a selling point for people. It seems like that may be an overstatement. The other thing, im kind of curious about which is a purchasing pool with other employers, only based on our cost and premiums. Part of the potency would be as if we actually did have a bigger stick. We werent talking about 125,0 125,000, when you cut out the medicare it is less. If you are able to combine with some of the other big counties. That would be a bigger stick. Therefore we would be able to negotiate better. Im a little concerned about why this is excluded why it is not a purchasing tool. I would say present state it is not because as abby said, how those conversations started, counties collaborating to perhaps thinking about building a bigger risk pool to increase their leverage back to health plans. Those conversations havent necessarily occurred to date. But as you said, they are intended to move forward based on what the executive director said. The other aspect, if you are looking to bring a larger purchasing pool collective together. You really do need some sort of risk stabilization mechanism to prevent certain entities in the pool to feel like okay, i have brought my more favorable risk into this pool so im going to start paying higher costs for other entities in the pool. There would have to be careful consideration among any eventful partners in a venture like this. I think we should move on here and get Public Comment. Just a recap of today was really to inform and gather input, so thank you. We discussed and identified some must haves and additional ideas for our considerations list. On 39, we will continue to define and refine our carrier partners. I understand the latest version of our presentation, we were changing a daily didnt actually show up on our website until noon today. I apologize for that. The next steps are not in your versions that you saw. Anyway, our intention is the next steps is certainly to respond to the many questions i came up today. A list of hot topics that will consider how best to provide that information back to the board and the memberships. As we have these conversations both here, back at the office and with membership Going Forward, take a deeper dive into some of the more preferred models. We will continue to gather input through the Community Engagement process. I mentioned before that we are engaging professional facilitator to come in and help us and next week we will be sitting down to design a variety of workshops on focus groups where we will be listening and talking with members at work, after work, wherever. Were going to have a variety of ways to do outreach, to have these kinds of conversations. We will get those locations up and posted and have invitations go out. That will really help us understand more deeply what our recommendations will be to the board Going Forward for the models that we will work on and develop our rfp in january. I hope that helps. I know natalie brought a signup list today. If you wish to stay on our mailing lists, i hope we have most of you on our mailing lists already. We will be inviting people through electronic emails so we can manage the groups that we put together. That concludes my remarks. I know you wanted to open it up to Public Comment. There is a signup on the table over there for anybody who wants to be noticed of a future meeting. Okay. Actually, to follow up on that. Going back to social determinants. I think it is important we make sure that imitations to join this go through routes accessible to people who maybe dont use electronic devices. Evite and outreach so there is some sort of announcements through our newsletters or whatever. Probably some language specific focus groups or whatever that allow people who are comfortable in different languages if were really going to be looking at this or have really robust interpreter services. Okay. Now, Public Comment on this it item. Please come forward. Good afternoon commissioners. I was waiting to see if anybody else would come up first. Im representing retired employees of the city and coun county. This is a very interesting presentation. A couple of things really hit me towards the end of the presentation. One is that it was our policy on this board that we design our own plan. We dont purchase other plans, we design our own plan for our own members for our actives and retirees. When we go then and put out an rfp, we are asking those carriers to then pick up our plan and have it be approved before the gm hc. The plan and the benefits originate here with all of us. Im hoping that you keep that in mind. First some of us, the options sounded like we are looking to purchase out there. I think that doesnt work for us. Especially with the level of benefits that we have. The other thing that struck me was i was still on this board when we consolidated down to three plans where before we had for her sometimes five or youd what we noticed was, the argument from some of the carriers was if you give a larger market share. If you eliminate that other plan i will make it through your while and the rates will go do down. You know what we discovered . Premiums went up, didnt they karen . Exactly. Commissioner breslin. Forgive me for the familiarity. The problem was that we got whacked. I am very skeptical with regard to that kind of suggestion, because it has not worked in the past. Im not so sure it is going to. I am not so sure that consolidating those risk pools works to our benefit. It works to the benefit of one portion of the population. I look forward to having you all to review those rfps and having to make the decisions. I think you can see, by who is here today, weve had a significant number of actives on a lot more retirees in the audience today. We are very, very interested in what is going on, and we will be watching, asking and commenting. Thank you very much. Thank you. Any other Public Comment . Please come forward. The Fire Department . Im sure he must want to comment. [laughter] remember, early retirees apply a lot to fire and police. Moreno shea, retiree. Although i have attended a few of these meetings, i am still a novice. One of the things i would like to point out, as a practical indication would be that many employees, active, remained with the city because of their benefits. I have in the capacity of a volunteer worked in several of the supervisors offices, as well as in other functions. I know many of our very talented young employees have remained with the city for an extended period of time. Although they have been recruited for very fine jobs, in the private sector, because of the Health Benefits. Also the expectation that they will be receiving very Generous Health benefits upon retirement. From a very practical, financial standpoint, and as a citizen of San Francisco. I think we need to consider offering these very good benefits to our employees so that they will remain in service to the city. Thank you. My name is fred sanchez. President of protect our benefits. Our two major functions are monitoring the retirement syst system. I am so pleased at what they have been doing lately. My biggest concern that is where the cost will escalate. We know it in the future. It is scary, that is what talks about things Like Universal Health that is where that all i share with everybody that we see all of the consolidation makes it difficult for competition when we are smaller groups and stuff, we saw, what was it blue shield dropped out of the early retirees, or something. They didnt want anything, because the groups are getting smaller. You have a very, very difficult job. We are governed like no other county with a charter. You have to be really careful of what the charter line says and how that impacts and what you want to move forward with in the future. This is really the active organizations. I think it is important that all of the employee organizations that are active that somehow we recruit them into this process because they are the ones that are really going to hopefully get Something Better and it is tough. I think you guys are digging in to try to keep the cost down and how you do that . That is your most difficult mandate. I appreciate your efforts. Go get him. Thank you. Good afternoon commissioners. I am sean buford. [inaudible] i am standing here to remind you that the police, sheriff, tend to have members who serve a full Service Career of 25 plus years that fall under early retirees. Considering the impact, if you were to make drastic changes to our membership. Certain changes i am hearing that may take place. I want you to remember our members serve 25 plus years, as we get older in age, the job is difficult to continue past a certain age, but they will not make the mental age of 55 until later. When youre are doing these bids, please keep us in mind and consider the impact that it could have on us. Thank you. Thank you. My name is carrie, im a retired employee and i worked for the city for 25 years. My Health Benefits are vital to me. I would just ask one thing, i would love to have, more choices for our hmos. If you consider that it would be greatly appreciated. Thank you for your time. Thank you. Any other Public Comment . Public comment is closed. Item number four. Opportunity for the public to comment on matters within the boards jurisdiction. Any Public Comment on this item . Item number five. Item five, opportunity to place items within the boards jurisdiction on future agendas. I think we have plenty of items here. [laughter] i would like to suggest, if are going to keep a ppo that we tweak the present ppo that we have, the city plan, to make it work. Since we arty have a ppo that people are using, and it did work very well at one time. Actually, like i said, the price for the early retirees, their premium is cheaper than blue shield. I would like to see a look at that model. I have nothing further. If there is no objection, this meeting is adjourned. This is one place you can always count on to give you what you had before and remind you of what your San Francisco history used to be. We hear that all the time, people bring their kids here and their grandparents brought them here and down the line. Even though people move away, whenever they come back to the city, they make it here. And they tell us that. Youre going to get something made fresh, made by hand and made with quality products and something thats very, very good. The legacy bars and restaurants was something that was begun by San Francisco simply to recognize and draw attention to the establishments. It really provides for San Franciscos unique character. And that morphed into a request that we work with the city to develop a legacy business registration. Im Michael Cirocco and the owner of an area bakery. The bakery started in 191. My grandfather came over from italy and opened it up then. It is a small operation. Its not big. So everything is kind of quality that way. So i see every piece and cut every piece that comes in and out of that oven. Im leslie ciroccomitchell, a fourth generation baker here with my family. So we get up pretty early in the morning. I usually start baking around 5 00. And then you just start doing rounds of dough. Loaves. My mom and sister basically handle the front and then i have my nephew james helps and then my two daughters and my wife come in and we actually do the baking. After that, my mom and my sister stay and sell the product, retail it. You know, i dont really think about it. But then when i sometimes when i go places and i look and see places put up, oh this is our 50th anniversary and everything and weve been over 100 and that is when it kind of hits me. You know, that geez, weve been here a long time. [applause] a lot of people might ask why our legacy business is important. We all have our own stories to tell about our ancestry. Our lineage and ill use one example of tommys joint. Tommys joint is a place that my husband went to as a child and hes a fourth generation san franciscan. Its a place we can still go to today with our children or grandchildren and share the stories of what was San Francisco like back in the 1950s. Im the general manager at tommys joint. People mostly recognize tommys joint for its murals on the outside of the building. Very bright blue. You drive down and see what it is. They know the building. Tommys is a San Francisco hoffa, which is a germanstyle presenting food. We have five different carved meats and we carve it by hand at the station. You prefer it to be carved whether you like your brisket fatty or want it lean. You want your pastrami to be very lean. You can say i want that piece of corn beef and want it cut, you know, very thick and i want it with some sauerkraut. Tell the guys how you want to prepare it and they will do it right in front of you. San franciscos a place thats changing restaurants, except for tommys joint. Tommys joint has been the same since it opened and that is important. San francisco in general that we dont lose a grip of what San Franciscos came from. Tommys is a place that youll always recognize whenever you lock in the door. Youll see the same staff, the same bartender and have the same meal and that is great. Thats important. The service that San Francisco heritage offers to the legacy businesses is to help them with that application process, to make sure that they really recognize about them what it is that makes them so special here in San Francisco. So well help them with that application process if, in fact, the board of supervisors does recognize them as a legacy business, then that does entitle them to certain financial benefits from the city of San Francisco. But i say really, more importantly, it really brings them public recognition that this is a business in San Francisco that has history and that is unique to San Francisco. It started in june of 1953. And we make everything from scratch. Everything. We started a you we started a off with 12 flavors and mango fruits from the philippines and then started trying them one by one and the family had a whole new clientele. The business really boomed after that. I think that the flavors we make reflect the diversity of San Francisco. We were really surprised about the legacy project but we were thrilled to be a part of it. Businesses come and go in the city. Pretty tough for businesss to stay here because it is so expensive and theres so much competition. So for us who have been here all these years and still be popular and to be recognized by the city has been really a huge honor. We got a phone call from a woman who was 91 and she wanted to know if the mitchells still owned it and she was so happy that we were still involved, still the owners. She was our customer in 1953. And she still comes in. But she was just making sure that we were still around and it just makes us feel, you know, very proud that were carrying on our fathers legacy. And that we mean so much to so many people. It provides a perspective. And i think if you only looked at it in the here and now, youre missing the context. For me, legacy businesses, legacy bars and restaurants are really about setting the context for how we come to be where we are today. I just think its part of San Francisco. People like to see familiar stuff. At least i know i do. In the 1950s, you could see a picture of tommys joint and looks exactly the same. We havent change add thing. I remember one lady saying, you know, ive been eating this ice cream since before i was born. And i thought, wow we have, too. I came to San Francisco in 1969. I fell in love with this city and and this is where i raised my family at. My name is bobbie cochran. Ive been a holly Court Resident for 32 years. I wouldnt give up this neighborhood for nothing. I moved into this apartment one year ago. My favorite thing is my kitchen. I love these clean walls. Before the remodeling came along, the condition of these apartments had gotten pretty bad, you know, with all the mildew, the repairs. I mean you havent seen the apartment for the program come along. You wouldnt have believed it. So i appreciate everything they did. I was here at one point. I was. Because i didnt know what the outcome of holly court was going to be. You know, it really got was it going to get to the point where we have to be displaced because they would have to demolish this place . If they had, we wouldnt have been brought back. We wouldnt have been able to live in burn. By the program coming along, i welcome it. They had to hire a company and they came in and cleaned up all the walls. They didnt paint the whole apartment, they just cleaned up the mildew part, cleaned up and straighted it and primed it. That is impressive. I was a house painter. I used to go and paint other peoples apartments and then come back home to mine and i would say why couldnt i live in a place like that. And now i do. Shop and dine in the 49 promotes local businesses, and challenges residents to do their shopping within the 49 square miles of San Francisco. By supporting local services in our neighborhood, we help San Francisco remain unique, successful, and vibrant. So where will you shop and dine in the 49 . I am the owner of this restaurant. We have been here in north beach over 100 years. [speaking foreign language] [ ] [speaking foreign language] [ ] [speaking foreign language] [speaking foreign language] [ ] [ ]. Good afternoon and welcome to the mayors disability counsel. This is friday, july 19, 2019. In room 400 of San Francisco city hall. City hall is accessible to persons using wheelchairs, and other assistive mobility devices. Assisted listening devices are available and our meeting is open captioned and sign language interpreted. Our agendas are also available in large print. Please ask, mod staff or any additional assistance. To prevent electronic interference, with this rooms sound system and to respect everyones ability to focus on e