Behaviors as a result of addiction. The Ripple Effect is pretty large. So many, many City Employees are experiencing the stress of their work today. So, like, three those three employees cant handle too many people, so do they refer to your health plan . Do they have contacts within the health plan that they send people do . They do. So thats the health plan liaison where we have direct phones, direct lines, and all three of our e. A. P. Counselors do utilize those. I am somewhat familiar as a Police Officer with the model there. I imagine that the model that im familiar with is is, from what it sounds like, trying to mirror for all members, which would be helpful to have a list of what is my understanding acceptable vendors to provide these services. I understand that three people cant provide these services to every member that might have a need. Is that the model that were trying to replicate for all City Employees . So right now, what were trying to make sure is the care that they get is the care that they need and it is at times immediate. Were also looking at what type of care are they getting and do we need to look beyond that . Weve also spoken to our health plans about how they are addressing First Responders because although the Police Department does have their own internal program, they do access external people, and its not for anyone but First Responders, so we are working to one work to enhance what we offer and work with health plans, as well. I think its a very good understanding. It took some time for the culture to change. Its acceptable for a lot of my colleagues and coworkers to treat things that would be very severe. I commend you for your work on that, thank you. I think the title Mental Health is sort of a standoff, too. This could be called something else. Behavioral health. Yeah. Behavioral health or counseling. Mindfulness. So thats a yeah. Some people oh, like, mental. Yeah. And we certainly will look at it when determining what path forward we need to take. E. A. P. Services is what we call it and how we promote use of our services. Any other questions . Thank you. Thank you. Thank you very much. By jumping ahead, i didnt allow for any questions on the directors report, so i wanted to see if there were any. Any questions . Any Public Comments on the directors report . I guess just one question. You have a tracking list of issues with six items on it, including the kaiser transportation benefit, which we had questions about. Do we have any updates on the tracking of that issue . That benefit goes into effect in january, correct . As i recall, the issue was that the transportation benefit didnt didnt include wheelchair access, and so maybe we have some update on that, sort of a gap. Are you prepared to respond to that today or we have it on a pending list of agenda items . So its up to you. At this time, were still working through the details for our transportation benefit. There is not wheelchair transportation available . We are in the process of testing the benefit to go live january 1 and well keep you informed as we continue to roll this benefit out at things change. Im a little confused about we understand that the current benefit did not include wheelchair access. Right. And so are you saying that that youre testing vendors for whole chair access. I mean, there are certainly lots of vendors who can provide wheelchair access. Im a little curious as to what youre doing. Were actually evaluating providing that level of transportation. I guess i can say on the record right now that i cant confirm that well have that benefit available when we go live with the transportation benefit as of this moment and not sure in the process when well be able to add that. Let me be clear what i think i heard you say, your transportation benefit is going to go live january 1. Are you continuing to aceasses whether youre going to provide wheelchair accessibility or whether youre going to at some subsequent point. So the service is expected and well give you an update after that january 1. Without the wheelchair so as of january 1, the information i can provide is we dont have the wheelchair accessibility. Okay. Ill have to go back and review the minutes of what our concerns were, but i dont think at least from my perspective, i dont think it was an acceptable out come that we would, in our rates and benefits, approve transportation without wheelchair benefit. And ill have to look and see exactly what we did approve and to understand a little about because what im hearing is that, again, if you are going to provide wheelchair then there will be an additional per member per month cost or something is what im anticipating kaisers going to come back with, and i dont think that was what we really intended. We intended to provide a transportation benefit and not exclude a certain percentage of our members, which is what the current benefit does that will start january 1. That is exactly how i remember it. That is correct. That we werent going to have it unless you did the wheelchair. So debbie mcconaughey, kaiser permanente. So the plan that we have january 1 will have the ability of transporting in a wheelchair, but we cannot transport them sitting in a wheelchair. So for example, its not a van where you can be transported sitting in your wheelchair, but if you have the ability to be transported where we would help assist the person in a wheelchair to get into the car, we could fold up their wheelchair, put it in the trunk, transport them, and then put them back in. Currently, we dont have the ability to transport somebody who must ride in a van in their wheelchair. Well, again, this is not my area of expertise, but as someone who observes wheelchair access in the community, a lot of the problem includes the fact whether the wheelchair can be accommodated in a vehicle and securely to meet, you know, the safety requirements, but also access to that vehicle. And sometimes if vans have steps and all that, a person who is wheelchair bound may not be able to so unless youre saying the benefit would not include a hoist to lift the benefit up in the chair to be safely seated, im still confused about the gap. Its one thing to transport the wheelchair itself, and thats pretty straightforward, but its the access into the fan. And since we witnessed people falling, trying to get into vans and falling trying to get out of vans, we want to make sure that the whole transportation is safe, not simply the ride itself or the wheeling up to the door of the van. Is that clear or am i no, i think its clear. Debbie, are you able to clarify assistance into the van because well need to get back to that. I dont want to confirm something thats wrong. Would you do this . Yes. Be prepared to speak to this definitively, which is prior to your implementation date. Yes. And im going to ask our director of services to review this particular area to see if it was specifically included in the rate quote that we accepted from you. Okay. Thank you. Okay. Are we back to Public Comment . Yeah. Thank you. By the way, even munis paratransit, a lot of our members are taking paratransit and medivan. Theres all kinds of services that will transport you in your wheelchair, so im not sure what kaisers problem is in finding a vendor or contractor to provide those services. Oh, claire svonsky. I go back to the jean miranda days of the e. A. P. , and im so thrilled that this is getting the expansion and maybe the attention that it deserves. I think i fought hard for 30 years with the city to just keep e. A. P. And to finally get it here with catherine at Health Services because it was at a number of departments and it was almost defunded a number of times. Theyve been through war themselves. Im not surprised that jeff litner doesnt have ptsd. He survived over the years with jean trying to keep e. A. P. Alive, so im thrilled to see it here and see the service where it belongs. By the way, muni has its own service. At least it was when i was there. Thats the third to coordinate besides police and fire. But im still concerned about this medical thing. Is this a medical group . Is this an urgent care facility . I think im not sure what one medical is. It says a Network Provider, and it sounds to me like if theyre a Network Provider like any other physician or provider, that when seniors show their card and they have their benefits there, that they should know who and what, and they should know what fees or copays are charged and shouldnt be adding these other fees, so i would just like a little more clarification as to what one medical is and what it means because i do write the newsletter for our organization, and this information is going to go out in about 1. 5 weeks or two weeks to all our raccf members to know what they should expect or be aware of when they go to Seek Services through one medical. Thank you very much. Yeah. Fred sanchez. Im the chair of protect our benefits. Two things about concierge service. Yeah. Thats unclear, and i dont want to comment on anything that i find unclear, and youre still figuring out what is on it. Im waiting for you to inform me, and i can inform our members. Currently, weve got three or four different even Board Members that say yeah, i pay an extra fee for the doctor. Says its overhead of the office, so theyre getting Different Reasons as to why they should pay a fee, and i dont even know who that fee is what that fee is, so thats something we await you to find out what these various concierge fees are, whether its individuals or medical doctors, but i dont think its good for us to comment until youve done your homework. The other thing id like to comment on is these e. P. A. , you know, coordinating with police and fire units. I know that the new chief has created a chieflevel position. Its called the health and Safety Officer. Its just a newly created officer im going to recommend to the chief mantha health and Safety Officer start to the chief that the health and Safety Officer start attending these meetings because theres a lot of things they could learn by attending these meetings. We had an officer before who tried to accept people with addictions and things of that nature. But even there, coordinated with the city e. A. P. Because they didnt want their employer to hear about this, and even though this was supposed to be confidential, they would rather maybe go through another avenue. And then, on a casebycase basis, like in the 89 earthquake, they contracted with Behavioral Sciences to come in and come to the fire houses and talk to the firefighters as to what theyre experiencing, and for the first time, i was shocked. Some firefighters started crying about their experiences. And then, there was peer pressure. They didnt want it viewed by everyone. Im a little wimp because i didnt respond like all the macho guys responded. So if they can go as individuals rather than Group Setting is rather than good. So i commend you for doing that, but i hope they coordinate it with the various different departments. Thank you. Thank you. Any other Public Comment . All right. I believe that were on number 10 now. Director yes. Item 10, presentation on cancer care thats relative to the sfhf proposition. Thisll be presented by page seitz metsler. Good afternoon. Im page seitzmetzler. I would like to start out on the first on slide two and look at the center of the chart. And what youll notice is there is that and this is just for 2018. 7 of your population was actively treated for cancer during that year. It doesnt mean that there you know, you would expect your population theres a lot more cancers, but during the year 2018, 7 were treated. That resulted in 10 of your medical spend. And if we were looking at the top cancers going clockwise starting at the top, what you see is that skin cancers, breast, cervical, prostate, and for medicare retirees, youll see skin, prostate, and breast are most commonly occurring cancers. Your most common with breast, leukemia, lung, and lymphoma. And specialty drugs for cancer can occur either through your pharmacy benefit or it can occur through the medical benefit, depending on the site of administration and the person providing it. So what i would like to do then now is just also note that kaiser is the only h. S. S. Plan that is exceeding the screening benchmarks. They are meeting the 2020 Healthy People 2020 goals in most screenings for most screenings. So if we look at page 3, what you will see is several things that is causing cancer to bubble up and become one of the number one expenditures. Of course, musculoskeletal is always up there. The population is growing older and people are living longer. That gives me the opportunity, if dr. Follansbee would allow me, for people to mutate. Secondly, treatments have changed. We now have immunotherapy, general treatments that target these cancers. We now have new models of care and youll see as we go through the place of service therapy, how its occurring now in the patient setting or even in the patients home. And lastly, we are improving. One of the things that youll see as we go through this is the stage of the disease when it is identified or being treated for, has gone down. So instead of being stage four, when its widely metastasized, theyre catching it earlier than stage four or earlier in treatment. I would mention that in 1975, your survival for Prostate Cancer was 68 . In 2012, your survival rate has moved up to almost 99 , and thats just because of education and treatment opportunities that are available. Can i ask a question about that. Sure. When you say survival, is it fiveyear survival, threeyear survival, tenyear survival . Five. So when somebody has lymphoma, and theyre getting some scans on an annual basis, do those costs include a history of . No. So its only for active treatment. Okay tiactive treatment. So if they had a scan, and those scans were related to cancer, they were captured in the treatment. But if someone had no Breast Cancer and there were no bills that came in related to the diagnosis for Breast Cancer, there would be no claims cost for that. So, for example, if a woman underwent a mastectomy because of a history of Breast Cancer. It would be captured in the cost. Even though it was in the okay. Any other questions . So moving onto slide four, what youll see is ultimately the best treatment is Early Detection. When our screenings rate is able to increase the stage at which theyre caught decreases, and youll notice an early cancer is only about 16,000. A latestage cancer is 41,000 or greater, depending on the stage of treatment. So with that, ill switch screens and turn it over to marina. Marina coleridge, Enterprise Services manager for the Health Service system. This is looking at 2018. The columns are looking at the screening rate by each of our plans, and here, were looking at our active and nonmedicare retiree population. And the gray shaded part is looking at utilization. And then, just to make this chart even more busy, weve added on a couple of targets. Weve got the national average. Thats the gray line, and then, the Healthy People 2020. And i know page mentioned that earlier. Thats a department of health and Human Services program from 2010 that has, like, i dont know, 1300 or so metrics that get covered and looked at all under four, you know, overarching goals around health care. So i wont go into details on it right now, but but to say orange line is for Healthy People 2020. I would say those groups tend to have the higher screening rates. Youre seeing some of the lower prevalences of the cancer as noted by the gray shading there. So our cervical screening for the population is just shy of the Healthy People 2020. All of our plans are below the National Screening rates i dont understand that because kaiser looks to me that its above your line. Yeah. Thats what i was looking at. Sorry. I think that was a version thing. Different version control. Ignore my comments. Kaiser and access plus are close to hitting the targets. And again, the gray shaded are the targets that were seeing. And then, we get over to colon cancer, and where we have a prevalence for the condition and the targets. And then, when you go to slide 6, this is the same layout, except this is looking at our medicare populations, and we only have the two plans. Again, kaiser performing really well here, and you can see in comparison to the screening rates, the preview dencedence the kaiser population than the screening population. So then, if we look at slide 7, what were looking at here is the top 15 cancers by population count, and what you see is skin is number one, both in the medicare retirement and the nonmedicare or pre65 retirees. Breast cancer comes in for the active population whereas prostate comes in on the medicare side, and it goes on down. The good thing to see is you have very low incidences of some of the things like ovarian and colon cancer is very hard to treat. So if we move onto slide 8, lets talk about skin. In the active, you notice that squamous skin cancer is number one with 2800 people being identified with squamous cell cancer. Thats a good thing in that squamous cell cancer is extremely slow growing. And although they can metastasize, and because theyre on those areas that have been exposed to the sun, your face, your arms, your torso, they are caught early and treated early. Whereas medic whereas melanomas are very aggressive cancers. The good thing is you dont have a whole lot of them, but the bad thing is they do metastasize very quickly, and they tend to go through the lymph system, and you may be treated for a melanoma, and it shows up in your brain or your lung a few years later, and by that time, you probably have a lot in your system. So that is an active cancer that is aggressively treated. And as we go through there, we watch through your wellness during the summer, particularly identifying an area like san francisco, we have cloud cover we called it fog when i was younger. But you do get sun burned even if its overcast, and sometimes people dont realize that. [please stand by] we can see our Breast Cancer exceeds california and national rates, as well as our skin cancer and our Prostate Cancer are higher than those benchmarks as well. When we look in our nonmedicare population, on the top right, we see that we are lower than benchmark for breast and cervical and skin, but the prostate is higher than the california average in the Health Service system population. The next slide is doing the same sort of comparison here, but we are looking at it by cost. Instead of looking at it by prevalence, which is what the previous slide was doing. We have, again, Breast Cancer, leukemia, and lymphoma, all of those are our costliest cancers, and we are exceeding the california benchmark and exceeding the national rate. Moving to slide 11, here we are taking a look at it from a longer to do no approach trending three years. We have 2016 through 2018, and there is a Little Orange dash line in there that shows you a trendline of how is our prevalence going over the years. So even though 2018 has increased over where we were in 2017, we do see, for example, in the Prostate Cancer and our male population, that has trended downwards over the threeyear period. Our Breast Cancer has trended up significantly over 2017, but slightly over 2016. That is also true of the Cervical Cancer that has been increasing over the three year trend. Can i ask a question . Yes, please. It is curious to me that 2017 was your middle column and lower for everything. So i am just curious, do you think your data captures all the diagnoses . Is there something theres something that is strange about why one year all the cancers would be lower. Yeah. I think so, too. As far as we know, all of our data is there. We do know we have some anomalies with some plans that we are looking into, with that is one we are still researching. It may take a while for our investigations to identify the reasons for it. That is something we are still continuing to look at. And your chronology goes from 2018 on the left, 2016 on the right. Usually we are used to seeing things the opposite way. Is that making you pay more attention . [laughter]. It makes me pay more attention. That is like when you go to trader joes on the fourth and they have the escalator on the right side and it is now on the left. I know there was a reason why they what you did that. It does keep us awake. [laughter] i was wondering if we could blame it on where you are from england, right . So, moving on, what are you looking forward to . What we anticipate in 2020 and beyond is, first of all, that you will see about a 12 to 15 increase yearoveryear Going Forward, and what you can see is , globally, they are increasing the same as the rest of the world. It is expecting to increase about nine to 12 . Japan is as low as 6 . From that perspective, unfortunately cancer is being treated and is being globally treated and everybody expects about the same growth rate. So then what does that mean to you all as far as this . If we are looking at the top 10 cancer episode treatment groups, what you are spending for breast is about 13. 8 million. You are spending about 7. 4 Million Dollars on leukemia. You are spending 2. 8 million on skin. I do have to draw attention to the fact that skin is orange and Everything Else is green. When you are thinking of acute, you usually think of appendicitis, you think of flu, but skin, because it is usually treated and then it is gone, has one episode. So if you had a swarm his cell on your finger, they would exercise it and so it up. That would be done. They would be no additional treatment and thats why it is considered acute versus chronic versus Something LikeBreast Cancer where you have chemotherapy or Radiation Therapy and things of that nature. If that makes sense. And so as you can see, you have kidney and urinary cancers at 2. 3, but that is basically looking at your cost 182018 based on the treatments that you have, which is, at 10 of your 550 milliondollar budget. So, i will move aside. As we take a look at slide 14 , we are looking at a per member per year cost and were doing that for our active and early retiring members. We do not have the financials for the medicare population. Is our top cancers yearoveryear, same thing where we are going left to right. And so cancer cost is trending upwards on the leukemia side. We have the cost trending downwards pretty significantly there. And our lung cancer trend upwards and same with lymphoma. That is what the trend has been looking like over these years. Same thing as applicable here in terms of what the commissioner has noted with the 2017 members that dip in some areas, not so on the cost of Breast Cancer, but that still is pieces that we are investigating. I want to talk a little bit about how treatment has changed over the past three years. If you look at the right column you will find them and you will notice that hospital inpatient stays was significant. It was almost it was slightly more, maybe two more than what the Outpatient Services were, and radiology, which is your Radiation Therapy, came in at 10 million. If you fastforward to 2018, which is the second column, you will see that your inpatient care actually dropped by almost 5 million, which is a significant change and your outpatient stayed somewhat flat, although it did go down a little bit at 14 million, but what you will see is that your pharmaceutical treatment of cancer increased by about, a little over 2 million. About 30 . So from that perspective, you see your growth and your outpatient because if you were to have maintains the 5050 ratio , you would expect the outpatient would have been around 11 million and instead, it is at 14 million and your pharmacy increase, where is radiation, what you would have expected may have caught up, but hasnt really changed yearoveryear during the same time period. So from that perspective, the good thing is that you are being able to treat people, outpatients, which means they are able to be in their own home and in their own setting. The difficult part is that was the changes in the treatment patterns with the drugs and the costs now are on the outpatient side. Questions . What would other be. That would be dme. Wheelchairs, it could be some of the genetic testing that would fall in there. It would be home health, hospice , things of that nature. Thank you. Any other questions . So one of the things that people often forget about when you think of cancer is longterm survivorship. There is a Significant Impact of cancer, and it remains high yearoveryear. It may be you are no longer being treated, but lets say you need to be fitted with a special appliance for a breast, lets say you did not have reconstruction, or you had a deformity caused by the removal of the cancer. All of those costs will continue as your body changes and ages, you will need to update. Those costs will continue. One of the stories that im sure some people have heard, but i always it just comes to mind, i had a family. I am a clinician. The wife had lung cancer. They were at a University Facility not in california and they were being treated aggressively and she passed. Her passing meant her husband not only lost his wife, which they were incredibly close, but he lost his house because he didnt have enough insurance to pay for it. He not only was grieving the loss of his house and his wife, he now had to figure out where he was going to live. And so those costs that go along with cancer lingered for many, many years after the active treatment. That is one of the things that often we forget about Going Forward. So earlier on in the presentation, i mentioned that the positive things that we are seeing with your increased screening is the earlier detection. So if we look at pages 17, 18, and 19, i will not go over i will not go over all three pages , but focus on the active, is what you see is that, for Breast Cancer, the disease stage zero, which means there is no test to says, there is no lymph nodes involvement, it is a localized lesion, is significant that out of your 680 people that were identified, almost 90 of them were at stage zero, and only, again i will use 90, my measurements might be slightly off here, were at stage three. The rest were stage stage one. That means it is very receptive to treatment and it is a positive finding. If you go down and look at the list, you will find very few stage four. You will find a few unspecified, a few, if my colours are correct here in the oral cancers, but very few stage four. You do have a fair amount of stage three, which is the yellow , particularly in lung cancer, and in colon cancer his. But overall, you are finding your cancers earlier, and that pattern is seen both in the pre 65 retirees as well as medicare retirees. So in conclusion, what we are going to watch for Going Forward is we will be reporting back on cancer because unfortunately i anticipate it will remain in a top consumer of your resources. So we will Pay Attention to the stage of the disease, when it was diagnosed. We are going to hopefully look for increasing screening rates, again for cervical, breast, in colon cancer as compared to the national averages, and we are going to really keep on top of the prevalences by each type of cancer to see if there is any targeted interventions or wellness activities or outreaches that we can collaborate with your various health plans on to improve screening and Early Detection. Any questions . I have a question. Thank you for the very thorough presentation. Im wondering if you have a breakdown by gender or by race or anything further broken down that breaks down the types of cancer. At this point we do have the Data Available to us by gender. Some of the cancers in this report we have made some comments about specific genders, for example, on the Breast Cancer, both genders can get Breast Cancer, but we have looked at it with a male population and without. That is not a problem. As far as looking at things by race and ethnicity, that is not something we are able to do today. It is a focus under our Strategic Plan and the direction we are going. Thank you for this. Is a really thorough presentation. Im not sure what your reasoning is, but i applaud the exclusion of Prostate Cancer from early screening. It is my understanding that Prostate Cancer in the United States, the issue around Early Detection and early identification of men with Prostate Cancer is still quite controversial in the developed countries. The europeans feel that the americans diagnosed early, label men with Prostate Cancer, treat, and yet their survival rates at 10 years, 15 years, are actually identical to their history, which is a much later diagnosis time, and so the fact that we are not necessarily encouraging early screening while this question is still being identified, and i know a lot of men with Prostate Cancer who have entered Clinical Trials looking to see what the history might be, and not necessarily accepting medical or surgical interventions. So i dont know if that is the rationale for your failure to follow that, or it is coincidence, but i applaud it. No, actually, it is a usps task force. The United States has taken it off a recommendation at this point in time. That is why we took it off of our screening policy. Any other questions . Thank you. Any Public Comment on this item . Seeing none. Would anyone prefer a break right now rather than charge through . Yes. [laughter]. We will take we are back in session. We are on item number 11. Item 11. Item 11 is a presentation on delta dental Teaching Network and utilization report this will be presented by the account manager from delta dental. Is it on . Okay. You have a presentation that we will go through. It is really some information and updated stats regarding some of the programs we have implemented as of january first of 2019. So with the first item, we are actually going to talk about our dentist accreditation. There were some questions regarding how we go through that process and so we do credential all of our dentists in the network. Before a dentist can be permitted to those networks to actually be listed as a provider we go through the credentialing and utilize the standards of the National Committee of quality and assurance. And our common practice is that in order, we do have a unit within delta dental that is fully responsible for this credential process. So making sure we are continuing to do this on an annual basis. The credential process, we actually obtain a state license making sure that also the dentist has evidence of malpractice coverage. They also have to provide us with a Drug EnforcementAdministration Certificate and specialty training verification. That would be for a pediatric dentist or an orthodontist where they are having to have additional training because they are providing a specialty within the dentist world. We do verify this annually and we do utilize the National Practitioner data bank to make sure that license is uptodate. We also read credential at least once every three years all the dentists. So making sure, again, not that their license is uptodate , we have a current malpractice insurance policy, we are also making sure that we are sharing with the dentist Employee Satisfaction surveys, or any kind of grievance and appeal that we received for people who are enrolled in their specific practice. So this is only in . This is for the p. P. O. And our premier network. Those are our two networks. Okay. Yes. I dont know, but is there continuing medical education requirements for dentists like there are for physicians . In california they have to show so many hours. Some are specific for certain kinds of training, but most was not. If you are a neurosurgeon, you can your credits can be for the specialty boards now are requiring recertification every 10 years for all the specialties , both surgical and nonsurgical. Are there requirements for dentists . I believe there are, but i dont know the specific our requirements because i do know that we do specific webinars for our dentists, and then i know that they also participate in a lot of the dental Association CongressNational Seminars and conferences that they attend. I can definitely i just want some information. If you are relying on re licensure, which the state does, obviously, and that requires cme, we would note that because you are not asking for independent verification of hours, youre just relying on the state. They will be fine, but we would know that. There are continuing education requirements for dentists in the state of california to the extent that we can provide more detailed information. Just to know that there are. Yes. The next set of slides will talk about the network and under the p. B. O. Plan. And remember that we have two sets of contracts. P. P. O. Contracts and premier contracts with our dentists. And then all members are eligible to Seek Services by a noncontracted dentist with us. So the first slide is on active, your active population. It is for the p. B. O. Contracted dentist, and we ran this report specific to your geographic locations and the particular of the data, or criteria of the data, was within a 10mile radius. You can see on the first slide, it is almost 100 . 99. 7 of your members that are enrolled in delta dental who have access to a p. P. O. Dentist with less than a mile away from their location. On the next slide, it is our premier dentist network. Again, very close, 99. 8 within a 0. 8mile radius. Our next slide is focused on retirees, and again, p. B. O. We are presenting first. 99. 3 in a 1. 2 mile radius. They have access to a p. P. O. Dentist. And then on the next page, premier, 99. 8, a little less than a mile. We are going to transition into your smile way Wellness Program benefits. This first slide is a reminder as to what that benefit is. You did approve that benefit to be installed into your plan both active and retiree plans. This is a specific wellness that for individuals that have diabetes, heart disease, h. I. V. Or aids, Rheumatoid Arthritis or stroke, they can and roll in this plan either by phone, by calling our Customer Service, or online through their online portal, and in role in this plan , and they get additional benefits. Typically this is the scaling where it is the deep cleaning of the teeth that individuals that have inflammation of the gums, and in all five of these chronic conditions, have a result of inflammation, and so typically theres that need to have additional dental work. So now you are providing that free of charge, meaning no charge to the member to have these additional services. Im sorry, i am asking questions. So the Rheumatoid Arthritis jumped out. Maybe i have asked this before or maybe i didnt know this, i didnt know if Rheumatoid Arthritis, per se, has a specific dental complication due to inflammation, or whether it was sort of bedcovers different syndromes and dry mouth associated with a other autoimmune diseases or whether it is because of mechanical issues that many people cannot do their own oral hygiene as well. Is that the first, is there a special inflammatory condition that distinguishes from other autoimmune diseases or other kinds of arthritic teas . I think your first and your third observation are the best in this particular circumstance. One meaning that there is a heightened inflammation that we really can associate with just specifically Rheumatoid Arthritis. I have had some of your members come and approach during your Health Affairs or wellness and ask the question, well, i have arthritis. Why arent you covering that . It is specific to Rheumatoid Arthritis. And then the third observation that you made aware theres a lot of deformity, that is associated usually with Rheumatoid Arthritis, meaning the crippling of the hands or different body parts. That does then cause a greater complication for a member to really be able to do that Preventative Dental cleaning and assistance to their teeth. So then you have more of the sliding scale of having more disease, finding more tooth decay. So the next slide is and just kind of a snapshot of the four different months and looking at the enrolment in the smile way program. Actives are on the lefthand side, retirees are on the righthand side. His the retirees are doing really well in this sense of the are embracing this plan, they are enrolling in this plan, and so you can see that uptick. Also with the actives. I mean there is definitely a response to this program and, you know, we went from 20 enrollees to 112 as of september really positive in that regard as to a self elect process, meaning they are self electing and calling us for their enrolling online. So some different suggestions to increase the participation within the smile way program. Currently what we have been doing is the Contact Centre, the delta dental or dental Contact Centre when youre calling the Customer Service line, the representatives know to promote the smile way benefit and where i say in parentheses, a banner within our system, basically what that is it is a highlighted it is highlighted one a member were to call in from h. S. S. , we pool up pull up their member record, it immediately they see them big, bold, yellow highlight that your membership has access to the small way benefit, and so as they are going through the process of answering the question for the member, they are also promoting this program. And then the other aspect that we have been providing flyers. So you have an active flyer and retiree flyer. They are just a little bit different nuances within the benefit, and meaning not nuanced and benefits for the smile way program, but we show a comparison of what your existing benefit is and what you get through the smile way benefit. So that is why there is the difference in the flyers. But we have been promoting these at the health fair. I actually helped two of your retirees in role at the health fair just recently. They were really excited to learn about the program and that was really the conversation that we had during the Health Affairs the next slide is what you a