Transcripts For SFGTV Health 20240704

Good afternoon everyone. Welcome to the Health Service Board Meeting of march 14, 2024 and happy pie day to everybody. Would you please stand for the pledge of allegiance . I pledge allegiance to the flag of the United States of america, and to the republic, for which it stands, one nation, under god, indivisible, with liberty and justice for all. Thank you. Item 2, please. Thank you. Roll call starting with, president scott who is excused. Chair hao, present. Commissioner breslin is excused. Commissioner canning, present. Supervisor dorsey, present. Commissioner follansbee, present. Commissioner zvanski, present. Thank you. Thank you. We definitely have quorum. Item 3, please. Thank you. General Public Comment. An opportunity for members of the public to comment on any matter within the board jurisdiction on the agenda including requesting that the board place a matter on a future agenda item. Ill read our Public Comment instructions aloud. Remote viewing is available on sfgovtv and webex. Welcomes Public Comment during the Public Comment periods. There will be a opportunity for general Public Comment at the beginning of the etmooing and a opportunity to comment on each item. In person Public Comment will be first then remote Public Comment. Anyone in person you are welcome to approach the podium now. Each is allowed three minutes to speak. All Public Comment are made concerning the item presented. Caller may ask questions of the policy body but no obigation to answer or engage in dialogue. The Health Service board will hear up to 30 minutes of remote Public Comment for each item. Remote Public Comment people received accommodation due to disability will not count towards the 30 minute left. Members attending the meeting via phone can call by dialing 4156550001 and enter code 26604081402. When prompted press. You will be prompted to enter the webinar password, 1145 and again. Press 3 and you will hear the prompt. When the system message says your line is unmuted this is your time to speak. Your will be muted when your time expired. For those watching on webex click on the icon to be placed in the queue. A raised hand appears next to your name. Please select unmute to speak. Once you hear welcome caller, you can begin speaking. When your time expired you will be muted. Click on the raise hand icon to lower your hand. Members are encouraged to state name completely but may remain anonymous. When your three minutes ended i will say thank you for your call and placed on mute and unmute the next caller. Thank you to sfgovtv and media service. Well begin with in person Public Comment. No one approached the podium. Well move to our remote Public Comment and moderator will notify if there is callers in the Public Comment queue at this time. We have one caller on the phone line. Zero commenters have entered the queue. Thank you moderator. The board also received a written Public Comment. The member was ella lam and requesting the board add over the counter benefit to the Kaiser Permanente senior advantage plan. Next item, please. Thank you. Next item is approval with possible modifications of the minutes of the meeting set forth below which were december 12 Governance Committee Meeting Minutes and february 8 regular Meeting Minutes. Colleagues, you have questions or other edits you want to offer . I move approval of the minutes of the february 8 and december 12 meetings as listed. Second. Moved and second. Well take Public Comment. Thank you. Public comment is now open. Instructions are displayed on the screen for those watching on sfgovtv and webex. In person Public Comment is first fallowed by remote Public Comment. Press star 3 to be added to the queue. For those watching on webex, click raise hand icon to be placed in the queue to speak. Well move to inperson Public Comment and no one approached the podium and move to our remote Public Comment and the moderator will notify of any callers in the queue at this time. We have one caller on the phone, zero callers entered the queue. Thank you. Hearing no callers, Public Comment is closed. Thank you roll call vote please. [roll call] thank you. The minutes are approved unanimously. Next item, please. Item 5 is president s report. Discussion item and presented by chair hao. Thank you. I have a couple things. First of all, we have a very meaty agenda including two items in closed session, so we will be able to get through this, im hopeful that but we need to be mindful of the next commission who come in after us to use the room. One time we stayed way too late and they were a little grumpy. Lets make friends with other commissions. The second item i want to remind fellow commissioners that we have the form 700 due on april 1 as well as the required annual ethics training, so please dont forget to do that. I think there is a penalty for late filing of form 700 and again, we dont want to make the Ethics Commission grumpy about this. Thats it. I guess Public Comment on my comments. Thank you. Thank you. Public comment is open. Instructions are displayed on the screen for those watching. In person is first. No one approached the podium, well move to remote Public Comment and the moderator will notify of callers in the queue at this time. We have one caller on the phone line, zero callers entered the Public Comment queue at this time. Thank you moderator. Hearing no callers, Public Comment is closed. Thank you. Item 6, please. Thank you. Item 6 is directors report. Discussion item and presented by abbie yant. Good afternoon commissioners. Ill try to be brief to get through the meeting today. Reminder to the black out notice is in effect for all the health plans and rfp for the medicare product, so there is language if you are unclear. Speaking of which, the medicare rfp is on track. We are planning to deliver that to this board on may 23 and the panel is fully engaged, the process is underway, the documents are being submitted and reviewed and hats off to michael and mary from aon. It is a very robust process and taking a lot of their time and we really all appreciate that. I also wanted to point out we have been in negotiation regarding our lease some time now. As you imagine, Office Space Lease negotiations are a hay day of the Real Estate Department for city county of San Francisco now is and we are going to benefit from the lease negotiation. We are however as part that is vacating the first floor where we had the Catherine Dodd Wellness Center open in main of 2014. We are caring her Mission Forward where we are goingWellness Center is a gym space to where we prioritize invasion and collaboration with among the staff and or the departments. The shift aims to bolster operational capacity and cultivate a culture of senergy and invasion comprehensive wellbe. So, i think that is a fitting way to move that on. I spoke with catherine last week to let her know. She was very pleased and surprised to learn. That move is underway and right now the Real Estate Division is putting a package of leases together that will go before the board of supervisors in april and once that is done the team will commense with the work and preparation well underway and the gymnasium equipment we have according to rules we are following all the procedures to distribute around the city and all go to good use by city departments that are participating in different wellness activities. I think we have a really good plan in place and will be able to are locate the Employee Assistance program and wellbeing center to space on the second floor, which is much more habitable then the space on the first floor has been, so we are looking forward to that. The Health Service Board Election is going to take place between may 17 and 31. We did a orientation for nominees a week ago, and the final slate will be approved after the form 700s are filed by april 11. That is the requirement, so let the campaign begin at that point. We will do the diva again this year, i think we mentioned before, it is womens history month. If you read the news letter, i did say a little about my own history with my mom and grand mother who served during the pandemic in 1918, so we have that in common. I also wanted to note that on the way over here today, the city, department of Human Resources opened a Career Center on the first floor and might want to stop by on the way out. It is pretty cool. The fact it is in city hall will help in a lot of ways, so we partner obviously every day with the department of Human Resources and recruitment and retention is a Key Initiative for all of us. And lets see, last but not least, the wellbeing programs, this month included renewed commitment to your own wellbeing and done a big campaign on sleep. Anybody with sleep issues i encourage you to take a look at it. With that, i think i will turn it over to the board. Thank you director yant. I also want to thank you for all the data you provide to us on a regular basis of the calls and other metrics that you are measuring in your department. Thank you. Well bring the annual report next month. Well flush that out in more detail for you at that time, so there may be more context to what you are receiving on a monthly basis. Thank you. If i can ask a question. About three weeks ago there was a hacking of the Billing Service for United Healthcare and my understanding is the Major Health Systems were not effected, it was small hospitals and individual providers. Has there been any impact on hss from this event as far as you know . Not that i know of. We did receive all the proper notifications and thats what we keep track of to make sure we are adequately notified and yeah, thats probably the biggest healthcare breach there has been and the feds are looking into it from what i understand. So, i do feel sorry for it the folks impacted. We are fortunate that it hasnt effected us that we know of yet. Big caveat. Thank you. Any other questions . Or comments . Im glad that you no longer have to report on the status of the ucsf negotiation with United Healthcare. Yes. Glad that has come to a end. Well take Public Comment. Thank you. [providing instructions for Public Comment] no one approached the podium. Well move to remote Public Comment. Board secretary, there are zero callers on the phone line and zero callers in the queue. Thank you moderator. Hearing no caller, the Public Comment is closed. Thank you. Item 7, please. Thank you. Item 7 is sfhss Financial Report as of january 31, 2024. This is discussion item and presented by iftikhar hussain. Good afternoon. Good afternoon. Yes, the result of the trust are similar to what we said last month. I do want to add one more bit of information in the claims running higher then planned, one of the reasons is the claims arepremiums are set on annual calendar year basis so the 10. 1 percent increase is not kicking in until january. A lot of reason you see the claims running higher are based on the older rates. Can you speak up a bit, because i didnt quite get all that . We talked about the decline in the trust balance because the claims experience has been higher then planned, and one thing i want to point out is the rate setting process is done on calendar year, so when we experience the higher claims, those rates were not adjusted until january of 2024, so a lot of claims is remnant of the lower rates. In january the rates were increased average by 10. 1 percent. The other thing i want to point out, we are seeing [indiscernible] 25 percent increase we expected last year. I havethis is notthe bad news is, the overall pharmacy expenses are quite a bit higher then, even with higher rebates. [indiscernible] Sustainability Fund is solid. The general fund we are expecting to be slightly ahead of budget because of the vacancies. We did do supplemental staffing during open enrollment to make up for some of the vacancies and we were able to do a surplus transfer to fund some of the expenses by taking salaries into purchase services. The net effect i think we are close to budget by the end of the year, and twl thereis one auditing process. Internal control process where they have given questions of the policies and they select sample of [indiscernible] so that is ongoing. Happy to answer questions about financials. Could we go todo we have the whole packet on we can look at . If we can look at your graph. In terms of it disparities between the claims and what we collected in the month and we see those curves sort of separating. If you can pull that up because i had a question. You may have answered it in part by talking about the application of the newthe first of the year. Application of the new rates. Rate. Yeah. So, i was looking at this and wondering if theit looks like thisobviously the expenses are always higher and revenues. But from month to month it looks like sometimesthat gap hasnt increased. In other words, it may have occurred earlier on, but in the last month or so and this plan and one of the others, the gap seemed to be about the same dollars. You see what im saying . Maybe thats the new rates. So, the gap between there lines on the bar are two reasons. One is stabilization. Right. So thats the two lines shown in the graphs. This is comuliative numbers. The net change in january we dont show. We show year to date but not the month. Did come down. If i subtracted revenues from the expenses in january it looked like that dollar figure was about the same as in december, so at least there wasnt a continuing increasing despairty. That was the rough calculation. I didnt sit down to that. What might explain that . The claims went down in january. Yeah. That was what i was asking. This is helpful. I wondering if it is useful to monitor this on a month to see what the month change is as well. We can see if there a trend of seasonality. We can certainly add that. Just curious, because obviously, to just watch month by month i throw up our hands is a little frustrating and i hope that the plans are getting the message that we are not just throwing up our hands and watching it carefully and they can do in real time rather then waiting for the new contract to sort of help whatever they think they can do would be great. Eel ill do that. I wanted to add to that dr. Follansbee, there is very extensive experience reports about the utilization of the health plans, so these are the big pillars how we evaluate dollars, but utilization drives the doctors dollars. The relationship between the spend and the utilization and the forecast is very important that we lay the groundwork for that and iftikhar presents on a mujtly basis to demonstrate the fiduciary responsibility to the trust and we watch this. Between[indiscernible] having a hard time picking up everything you are saying. I dont want to miss a word. The dollars is one way we continuously monitor the trust to make sure we got enough money to pay the bills, but what well look at starting today explaining the experience wree are seeing and the utilization trends are what you will be looking for as far as seasonalty and that type of thing is really looking why are people using services because in general we want them to use services, but when they start getting effected by pharmacy cost and other things, that may be news. Those are the type of things we continue to watch for and lays the basis for forecasting what the rates could and should be going forward. It is a very complex subject and we try to break it apart, but iftikhar presents to you as the cfo those reports letting you know as the board and fiduciary responsibility we carefully monitor the spend against what we projected. Thank you, any other questions or comments for iftikhar . Thank you. Well take Public Comment. Thank you. [providing instructions for Public Comment] well begin with in person Public Comment and no one approached the podium so move to remote Public Comment and the moderator will notify of callers in the queue at this time. Board secretary, we have zero callers on the phone line and zero callers in the Public Comment queue. Thank you moderator. Public comment is now closed. Thank you. Item 8, please. Item 8 the presentation of the 2024 rates and benefits calendar for the plan year 2025. Discussion item andprinted by executive director abbie yant. Ill try to speak louder this time. The rates and benefits calendar is before you today. March 14 first page telling you what is on the docket for today. I imagine that we will release the march 28 meeting because well be able to get through the agenda today. Thats forthcoming. Going forward, well look at stabilization reserves next month and retiree dental rates. Going forward, as mentioned, may 23 is going to be where we are looking at the result of the rfp. We may bring the recommendation to you in may and then the contract itself will that to you in june. So, full docket for the next couple months. Appreciate in advance all the work you will put in on reading these materials and hats off to mike clarke and ann thompson and team being expert helping us put the packages together, they are pretty complex. Thank you. Any questions or comments for director yant . If not, well take Public Comment. Thank you. [providing instructions for Public Comment, which are displayed on the screen] no one approached the podium. Well move to our remote Public Comment and our moderator will notify of any callers in the queue. We have zero callers on the line and in the queue. Thank you. Hearing no callers, Public Comment is closed. Thank you. My apologies executive director yant. Did not mean tomy apologies for that. Well take the next item. Item 9, review and approve 10county survey results for the 2025 plan year rates. This is action item and will be presented by iftikhar hussain, chief Financial Officer for hss. So, we are looking atlast year we had large increase. We go back and look at the other counties and you see now that our experience and our pain was shared by most california counties in terms of the very high increases in rates of insurance plans. Our number isthe 10 county average is 9. 46. Just as context. Last year under more normal times it was 3. 21 percent. And otherill throw other numbers for reference. Cpi during this time was 3. 1 percent. And the National Benchmarks getting away from california, about 6. 8 to 7 percent. Certainly what we are seeing is california is a outlier and our hope and our plan on negotiation process we are trying to get those rates back down certainly from the high we have seen in this year. So, presented before you is a package showing the rates and happy to answer any questions on the report. Thank you cfo hussain. When i saw my numbers my eyes popped for a second. Do we have any sort of story or information behind alamedas eye popic 16. 27 percent increase . I did go back to see if there is a pattern on certain types of plans, certain insurance, certain carriers and are there really wasnt any. Okay. Just a broad increase across various types of products and various carriers. Okay. I didnt analyze it carefully, but looked like kaiser rates have gone up significantly in northern and Southern California. You didnt notice that . I like towhen i went to see if kaiser was the only one and they were not. United, blue shield, anthem. If i go into the survey they all had large increases. You indicated california seems to be a outlier, im sure we are still assessing that. Do you have theories why that would be the case . Yes, my sense is that the california market is very consolidated, especially Northern California. See if mike wants to weigh in on why california is a outlier. Also seems housing cost in california many countsies are much higher then across the country in general and also labor costs i think. Seems to me that again, los angeles and Orange County each had significant increases, historically Northern California has sort of been worse and many rates still are higher in the Northern California counties compared to Southern California ones. There are differences, but typically around california has been more costly for healthcare and it seemed like Southern California is catching up to Northern California. Yeah. Mike clarke, aon, california versus the rest of the country is kaiser influence. If you think other health plans like blue cross, blue shield, United Healthcare, sig na, they are negotiating so as the increases play in it happens over 2, 3, 4 year period. With Kaiser Permanente, it is one system where vast majority of cost are incurred and it happened the catch up effect from the pandemic around Wage Inflation and bargaining all happened in this one year period and that was part of the message kaiser shared last spring preparing for the 2024 renewal not just for hss but as you can see counties and employers acrautss cross the state. The impacts are not all that whatexpense inflation, it is just the concentration of kaiser and one year timeframe, because of the fact it is one system and where that catch up was happening for kaiser versus other parts of country, it is more a catch up over a couple year period. Thank you. Is kaiser only in california . Kaiser is predominantly in california, but there is also 7 other geographic regions where kaiser is offered across the country and in fact hss offers three of those to retirees with washington, oregon and hawaii. Got it. Thank you. California operations90 percent of kaiser is california. Thats what i wantthank you. I like to recognize [indiscernible] on our staff who is the heart and soul of this report and puts a lot of hours into it and very exacting so i want toi know hes listening so i want to make sure he hears it. [laughter] thanks yuri. You mentioned the consolidation in Northern California, which is real and San Francisco we have seen further consolidation now with the purchase of saint mary and sant Francis Hospital at ucsf so we are dealing with three Major Health Plans so we can maybe begin to anticipate what the impact might be of the consolidation in certain counties. There is often only one player, the Hospital System and so this is really a very acute problem that we are facing and others are facing too. I add to that, im sitting on the healthcare Advisory Board or affordability Board Advisory committee which is stacked against the purchaseers because there is a lot of providers that want to see the rates go up. The current recommendation is 3 percent cap year over year and see what happens with this recommendation whether it gets contested or fot not by the effected parties. It is a very aggressive cap and you imagine the Provider Community is not very supportive that. And then, i know our colleagues at the Purchaser Business Group on health was in washington yesterday to describe this phenomena we are experiencing right now with these extremely high rates of increase year over year with health plans. There is very little control that is happening and so it is not unique to San Francisco, it isnt unique to california anymore. This is nation wide. It is one thing to have say united and anthem and etna because if you switch from one to the other you have the same Provider Network, but when you have a integrated system, just kaiser, it is just too much of the market, so for ourclose to 60 percent of kaiser and it would be really difficult to find providers for those if you didnt have kaiser. So, that exacerbated the market consolidation problem. Any additional questions or comments . If not, well take Public Comment. Thank you. Public comment is open. [providing instructions for Public Comment] sorry, we forgot to take a motion. Where is president scott when you need him . Okay. I like to make a motion that we approve the 10 county survey results as presented. Second. Properly moved and seconded. Now we are ready for Public Comment. Thank you. [providing instructions for Public Comment] well begin with in person Public Comment and no one approach ed the podium. Move to remote Public Comment and our moderator will notify of callers in the queue at this time. Board secretary, zero callers on the phone line and zero in the queue. Thank you. Hearing no callers, Public Comment is closed. Thank you. Take a roll call vote, please. Chair hao, aye. Canning, aye. Dorsey, aye. Follansbee, aye. Zvanski, aye. It has been unanimously approved. Item 10, review and approve proposed modification to june 30, 2023 selffunded and flexfunded helths plan contingency reserve amounts. This will be presented by mark clarke with aon. Mike clarke, aon. I will talk through the rational for todays recommendation and get into details of what it will mean for the proposed modifications to the health plan contingency reserve amounts. If we go to page 4, background on why i come today with this recommendation. We heard from the employers at the february Board Meeting loud and clear around the fiscal challenges they are experiencing from city county of San Francisco to San Francisco Unified School District and Community College of San Francisco. Upon reflection, our team at aongot together with executive director yant and her team at hss to brainstorm what are reasonable ways we could possibly impact the projected budget in the 2025 in a way that doesnt compromise the fiscal integrity of the plan. We looked at the reserve levels, certainly we cant do anything to influence the not reported reserve but contingency reserve, felt there is opportunity within the framework of what is prescribed in the policy, the board policy for that to propose a modification of the contingency reserve. Page 5 is summary of recommendations that well talk through today and ask you to consider at the end of the presentation, first for the medical selffunded flex funded helt plan contingency reserve amound approved on january 11, 2024, change these to fiscal method. That is part of what is in the policy to the 95th percentile interval and ill talk what that meansane bit, which would take those reserves down to approximately 18 million. The second is to amend the Health Service board contingency reserve policy 210 on one time basis for june 30, 2023 selffunded dental ppo set at zero. Again ill talk through the rational behind that and finally to ask the Governance Committee of Health Service board and the full Health Service board later in 2024 to consider the elimination of the selffunded active dental ppo plan only from this policy. The dental component is the active plan. We are not talking in the presentation or recommendation about retiree dental. That is fully insured plan. Just background on the policies, the contingency reserve policy is one of three as you see on page 7 and we is have a link to term of reference document where anybody can find the language for the three reserve policies, including 210 the focus of todays discussion. Just background, what is contingency reserve. We talk about it every january. I stand here and ask you to approve the updated amounts. Think of it as the Emergency Fund for the trust. As we talk through this with the team, one of the leaders said, think of it as your emergency pool of money you may have cast aside for emergency appliance repairs, emergency car repairs, emergency medical bills, whatever the case is. Think of the contingency reserve as that Emergency Fund for the trust. This policy was first implemented in 2007, and it protects the trust from highly unusual adverse high health plan experience that could occur in these plans and you can see the 6 elements actually written into the policy that could drive those deviations from expectation. The objectives of the plan are to protect that unusually high claim experience. It is prudent for these plans to have a contingency reserve or could be known as excess loss reserve to absorb adverse financial strain. The reserve allow hss to have a budget based on predetermined funding level and main that regardless of claim experience, and policy 210, having contingency reserve can serve the same purpose as stop loss. I presented numerous times how you dont necessarily need and require external stop loss for the medical plans, because you have these contingency reserves in place. Now, you are required to have one set of plans, blue shield of california requires the 1 million life and access plus is and trio plans, but otherwise not required to carry stop loss insurance for the plans. The reserve policy states reserve apply to the flex funded hmo plan. The non capitated cost because those are fixed on a per member basis. That covers blue shield hmo and health net. Selffunded ppo plan and selffunded dental ppo plan. For those and pie day so perhaps well talk stats here. The calculation methodology are outlined in this policy which were last updated in 2013 and the calculation that aon Team Every Year is based on three levels of statistical confidence so that is what we use in the annual reporting at the close of the fiscal year to the chief Financial Officer and those are performed at the 95, 97 and 99 percentile confidence interval, so ill show what that means. The 95 percentile is really a industry standard, so you could the 97 and 99 to be more conservative amount. The practice though has always been to set the most conservative of the highest amount. The 99 percentile has always been used for setting of the contingency reserves. So, what does all this mean . Thanks to the good old internet i was looking for a way to try to help illustrate what we are really talking about, and if you think about how random events can happen statistical probabilities you may be familiar with a bell shaped curve. When we present rates to you every year, it is based on average expectation, but there could be deviation around that. Most cases the deviation tends to be somewhat narrow around that average, but you can have deviations that can be significant. For instance, why does your policy say 95, 97 and 99 . The notion statistically of a 95 percentile confidence interval is to identify data points that are within two standard deviations of the mean. Again, a fancy term but means you are capturing the likelihood of what can happen 95 percent of the time with 99 percentile you are spreading it out to a third standard deviation. If you look at the very bottom here, you kind of see how i drew the arrows. Thats essentially the framework behind our calculations to produce the contingency reserve amounts that we do every cycle for each of these three confidence intervals. The 95 being the lowest end but still very much capturing experience that is expected all most all the time. 99 is really capturing so much of what could happen. One thing preparing for today, wanted to get a sense of how does any of these compare to what is typical for Public Sector business, of which we have a large Public Sector book of business across the country and one of my colleague in chicago leads Public Sector business so just talking to her what is typical, the 95 percentile confidence interval is typical for how we work with state clients, municipalities clients, et cetera, and then just to have one of many references you could find doing a web search, here is one from National Institute on Health Article talking about statistical validity of 95 confidence interval. I would never come with this recommendation today if i didnt feel you are still adequately protected from these adverse experience potential. Thankfully, hss never had to tap into the contingency reserves over the course of time, but if you did, we certainly want to make sure that there is adequate amounts here and i think thats why the policy allows for the calculations of these three different levels. I would never advocate for taking below 95 percentile confidence level. For a medical plan standpoint, everything i am presenting here is within the framework of policy 210. Just using a different allowable method within policy 210. You can look at the Bigger Picture of liability in general. Contingency reserves are plan liability of sorts. There are required liabilities per county rules, and first for most it starts with the [indiscernible] which are essentially money that is set aside to cover the cost of any services that happened prior to a particular date that end up not getting paid until after the date. If i go to a hospital june 29, the last day or next last day of the fiscal year, that claim isnt going to get paid by blue shield or united until july, august, whenever. So, you have to set a reserve up at your fiscal year end Financial Statements to allow for the fact that you owe that money, because someone had a hospitalization late june, but it isnt paid until after june 30. Thats the largest part of the required liabilities. Thats why your auditor, mgo right now audits those calculations as i know all too well the questions i get. Those are audited as part of the Financial Statements and you can see other things that could roll into that required liability. Another example ill talk about later today is money that you collected from the sutter legal settlement. That had to be reflected as a plan liability because it would be cascadeed in the rates, but when the check is received it isnt in the rates that day. We now go through and have policy 213 for you to allocate that into rates into the future, but at the time the check is received that is a liability that cascadeed to the future for the plan. So, contingency reserves are not a accounting required liability, but they are a prudent process to protect the trust and so, it is really a policy that allows for hss to hold certain amount of funds for the contingent liabilities, the possibility of adverse plan experience that the contingency reserves establish as well as the Rate Stabilization reserves so those are established by policy and on the Financial Statementsas those net assets exceed the total amount for the items, hss is fully funded for these items. Mike, you referred to policy 213 several times, but in my printed materials i see policy 212. Policy 212 is the213 is the new legal settlement policy. That was put into the terms of reference document early in 2023 that allowed for the sutter legal settlement dollars to be distributed and later today ill talk about there latest wave of sutter legal settlement dollars. The original reserve policies and this goes back to page 7 are the contingency, the Rate Stabilization and the incurred and not reported policy. Page 7 list 210, 11 and 12. Okay, but not 213. 213 is not a reserve policy, but it is a new policy that allows for how hss will handle the receipt of legal settlement monies into future rates. Thank you very much. Absolutely. Okay, so just closing up discussion on contingency reserves on page 16, a lot of background here recognizing it is very complex, but bottom line is, why we focused on contingency reserves is those changes in reserve from the prior fiscal year end to most recent fiscal year end flow through the Rate Stabilization calculations. So, every year when we talk through how to adjust the Rate Stabilization amounts that flow into the rate cards for the selffunded and flexfunded plans, the change in contingency reserve is a element to how the calculations occur. If we reduce the contingency reserves, then it reduces both the next year portion of rates in total as well as allows for carryforward past next year. If you think about it, the policy for Rate Stabilization is typically apply 1 3 that amount into the next years rates, 2 3 cascadeed forward from there, so ill talk about in april, this particular action if approved today can save about 4. 2 million total and total cost rates for 2025, and would allow 6. 4 million to cascade into the future after 2025. Thatsthink that as the real application of when i walk through today and how it benefits both members and the employers in 2025 and beyond. With that, page 18, transitioning into the application on the medical selffunded and flexfunded plans. I did and i think cfo hussain for this, but didnt mention verbally at the january 11 meeting, so what is captured in the Meeting Minutes, what the savings potential could be to migrate from the 99 percentile to the other allowed methods in the policy, 95 and 97, and these modifications today on the selffunded and flexfunded plans can reduce the overall contingency reserve for the plans by 8 and 8 and a half million verses what was approved in january. So, numerically on page 19, for these plans and three major sets of the flexfunded and selffunded plans. The blue shield hmo and united ppo plans being the top. The canopy care hmo in the middle and selffunded ppo plan at the bottom. You see the amounts orig inally approved. That is what was approved in january. What i ask you to approve today is the modification using the 95 percentile calculations that add up to all most 18 million. This is still roughly 5 percent of total expected claim costs for these plans. I know you think about total hss budget is for total spend being excess of a billion, but keep in mind, kaiser is fully insured and all most half that. The blue shield capitation cost are very sig cont portion that. The medicare plans are fully insured. They fall outside of selffunded or flexfunded, so in the end about a third of total hss spend is claims and this 18 million number represents about 5 percent that. You can see about 8 and a half million reduction in total contingency reserve amount and this is illustration here. Well talk about actual stabilization approvals next month, but to give a idea how this cascades into rating. I took the example of blue shield hmo and [indiscernible] predominantly think as access plus and trio. The revenue shortfall expected for 2023, there was a buy down in Rate Stabilization of 6 million, 592 thousand. As we review and as cfo hussain reviewed with you, we had a higher cost year for these plans, so there was more actual revenue shortfall, but if you work down to the second line, what was originally proposed increase the contingency reserve for these plans by 2 million, 782 thousand. With the modification to use the 95 percentile approach it actually reduces the change in contingency reserve bybrings to 2 and a half million reduction and this total difference just for the plan alone is 5 million, 261 thousand. So, that is 5 million 261 thousand of the 8 and a half million with the other plan s being the rest. Ultimately if you use the 1 3 policy, 1 3 of the difference gets applied in 2025 rating. Million, 753 thousand. And then the remaining 3 and a half million cascades to future rating. This is the Practical Application of the recommendation im putting forth today. And then for dental. Dantal im asking a different approach from you. Not staying within the policy. Why is that . Clearly a contingency reserve is prudent for medical. You can have high cost expenses, but that is because oen there medical plans, the member exposure is capped for out of pocket maximum. If you have a Million Dollar claim, that is paid mostly by the plan. However, for dental, the financial responsibility per member is capped on the plan itself. You have annual maximums, which on the active ppo plan is 2500 covered life and for orthodonic benefit you have lifetime maximum from 1500 to 2500 depending on the type of provider you use. If you think about from a practical standpoint, of all the items i listed earlier, what could potentially cause a huge spike up in dental experience . Because the plan exposure is capped, we dont necessarily see there is a high claim element to this. We dont necessarily question the credsability credibility of the experience. There is 30 thousand employees and 70 thousand total covered lives in the active ppo plan and we got a example a couple years ago, what happened during a catastrophic event, the covid19 pandemic. People used less service because they couldnt access their dentist. If we look at page 25, part of the review of this we are recommending for now again, amending one time the policy to set the contingency reserve at zero on the way to having the Governance Committee and Health Service board consider removing the dental selffunded active ppo plan from the contingency reserve policy. This will reduce essentially the change in contingency reserve by over 2 million, because from where it was approved earlier, and then that would allow it to also cascade into 2025 and beyond rating. So, with that, ill close with the last page on page 27. It is recommended that the Health Service board approve the recommendations below in these three components. The first is approve the modification of june 30, 2023 medical selffunding and flexfunded contingency reserve amounts from those originally approved the 99 percentile confidence interval amounts january 11, 2024 to the 95 percentile confidence interval amounts captured on page 19 of this presentation document which total 17 million, 992 thousand, 721 for the medical plans. Second, amend the Health Service board reserve policy 210 on one time basis for the june 30, 2023 selffunded dental active ppo plan contingency reserve amount to be set at zero and third, also for the dental, ask the Governance Committee of the hsb and full hsb during 2024 to consider the elimination of the selffunded active dental ppo plan from hsb contingency reserve policy 210. Thank you mike. That taxed my brain. Mine too. Yes, but we appreciate you throwing in some live examples for us to digest some of the information. Colleagues, do you have any questions or comments for mike . Im taxed as well. This is very complicated, but i think the fact you highlighted we never touched the contingency at 99 percent. If we had 95 percent, i assume thatwe wouldnt have [indiscernible] then you outlined what could happen, what catastrophic events that can happen that might lead to a needit seems pretty unusual on one hand. 95 percent still seems to be relatively Robust Reserve for the way i understand this quite frankly, so i appreciate your attempt to bring me to this point. [laughter] my compliments to you mike and abbie and the team. I understand a lot of pressure you must be under and being creative i think isand not only creative, but presenting in such a making complicated principals somewhat easy for me to understand, i really appreciate the effort, so thank you for that. Absolutely. Happy to make a motion if i may that we approve the three recommendations as presented on slide 27. I dont have to Read Everything verbatim. Second. You stunned us intothank you, been properly moved and seconded and take Public Comment. Public comment is open. [providing instructions for Public Comment, which are streamed on the screen] well begin with in person Public Comment. Good afternoon commissioners. Through the chair, have mike explain wlaut the difference will be with the dental plan go from selffunded to however it will befunded afterwards, please . Lets finish Public Comment and then well have you explain anything else. Remote Public Comment and the moderator will notify of callers in the queue at this time. Board secretary, there are zero callers on the phone line and zero callers entered the queue at this time. Thank you moderator. Thank you. Mike. So, the funding method on the active employee dental ppo plan does not change. It remains selffunded, selffunded today. It will be selffunded going forward. The rate reserve amount will change as a result of this just because the change in contingency reserve does bring more into the Rate Stabilization fund for the active dental ppo plan that it would be otherwise with the amount approved for the contingency reserve in january. So in other words, we are effectively the recommendation today is remove this Emergency Fund . Correct. Exactly. Remove this Emergency Fund from the active dental ppo plan and today on one time basis with the request, the committee and full board review later this year. On theso, nothing changes about the [indiscernible] the money is still there to pay outstanding claims. Nothing changes about the Rate Stabilization process for dental, other then there is now more available in the Rate Stabilization surplus for dental then there would be otherwise, and all we are doing is removing this Emergency Fund because there hasnt been historical precedent to need a Emergency Fund for dental plan. Medical plan, absolutely. Dantal plan, primarily because the plan exposure is capped by plan design mechanisms i dont see the need for a contingency reserve on the dental plan. Seems like a over abundance of caution . Correct. Okay. Any other questions before we take roll call vote . Roll call vote. Chair hao aye. Canning, aye. Dorsey, aye. Follansbee, aye. Zvanski, aye. The proposed modications are approved. Well take the next item and 10 well take a break after that. Item 10, to reitem 11 is review the selffunded and flexfunded health plan 2023 experience. This is discussion and presented by mike clarke with aon. Hello again. Mike clarke, aon, presenting on the selffunded flexfunded health plans 2023 experience and the plans that well cover listed on page 2, the starting with the hmo plans for blue shield of california and the correlating United Healthcare epo plans offered to non medicare split family lives and those plans. The health net canopy care flex funded hmo, non medicare ppo plan, blue shield is primary administrator [indiscernible] then finally, the dent al ppo plan. And then we got a couple appendix exhibits. In years past we coupled the Stabilization Fund rating because of the dependence today on the contingency reserve action on the stabilization we are doing all the experience today and do all of the stabilization actions in april and then going forward, well complete our experience reviews in april with the kaiser hmo plan so for active early retirees and medicare retirees and United Healthcare Medicare Advantage plan. In may, most or all the selffunded and flexfunded plan rates in contributions may 23, will seek approval for the kaiser 2025 rates and contribution active and early retirees and medicare plan retiree plans in june. Just to give you a flavor of what well talk through today. The good news generally a favorable experience year after pretty high 2022, especially for some of the plans. So, this experience will be a factor in the underwriting. I want to caution, these same percentages are not necessarily what you will see for rate changes because stabilization changes play into it and administratives fee, but if we look at plan experience for the blue shield hmo plans, 6. 9 percent, which is a little lower then what we sigh see in National Trends and favorable experience for the others. [indiscernible] 2. 2 percent increase and [indiscernible] non medicare ppo plan saw decree per employee cost and 2. 3 increase on the active dental ppo plan. Ill talk what drives these particular results, starting with the blue shield hmo and United Healthcare epo plans. As i say on page 6, the United Healthcare administration was new for 2023 so we are capturing that experience into the plan. I thought it would be helpful and you see on page 7 just to see the relative headcounts. Obviously most of the people we are talking about here are access plus and trio. They will continue to be. But, you have some individuals in those split family environments, most retirees, but a few actives who have one or more Family Member that is medicare enrolled in United Healthcare Medicare Advantage plan. Any time you see that with these United Healthcare plans, thats what we are talking about. The headline here and cfo hussain has been talking about this month in and out with Monthly Financial presentations is Prescription Drugs. Last year there was a large increase in medical and Prescription Drug for 2023. We saw moderation of the medical expense. A lot lower experience going over 1 million in large claim pooling and well look what that was in a bit. Overall after large claim reimbursement, relatively modest 5 percent on medical increase which is a lot lower then National Trends. Prescription drugs, even rebates continue to drive double digit percentage increases. If you look at the components of the plans and increase that added up to the 6. 9 percent overall on page 9, youll see that the Administration Costs went up and it was largely the large claim pooling fee increase that drove that. The physician capitation costs, so that fixed per member component of cost that are the physicians paid for services, only went up 3 pote 3. 4 percent. Blue shield doing a nice job of managing that spend. Again, medical claims actually went down because there was so much lower instance of folks going over a million, you will see a lot less paid in large claim pooling at the bottom of it page, but the alarming numbers are on the pharmacy side. Cfo hussain talked how pharmacy rebates are increasing, beyond expectations. They went up 19 percent. Thats the good news. The bad news, claims went up 18 percent. So, from a high claimant perspective, we still see the same types of diagnosis that are impacting members over 500 thousand and large claim pooling for blue shield kicks in at a million. Child birth, cancer, cardio vascular, these are things we talked about in prior years. But again, you had a lot less reimbursement of claims over a Million Dollars. It was all most 22 million in 2022. Last year, 3. 2 million. Another thing we look at on page 11 is what is happening with rates of chronic risk and chronic disease in the population is this from the blue shield data for acsess plus and trio. You see the lighter bar on the left side was two years ago, so 2021. The middle bar was 2022 and the most recent year or cy bar on the very right side of these exhibits is 2023. You can see there was a increase as people started to get back to care from 2021 to 2022 of identification and these numbers are individuals per thousand lives who have these conditions, but largely a leveling off of chronic risk prevalence and membership. I say with the exception of mus cural skeletal. This helped to create the environment where the medical claims increased only 5 percent overall. Another really positive statistic on page 12, starting with the fall of 2020 when folks were hesitant to use care for obvious reasons, but going through the next 36 months from there, a continual increase in members seeking screenings for breast cancer, colen cancer, prostate cancer. 8 and a half percent higher rate of preventative screening in the most recent 12 month period blue shield has reported on through september relative to the prior 12 months so good to see people getting back to those Preventive Services. And then Mental Health utilization. If you look in the total, you see dips in the top line growth, generally has maintained through the pandemic, but what youll see in the chart is there colors attributable to inperson care are taking over a little bit. We saw telehealth playing out starting in october 2021, which is very left of this and the right of this is september of 2023, so it covers a 24 month period, and in 2023, we actually saw more Mental Health utilization delivered in person relative to what we have seen in the past, but the good news is members really appreciate both modalities in person and telemedicine. Closing out this particular plan, the Prescription Drugs and you will see a common theme throughout the medical plans drove a lot of respond. All most half the spend especially medications, by relatively small percentage of the population and those drug classes here focus on antiinflammatory, dermatology, skin, antiviral medication. Going into the renewal cycle, discussion well have with blue shield there is a lot of focus on Prescription Drugs going fl to the 2025 renewal. Switching to canopy care. We dont have quite as much to talk about here. At least we have a year over year comparison. The plan introduced the start of 2022. 2023 was the close. We have seen substantial increases in the population in the plan. Started out maybe about a hundred, and now we are seeing over 500 actives in the plan and 52 early retires in december 2023. Overall plan expense just a modest 2. 2 percent growth on the per capita basis, but we did see higher medical fee for service claims. Most medical expense in this plan is capitation, so even hospital expenses, but a lot is Mental Health, which is a good thing. That means people in the plan are increasing their access to Mental Health and then pharmacy claims really went up for the plan, mostly by specialty and you will see that in the statistics on page 18 that add up to 2. 2 percent. Switch ing to the ppo plan, here you see again the population, how it distributes between blue shield administration or blue shield took over is the primary Plan Administrator after the rfp process for 2022. United retaining administration for those non medicare split retiree family lives, and where we primarily seen the growth of enrollment in this plan is you see looking at the next page is in the active employee segment. The retiree counts largely remained similar, but we saw about 150 more individuals in the plan in 2023 then 2022, and it was all most all from the active employee population. I do feel that is a factor in why the overall per employee expenses decreased in the plan. Some it could be how blue shield is managing the plan for majority of the folks enrolled here. High cost claimants, primarily cancer and muscle skeletal. Blue shield was able to administer is, what does chronic condition prevalence like in both population and i dont think there is a surprise that on the ppo side more members are generally paying higher contribution to be in the plan, especially for active population and then many ppo enrollees are the early retirees relative to other plans. We see a higher prevalence of chronic condition risk for the ppo plan data and [indiscernible] Prescription Drug costs went up 9. 6 percent, so lower then some of the other plans. Cancer, dermatology, antiinflammatory lead the way there. Finally dental, as cfo hussain has been reporting, modest increase in claim experience and the good news is, you see that 2. 3 percent on page 26, looking at page 27, there was a tick up in use of Preventive Service for dental with active employee ppo plan. Even though still about 1 and 3 covered lives dont have a dental cleanjug we are talking about strategies to get more people to the dentist, it was good to see overall preventive use did go up a little bit. Something else we talked a lot about is the smile away program. This is for members identified with one of i think 9 chronic conditions and we have been trying to get the plans to share secure data, more effective then the medical plans, but delta dental to have access to the elevated benefits, so more frequent paradontal claiming and things that nature. We found 18 percent increase in membership in smile away from 2022 to 23. No surprise on page 29. We saw higher use if you look at the overall distribution of services across Provider Network type, including the outer network and non contracted. More members using non contracted dentist with network struggles that delta had and in particular on page 30, how did the numbers play out by county and i will present exact same data for the retirees next month, so no worries about that. We talk about that in april. Here you can see especially santa clara county, marin county, Sonoma County and commission zvanski [indiscernible] have higher rates of non contracted dentist utilization so well continue to work with delta to address this. With that, i will close and take any questions. Thank you. Thank you for the very thorough and informative presentation. Colleagues any questions or comments for mr. Clarke . I think mike, you managed to stun us silent. [laughter] in all seriousness, thank you. This is very informative and help us understand why the rates are the way they are. Well open up for Public Comment. [providing instructions for Public Comment, which are displayed oen the screen] no one approached the podium and move to remote Public Comment and the moderator will notify of callers in the queue at this time. Board secretary, we have zero callers on the phone line and the queue. Thank you moderator. Hearing no further callers, Public Comment is now closed. Thank you. We will now take a 10 minute break. It is 2 27. We will see you back here at 2 37. [10 minute recess] [meeting reconvened] well reconvene and holly, would you please call the roll . Roll call vote starting with chair hao, present. Haning, present. Dorsey, present thank you, we have quorum. Item 12. Item 12, review and prove sutter legal settlement 2025 recommended rating bydown action per Health Service board policy 213 for the blue shield california hmo and uhc ex po and non medicare ppo plans. This is action item and presented by mike clarke. This is impetus of the design and creation of Health Service board 213 early last year for handling of legal settlements payed by there plan. There is lot of Background Information i will not go through again as we went over that. The first payment approved 2013 by the board. At the time it was indicated yes, majority of dollars received but there was expectation 2 million was yet to be paid and time to incorporate into the 2024 rating process and so, this is todays recommendation is to apply that amount for the 2025 plan year. So, as you see on the cover page, the plan this applies to based on the plans applicable at thtime to what created the settlement originally are blue shield access plus and trio plans with United Healthcare epo plan for non medicare splits and non medical ppo plan. Background information is here for reference. Im not going through that specifically today, but i do encourage anybody who wants reflesher on both the policy creation itself and what the policy says as well as the background on the actual settlement itself. Ill skip ahead to page 9. H is rks s being the amount received is 14. 8 million. 11. 8 million distributed to [indiscernible] the funds paid were slightly mer then the original remaining 2 million expectation. It was 2 million, 228 thousand 280 dollars to be precise received by hss july 5, 2023. Based on the distribution of individuals population weighting calculated by hss we are looking at 1 million, 916 thousand, 321 to be distributed within the hmo epo plan. On page 10, hss believes this will be the last of the payouts from this particular legal settlement, but if futher settlement dollars become available those would be handled in 2026 rating. So, on page 12, for the blue shield hmo and United Healthcare epo plans, how we are going to look to distribute those is similar how we do the distribution of dollars for the Rate Stabilization process for this plan. On page 13, a lot small print in this table given the distribution of individuals by tier active employees, early retirees and the split Family Members in the uhc epo plans, but ultimately all based oen the january 2024 headcounts we received from hss which you see in the next last row of the table on page 13 and allocating a total annualized amount of 1 million, 916 thousand, 321 produces the monthly legal settlement buy down amounts you see at the very bottom table of page 13 for these plans that will be part of the rate cards for these plans that will be presented for your approval in may. And then for non medicare ppo plan very similar process. Page 15 to distribute the 311 thousand 959 dollars. So, with that, go to close of the document on page 17 with the Health Service board legal settlement board policy recommended approval the use of dollars received by hss to date sense the end of the last plan year for use in the 2025 Health Plan Rating buy down. Specifically for the blue shield of california access plus trio hmo plan that include non medicare split family lives and [indiscernible] non medicare ppo plan administered by blue shield and United Healthcare. Thank you mike. Colleagues, any questions or i move we approve the recommendation in terms of buy down and rate cards as presented. Second. Moved and seconded and well take Public Comment. [providing instructions for Public Comment displayed on the screen] well begin with in person Public Comment and no one approached the podium and move to our remote Public Comment. Ill check to see if there are callers in the queue at this time. There are zero callers in the queue and raised hands. Public comment is closed. Thank you. Roll call vote, please. [roll call] this item has been unanimously approved. Thank you mike. Item 13, please. Item 13, review and approve vsp vision fully insured 2025 rates and contributions. Action item and presented by mike clarke with aon. Mike clarke, aon. This is my final benefit presentation today for the Vision Service plan fully insured 2025 rate contributions. I wont go through the preface for reference, but this is fully insured plan and it comprises following plans, the basic vision plan where the rates are embedded within the medical rate cards separate line item, premier vision plan, higher level of benefit members can play beyond the basic plan, Computer Vision care provides benefits to about 20 thousand employees and Employer Paid as well as the buy up contributions referenced earlier. What i like to do is skip ahead to page 9. There is a lot of information just for context, but in the interest of time, just provide background within a 5 year rate agreement period with vsp where year 4 was prescribed not exceed 2 percent overall rate increases based on the overall loss ratio of the plan. It just so happens that the full 2 percent wont apply. There will be increase to the premier plan only but not the other plans. If you look at page 10, what youll see is two of the plans Holding Steady in 2025 with rates relative to where they are today in 2024, so the basic plan rates remain the same as well as vision care rate of [indiscernible] premier plan increase by 2 percent, which means average the overall total premiums increase 1 percent. This is more favorable in renewal action for 2025 then outlined in the 5 year commitment for 2025. On page 11, what you see a continuing improvement of loss ratio. Total rates and claim exceed the premium for 20s 23 because all is more migration to premier and this was noted by chief operating officer in the december meeting on reporting plan election it great to see the premier plan continues to rise in poparity. There were a couple slides, 12 and 13 i wont go through but show the experience for each basic and premier plans and page 14, you see exactly what im talking about stating in 2018. It was 15 percent of total numbers elected. You rup to 35 percent, so terrific to see the value the membership places on having net premier plan choice. On page 15, basic plan which is part of the rate cards. No change there. Total premium for the premier plan up 2 percent and so what the member pays then to be in the premier plan is the increment, the difference between the basic plan rate and premier plan rate. Those member paid contributions increase approximately 3 percent across the tiers. From a aggrated spend standpoint, the premium dollars project 11 and a half million in 2025, roughly 5. 1 million will be paid by the employersmost of the basic plan costs covered in the rate cards, plus the vision care benefit and then the member plan cost is primarily in the form of the premier plan increment. That is a choice of the members. In closing, on page 18, the recommendation is that the Health Service board approve the 2025vsp vision plan insure premium rates and premier plan member contributions as outlined below. There is a exhibit of the plan design in the appendix there for reference as well. Vice president hao. Thank you mike. Colleagues, any questions . I move that we approve 2025 vsp vision plan Insurance Premium rates as presented. Second. Properly moved and seconded and take Public Comment, please. [instructions for Public Comment are streamed on the screen] no one approached the podium. Well move to remote Public Comment and ill check to see if the are callers in the queue at this time. There is zero callers in the queue. Public comment is closed. Thank you. Roll call vote, please. Hao, aye. Canning, aye. Dorsey, aye. Follansbee, aye. Zvanski, aye. The rates for vsp fully insured 2025 rates and contributions are approved unanimously. Thank you. Item 14 please. Item 14, reports and update from contracted health plan representatives. This is discussion item and can be presented by chair hao. Do we have any members of our plan representatives who would like to speak . Donts all come at once. Alright. Seeing none, we dont need Public Comment since there was no comment. We are now moving into the Governance Committee portion of this agenda, so would you please read item 15, please . 15, review and approve the 2023 annual selfevaluation report. This is action item andprinted by board secretary lopez. While holly is getting set up, this is annual exercise this board undertakes that we take the opportunity to reflect and evaluate our performance and service on this board and so holly will be presenting to everyone the results of our selfevaluation. Have a short presentation because the annual report was presented in your materials so there is details there. This will be the high level. The process and selfevaluation areas. The Governance Committee met in december to approve the timeline and the evaluation itself with questions. The annual survey conducted by the Board Members in december 2023. There were four areas of the evaluation, the governance structure and policies, board member interactions and Committee Meeting activities, goal setting and communications and the forth was the board interaction with management. There was hundred percent Completion Rate with 7 seated commissioners. There is a note in the 2022 evaluation there were 6 seated commissioners at the time, so the comparison is different. Not a one to one. These are the executive summary highlights. 32 questions total and decrease from last year as the Governance Committee reviewed questions no longer needed to be on the survey. 11 questions increased 20s, decreases and one remained the same and that 20 question rating decrease most likely has to do the 6 seated versus 7 seated. The data changed. These are 4 total areas. We can sit here for a minute or move on to recommendations. Any question or comments about this report . I know the scores have gone up and down in various areas but it seem weez are on the right track, but i do note there are a couple comments or some of Board Members did express concern and so that no one is surprised i think if there are concerns about how we are functioning as a board together that those be brought to the attention of our president , so that those can be addressed and we can correct them before anything elseanything larger occurs. Not suggesting anything catastrophic in the report but i did see a couple moments of for improvement. Reviewed all the comments as well and appreciate the Governance Committee thoroughness evaluating all this and holly your summary. I point out, no one criticized me for talking too much. Some sense that some of the commissioners were not speaking enough. I find that everyone has a ample opportunity to speak. I wasnt particularly alarmed by that. There was another concern raised that in terms adherence of commissioners to various policies and all that and having been board president at one point and involved in the process, we feel there is confidentiality around interaction between the president and other commissioners over potential violation of policy. Dont feel that is a area that should be widely disseminateed to this board unless there is a serious problem that is reoccurrent and at least from my term as board president that was not a issue, so i appreciate the comments, but also feel we need to operate within some respect for all the commissioners and participation at every level. Absolutely. Thank you. Any other comments . Thank you holly for your presentation and for your work in putting this together. Well take Public Comment. [providing instructions for Public Comment which is steaming on the screen] my name is fred sanchez, president s of protect our benefits. I like to commend this board particularly. They do their homework, obviously read their packet before they got here. I looked at other boards you see they are reading during the course of the meeting. That doesnt happen here. Everybody is super accessible from the secretary to the executive director. I cannot commend this board enough. If the rest of the city ran like this board, the city would probably have a huge surplus right now. Anyway, thank you very much for your time. Nice to hear. Well move to our remote Public Comment. Ill check to stee if there are callers in the queue at this time. There is zero callers in the queue. Public comment is closed. Thank you. Commissioner canning just failed to do the motion and second. We can have a motion now. [indiscernible] it is action item. [indiscernible] the report. May i make a motion that we approve the 2023 selfevaluation report of the Health Service board . Second. Roll call vote, please. Hao, aye. Canning, aye. Dorsey, aye. Follansbee, aye. Zvanski, aye. Thank you. We have a approved the 2023 selfevaluation for the board. And, item 16, please. Item 16, review and approve the 2023 board Education Report and board Education Plan for 2024. This is action item and will be presented by the board secretary holly lopez. Thank you. Board secretary, holly lopez. Today we are going to be looking at the result ozf the Education Survey report and Education Plan for 2024. So, this short amount of slides goes over the education experience offered in 2023. The top chart shows there were seven Education Opportunities presented at the full board that are also open to the public. The second section offers selfstudy education hours for each commissioner throughout the year selfreported. And then the bottom portion of the slide recognizes the commissioners city wide and required trainings, and that are noted throughout the year that are done on the commissioners own time. And from the board selfevaluation, topics were ist listed and asked to be ranked for topics in 2024 the first place was a tie between the Health Plan Integration systems conversation and a high cost high risk conditions education opportunity. The second place was request for data transparency topic to improve equity andhave a forum on the cmms drug policy and how it can effect the drug cost when implemented. These topics will decide throughout the year and when appropriate and given either by a internal subject expert or outside speaker. The bottom page portion of the page listed the resources will be public so anyone who wants to know the education presentations throughout the year and watch them again. The last slide is to approve the Education Report and Education Plan for 2024. Thank you holly. I think that when you summarize all the things we have learned collectively and on our own, wow, we [indiscernible] which is great. I think we should be about continuous learning, so thank you. Uhhuh. Colleagues, any questions or comments before . I move we approve the Health Service board Education Report and Education Plan for 2024. Second. Properly moved and seconded. Take Public Comment please. [providing instructions for Public Comment which is displayed on the screen] well begin with in person Public Comment and no one approached the podium so move to remote pub lblg Public Comment. Board secretary, we have zero callers on the phone line and zero callers entered the queue at this time. Thank you moderator. Public comment is now closed. Thank you. Roll call vote. Hao, aye. Canning, aye. Dorsey, aye. Follansbee, aye. Zvanski, aye. Thank you. The 2023 board Education Report and board Education Plan for 2024 has been approved. So, now well move to item 17 please. Item 17, vote on whether to hold closed session to review and approve the 2023 annual employee performance evaluation report. Would you also call item 19 at it same time . Item 19, vote to elect whether to disclose any orexcuse me. Sorry, wrong one. 21. 21 is vote whether to hold closed session for a member appeal. Both are action item and will be held in closed session. Colleagues we have two items in closed session, which our board secretary just read and so, we need a motion now to hold these two items in closed session. Madam chair, i move we hold the two listed items in closed session. Second. Properly moved and seconded and well take Public Comment. [providing instructions for Public Comment which are displayed on the screen] no one approached the podium so move to remote Public Comment. Our moderator will notify of callers in the queue at this time. Board secretary, there are zero callers on the phone line and the queue at this time. Public comment is now closed. Thank you. Well take a roll call vote. Hao, aye. Canning, aye. Dorsey, aye. Follansbee, aye. Zvanski, aye. Alright, well now convene in closed session and so all parties not party to these closed session matters, thank you, farewell or see you later. [laughter] [closed session]