Transcripts For SFGTV Health Commission 101816 20161031

The motion to send forward. I second that. And as amended . Yes, as amended. And so, movele amendments, and then move it as amended and then as a committee report, for the november, first 2016, board of supervisors meeting. Make the motion. And i will second that. And we will do that without objection. We are done. Mr. Evanthat all. No more items. Meeting adjourned. Thank you, everyone. Good afternoon the commission will please come to order and call the role. Pating, present. Loyce, present. Singer, present. Chow, present. San chez. Motion and is there a second . Okay motion and second the minutes are before you for approval, are there any corrections or additions . Yes i like yes, commissioner sanchez. Just dropped my notes, here. What page, commissioner . Sorry, it is last item on the agenda, page 6. Page 6, pertaining to the second paragraph which is fine, may not [inaudible] commission period. I also stated after that that director garcia has aurder already reviewed accepted and implemented staff and board protocoles and also said the Commission Rule is clearly defined in city charter section 4. 102. I would like to submit that for correction. Thank you. Okay, so thats a it was deleted out. Right. Its a addition back to the minutes. Without objection well add that as part the amendment. I wanted to also add under page 3 in the fourth paragraph regard thg waiver, i think we should define the waverit says mrs. Wagner says sometimes when a waver and discusses the wavers. Is it accurate to call that the medical waver or is there a section 8just add medical waver because you read it you dont know what waver we are talking about. Third paragraph . Fourth paragraph page 3 in regards to the cost structure and revenue projection about the waver. Thank you. That was my only addition if that was okay we would thenwith those additions if we are prepare today disicose those or proceed student the voted. Anyone else have additions . No, then we are ready for the vote. All in favor the minutes as we are have corrected aye. Opposed . The minute are approved. There is no Public Comment on that item and item 3 is directors report. Director garcia. Good afternoon commissioners. I want to thank those who addended 150 Year Anniversary celebration at laguna honda. That was a excellent day for us and had over 150 people for 150 Year Anniversary. Also many resident attended the ceremony and we had lots of activities going on around and also i think many of those individuals dr. Sanchez took us up on the free flu shots that day. Like to thank all you for that. Today we also celebrate the hundred Year Anniversary of board of supervisors chambers so attended that as wellism one area that i will highlight a couple items on the directors report and happy to answer questions but one of the areas trying to get to the 21 cinchry department of Human Service is looking at expedited engineer process and have a website now that highlights video clips of city tech workers to support the hiring campaign and they are also working on a newly developed Candidate Experience initiative focus updating the communication and interaction with candidates to make the hiring process easier to understand. They are working with us very closely and insureing we are able to hire in a more expedited manner particularly around the [inaudible] area. Also, just to let you know, we are very proud to announce [inaudible] architects received twnt 16 architecture award for Health Care Building project for zuckerberg general building 25 in building magazine so happy they received that award. I will leave it at that and if there are other questions on the directors report i am happy to try to answer any of them. Commissioners, questions on the report . Commissioner sanchez. The directors comments and i really want to say that the whole campus, the whole community at laguna haunder turned out for a inspiring and reaffirmation why we have laguna hondas. Volunteers to the cus toneians to pig and goats, cover the waterfront it was all there at lugina honda, the singing and tradition squz quality of staff and patients themselves so want to say well done and give a e for excellence because it was as good if not better than fleet week. I didnt mention [inaudible] for getting that done so thank you. Especially those able to attend were very appreciative of the hospitalality laguna displayed to the community and where ever i went when we were going through the tour the public with me were commenting on what a fine facility and the types of service and know several commissioners were there and appreciate it the same and hoping they had as uplifting experience we actually put together a very first class rehabilitation and lung term care facility. Thank you. Through the chair, i observedi also wanted to thank particularly the cal mens basketball team. It rfs unbelievable to see them on the first floor and were lined up to get into the elevators and some of them had tobound bends down because you forget how tall the kids are. 7 foot 1, 7 foot 2. It was a fantastic celebration and whole knhunty responding so go bears. We should get into the partisanship here. It was very nice of them to come too. It was also fun to see the resident getting portraits dunch done in the sketches. Anybody else like to make comments concerning the directors report or her items. . If not we proceed. Iletm 4 is general Public Comment and havent received request. Item 5 is report back fwraum the community and pub lic Health Committee from today. Good, thank you. The committee on community and Public Health heard two reports. The first report is on the fwlack African American Health Initiative by iona bennett who is newly aopponented director of interdivisional initiatives. This is a new division in the department of Public Health, which in the future will begin to span Public Health division and San Francisco Health Network as we try to integrate prevention and Community Impact initiatives across both our divisions. The report commissioner, it isnt a new division, it is a person that reports to me looking at that, but not a new division. We didnt create a new division for that. Wanted to correct that. Okay. We heard 6 areas that the bah he initiative is involved in. One is heart Health Initiative which is lower hypertension in African American knhunty. Behavioral health to screen alcohol misuse detection. Womens initiative to evaluate screen for Breast Cancer and increased screening for sex wale transmitted diseases particularly chlamydia. There is one on cultural humility and Workforce Development diversity hiring. We reviewed the initiatives in the most broadest form about how the divisional initiatives will be coming together and combining both the San Francisco Health Network and Public Health division and what i like to report out of this is that, we are making a difference in black African American health. For hypertension, we closed the disparity gap for African Americans in the Health Network. We have 62 percent of African Americans in hypertension control compared to the 65 percent of non African Americans in control and this is a naroge of the gap from African American helths is 57 percent controlled and raise today 62 percent and only 3 percent behind our general population. We are still slightly lower than the National Average but catching up and by this year hope to reach a goal of 70 percent overall hypertension control throughout the city, which is just slightly behind the National Benchmark of 72 percent. So, this is a very positive sign that within our network that we are closing disparities gap for hypertension which is a major Health Initiative in the African American community. Two areas showing some early improvements with closing the gap are also in chlamydia screening. Chlamydia is a sex wale transmitted disease and for our youth we are actually already increasing screening in the African American community greater than 80 percent of all those identified as potentially at risk. In our Primary Care Clinics the numbers is not quite that high but making early progress as well. Lastly, with regards to Breast Cancer screening, in 2014 we started the year at 60. 5 percent of African American Breast Cancer screening versus 71 percent for non African American population but already at 64 percent and this still trails behind non African American community we moved up 4 points and starting to bend the curves in turnls of closing disparities. I think these are wonderful examples how the department is mubing on a population and prevention effort as well as improving care within the specific clinics with high disparities. They are very very optimistic numbers. These are early numbers and expect it to further improve and we gave dr. Bennett and her team accolade for the good work they are doing. Second report that we heard is really update of proposition c. Proposition c was passed i think in 2014. This was a proposition which continued funding for the department of youth and families. But 135 million have been awarded to department of children, youth and families, of which the Health Department is part of the collective impact or the departments that have not received the funding but participate in the Services Related to the termination of the funding. We just heard that the initial appraisal of proposition c the team pulled together a joint committee of Department Heads that have been working on a framework to identify 5 areas for improvement in health and children youth and family services. The first is the help kids live in safe and nurtureing environments. The second, attain Economic Security and housing stability. The third, make sure that children are physically emotionally and mentally healthy. The fourth is, they thrive in a 21est century learning environment and they succeed in post secondary education and on career paths. This is a tall ord er. The helths department is collaborated with Mayors Office and School District and many others in the community to develop a 5 year plan. The 5 year plan on a preliminary stage the agreement include the following agreements to share data across our system on children, youth and families between school and health system. The Health Department will have training and capacity building. Perhaps trainings regarding cultural and huh humility. There is a attempt to the need for better coordinating services. So again, this is prop c passed last year reauthorized taxes to go to child youth and family services. 135 135 millions. Thee are new not dollars, they are continuation and the department is working on a plan with other departments in the city to better improve our children, youth and family services. Thats the report that we heard. Ill take questions if there are any. Commissioners, questions regarding the two important reports . Yf had one on the childrens report. Im trying toi remember when the original children funds were put together and a series of different types of programs they had, so it sounds like this one they are creating a 5 year plan, but it looks like two years are being spents creating a plan for two years of a plan . I will ask the director or mrs. Chala this is a new initiative and it is a commission, so the departmenti have a seat on the commission, so it is utilizing the new dollars coming in so it is a new level of initiative that goes across. It isnt just dcyf it is city wide ability to look at collective impact model to Work Together to insure the children get healthier and receive education. It is new mission and process going on. Will the plan that is created be for 5 years or it is within the 5 year we create a plan, the plan sh for 2 years . The plan is for 5 years and we are aurlds initiating many the initiatives now. The way it was written it sounded likei was looking at the timeline. It looked like we had two years of a three year planning process. Okay. And so in those programs well continue to get updates. I thought it would be important to know that activity going on and can come on a annual basisi think a annual basis is the best. Next time maybe bring some of the other partners. That would be nice. You can get a sense what we are doing. I dont understand the new process because in the past we had a series of joint commissions meeting. They brought three our four commissions together so this seems to be acordinated and thoughtful rft and think it would be good for a presentation before the full commission. We will do that. Commissioner singer. Thank you for the report. Director garcia i have a question for you that continues discussion you and i have been having a great example of it. I want to ask the question carefully so it isnt misunderstood. If you look at the Health Disparities work that was presented and you look at the differences lets say in hypertension which is a difference 57 to 61 percent, which is 8 percent or so difference, probably a little less, not great, but when you compare it to the difference in the rates of chlamydia or alcoholism, which are all most one is order of magnitude and one is 5 x and Breast Cancer, which is a huge difference, but not that many people, if you will. And so, how do you at the Department Level think we have all these issues and some are not as bad as others. How do we move resources around in a rational way so that the community is getting the most help we can deliver possible and we are not trying to improve something by small bit like hypertension which is not something you want to have and improve it, but spending resources somewhere else where you may not have 10 x difference or may have 10 x difference . How do you think within managing the Department Resources how to shift things around and not looking backwards . It is a multiprong approach because before we decide today look at Community Based organizations and School District and all the other departments we wanted to look internally in our own system to make surebecause then we learn how we do that. An example would be our Primary Care Clinics and focuses with the Primary Care Clinic how well they look at the African American community and insureing they get the best care possible. You see they are under knowing all our folks know African Americans have a higher issue regarding hypertension but not geneing adequately. We are learning as we do this but there will be a time in order to move that dial we may have to put more resources from someplace else or change what we are doing in other areas. Another way we can look at the Community Base side isand we do this periodically every 5 to 10 years, is refocus the outcomes of requests from of the providers we brokeing. One is before we start preach toog the community with school dist rth or sutter or [inaudible] we are trying to get our house in order to make sure we know how to do that and share the best practices because we are responsible for the entire health of the city and then we also have the ability to refocus our rfps in areas as a example of chaum, alcohol, where we have lost the Alcohol Services in the city so how do we ree look at that and how do we insure our African American based organizations in the area of service are focused on that . They will do what we pay them to do and it is a matter of multiprong approach. Not sure if bennett would like to address this since she sh working on that but those are conversations we are having as well. To use your words, get our own house in order first, if you think where you tried to do that, what are some the places you are satisfied we have done that and what are some of the places we feel we have more work . The primary care centers for sure and within our system because that is the majority of some of the work is done. If youas a example, quaknow i know doctor bennett had to sit down with the providers about chlamydia. It is smaller population the disparity doesnt mean it is smaller number it is still high that we should focus on that, so somethat is why doctor bennett reports to me so has the authority to have those type of conversations with many of the areas of focus with us and doctor bennett you want to come up and give more . And then at the plan would be how well we do that and best practices we can share with other groups with High Percentage of African Americans but the nest area of focus after primary care will be Mental Health and substbs abuse to address alcohol and work with std programs, but we do a lot of std work within our primary care centers so have to get people to focus. I think that question is a classic balance in medicine and Public Health. There are things that cause misery that are wide spread and there are things that are very small, but are deadly. You are always trying to balance the severity of the problem, the number of people impacted and hypertension and the death related to it is such a massive number of people in comparison to any of the other things we do and it is i would say a small relatively small difference, but it is a large difference in health. Spending the next 10 years with controlled hypertonegz versus uncontrolled hypertension has a big impact on the life course of that person. Chlamydia does too but a different impact so have a huge disparity we need to target but has a different impact but that why they both ended up there. There are people who would have said take a slice off the top that are most deadly and we did doont that. We included things where we had large disparities to work on even though they were not the 4 top causes of death and included things that were big causes of death so it was a balance where the greatest harm to the population and where the greatest deficiencies were in our work. Where are we missing the mark and have the most impact. Thank you. When we reviewed on the committee, all the measures were heated measures as well so they are all impact in terms of hyper, tension control, chlamydia, Breast Cancer and alcohol. There is dollars and National Effort around all of them. I feel comfortable those represent diseases with larger systemic and health impacts. The pornts part and role dr. Ben nett will pay is urwurk wg delivery sishm and prevention area uzto leverage and practice between Public Health and Delivery System and strent on both sides and for this particular population i think that is important. Eightyone of the storeies that is missing in the population heth report is the effort of dr. Ben lt and primary clinics have done to make this happen. This is not just a population of no name clinicians treating people with risks recollect it really is with the team based aproferp in the clinic it is a ma, a doctor, a pharmacist and nurse who know who is out there and not knhing coming in and having problems to get them in and get their Blood Pressure controlled. There is a lot of actually medical home care. These are evidence that the medical home is working in those clinics and have a [inaudible] African Americans. If you look one level below there is another level of comp tense we are missing if we only look at the disparity but changing the disparity is significant. We have looked at parallel friend for decades and within a short time dr. Bennett and director garcia made important changes and able to show the numbers here. It is reflection of the commitment oaf staff and focus on particular areas and everybody being focused on that and can see the difference it makes. I think i cant say enough about our primary care system responding to this challenge and i think they have done a incredible job. Also own the Public Health side too, when woo we do our initiative we have to focus in the same direction to take advantage of the campaign and education and Health Promotion as well because people will want to come into the primary care home and if they dont come we cant manage their hypertension so that is reason why we have Wellness Centers to reconnect people back to homes. Would it be fair to ask dr. Bennett to describe a little of her function because this is new trying to bridge our two major departments, right . I have been in this position 6 mupths, it is newly created and my title is long with lots of syllables but says whault i do, director of interdivisional initiatives so hopefully will be able to achieve is wrun, look at the projects we already have and hope to facilitate how the Population Health education and data and epidemiology is feeding what we decide to dine the clinics and how the problem is noted in the clinics feeds what we do around education and epidemiology so make thg things we already do bet squr other is seeding new projects and trying to find people doing similar thing jz connect them and i hope what happens is that there is a little cultural transfer between the two that the big drivers on the clinical side are actually known to the population helths side and makes it easier to work with the clinics, but also gives them some of the Quality Control rigor numbers that happen on the results based medical side but also the hol istic Community Wide education disparities and equity focus that come in population helths inform on the clinical side and meld the best sides because they are two very different cultures. One the examples that well work on is we have two specialty clinics in the Population Health side. [inaudible] yet, because they are not part of the network umbrella, they dont have the same medical records ability that the other sides do. It is very distinct in terms how they are managed from a quality. I do believe and these are just structural thijs things we have done over the last several decades but tb and std deserves the structural supervision the network with provide for them yet keep a population focus through the direction and leadership of the Population Health side under dr. Aragon so we have hybrid in this. Different items coming in and i think iona has jumped to every of the areas. One of the other things working on is new gen clinic closure so there are special projects she has done great leadership and more to come as we try to delve into this. Welcome aboard. I think this is evolution to try to bring together our Population Health and clin cg service. Thank you and well look forward hearing from you again. Any other questions . Any Public Comment . No Public Comment for that item. If not we proceed to the next. Item 6 is hemth care accountability ordinance. Commissioners, two things, one doctor chow asked questions and responses are in your pile of paper on the right and also you will be voting on the item at november 1 meeting. Today is just discussion. Thank you for your time. Patrick chang. Senior planning at dph and want to share with you the recommendations that the work group came to at the last review session. They are here and want to thank them for their commitment and hard work and they are very seasoned around this and very devoteed to their constituents and so they were instrument lt to the process and hope i represent the hard work properly. I want to share a few bits of the process we went through and the recommendations that came out of the work group to vote at the next meeting. So, just a quick refesher of the Health Care Accountability ordinance came out of board of supervisors 15 years ago and requires employers who are those who have city contractwise the city and countsy or leasing city and county space for their business and covered employers must provide compliant health plan that meets all 16 of the minimum standard or pay inlieu fee. To answer your question commissioner chow, hast last year there were 26 vendors who paid a combination of 1. 3 million in fee and also the settlement dollars. The fees for fiscal year 1617 is increasing 4. 65 and tie today the hmo premiums for the state. And also can you go over that again . Sure. What was the income for the program or are these just the penalties . The 1. 34 million is amount of the 26 vendors that had to comply with the ord nnls paid into the system oreth in the form of the monthy fee to cover their compliance or settlements to pay for violations for not complying. So, how many people does this impact . That is a great question. Unfochinately we dont have a concrete number because there is no place where all the contracts are held because the ports will keep their contracts in one place, sf keep their contract in another place and so we dont have the methodology to compile the numbers and so we dont have that , but some estimates put us about 100 thousand covering including Community Organizations as well. Significant chunk of San Francisco employees benefit from this ordinance. Thats the total number under the hcao, but i heard and still wondering how manyyou are saying you dont know how many people were uninsured and they paid into this fund, right . Which is what they are suppose today do if they did buy inshurns. They pay to sf general . Those are 26 vendors but dont know how many people no, we dont. Thank you for clarifying. We dont have know how many employees are under the 26 employers. You probably dont know this but how many employ oars and employees just coverthe aca does not impact because of employer size . That is great question and i dont know that right now, but i will do come back the think im trying to get at is the issue of stacking on top of employer requirements. Right. I think what im hearing is our we overlapping and maybe duplicateing some of the requirements and in the last few sessions the standards were lied up with the child benefits so that cleaned up a lot of duplication that may have happened once aca went into full implementation and sobut in terms of the number of employees that may not have been covered otherwise, i think that will take some more numbers for us to look at to see how many employees would not qualify for subsidies or will not qualify for medical and so would require some form of coverage and how many that overlap with this population. I think that is something that ill go back and look at more clously. To me those are important questions because given that we learned how the aca will function, the idea of how much to rely on someone else doing all the hard work to respond our money onyou just heard it disparities before so think long enough in the tooth and aca with this acho to take a look at that so that would be interesting to see. I agree. I think that something that came out in the work groups is a lot of thewhault we want to make sure San Francisco continues to set the bar in terms of the benefits are residents and employees have access to and so what is the floor in terms of what workers will be entitled to if they are working for a San Francisco employer and make sure they protect that type of coverage so people are not getting signed up to minimum Compliance Plan according to the aca but have to deal with high out of pocket cost eeben for a bronze or catastrophic plan so how we make sure we protect the proith right for people to have comprehensive robust coverage especially working in San Francisco. How to continue to stay in a pioneering role moving forward. I dont think the a ca does that chblth i think there is a lot of benefits to it. What we have found in the work group is that because helths care costs are increasing for all player s across the industry and nation, there is many feel that the benefits are being less affordable to how to find had balance to provide affordable overage coverage and also protect thg price point for the consumer especially for a lot of low income workers i think we should continue the presentation. I am sorry i interrupted. You were commenting on my question, so i apologize hch i think we should get the rest of the presentation because this is a complicated topic and get into questions again. Okay. Thank you, sir. So, our stakeholder process we had 16 organizations represented and it was a mix of for profit non praulft, labor advocates, brokers health plan representative and city agencies involved in administration and enforcement and had three meetings beginning Early September through early october and weout of that meeting came we were able to come to full consensus on the recommendations in three meetings and so some the things that weep spent lot of time on were, provide a glossary of the items. Fortunately with Health Reform and the values of helths plans it made this process what was typically exceedingly complicated to just very very complicated this time. There is a less variability in plan make up and design because of the [inaudible] that was something that came up a lot in our discussions around out of pocket maximum, detucktable and coinsurance and copayments, these were the known standards that got the most attention as in past years because they do impact the affordsability for employers and employees. Hra and hsa continue to be a very prominent factor in our discussions and the work group really came up with very creative ways to leverage them even more for the next two years. Well get to those in a little bit. These are current minimum standard and priorities wruns the work group wanted to discuss especially because thee have the most impact on affordability. In spite ofbecause of the cost calculators health plans use silver plans take on 70 percent of cost and so if we were to lower one of these areas it will bulge out somewhere else. It like squeezing a water balloon. If you squize the water bulges in another place so striking the balance to make sure it is affordable while making sure it is robust coverage for employees. The current standards have employers paying the full premium. Hra and had s allowed. [inaudible] medical detucktables are 1500 and so on and so on. The recommendations that the work group came up with, the contribution this is pretty central tofor affordability for employeremployees and something in place since inception of the ordinance and work group came to consensus to maintain the current standard for the next revision. The first recommendation for change was to increase the current out of pocket maximum sealing of 650 to [inaudible] which is also the 2016 aca sealing for out of pockets. Look agthat plans on the market place smaum group plans, for bronze silver and gold all the out of pocket maximums approach this number for next quarter. The work group came to consensus that this amount would offer enough voret for employ ers to choose from silver and gold plans and also protect consumers from next year increase and what will be increase in 2018. We felt good about this balance and this recommendation. The next recommendation for change was on the deductible. This was very highly discussed item and the current deductible is 1500. This is decrease from 2012 and so the recommendations that the work group came to consensus on is increase back up to 2 thousand. This would allow for widest range of plans for employers but also require employers cover the full deductible and may do so with employer funded hra or hsa. This was a very hot button topic in that what is observed since the detucktable introduced to minimum standards in 2010 is a lot of employers in the work group and research has said detectable will discourage people from seeking care and using their Health Benefits in spite of Preventive Care service standardized at now charge. There is still a lot of education around what elths covererage is and inshurn is what aca gives people so that is why acknowledged. While that is happening in order to make sure we remove the barrier especially for lot of low income workers that wrurk on our city contracts we want to make sure the cost barrier isnt in their way and will not preclude them seeking care. The work group came to full consensus on a recommendation for this. Increasing the deductible to 2 thousand but the employer would fully provide first dollar covererage through a hra or hsa so allows employers to decide what is a allowable expense and any used dollars or staff that doesnt use coverage the dollars are not expenditures for them. Employers can just [inaudible] those cost. The next recommendation is decrease the prescription dedectable to 200 from current 300 andcurrently this year california planidated all health plans would cap prescription copayments at 250 per prescription per month. In response the vast majority of plans on the marblth place if they had a deductible set the detuckts at 250 and so the work group came to consensus to line up with that amount for the annual amount. The next two recommendation are package deal for the most part because employers will be paying for the full dedectuble to 2 thousand, there was full consensus increasing the coinsurance to 30 percent and increasing copayment to 45 is reasonable and will allow employers to choose from the most plans. Once employers have covered the first 2 thousand say for a staff, that coinsurance will kick and staff member pays 30 percent the cost and health plan will cover the rest. The 30 copay is sweet spot for a long time. It was a standard for 4 years or so, but silver plans and hand full of kaiser plans and hmo plans increase copays to 40 so in line with what is in the market place. The work group was comfortable with increasing that since the first dollar coverage is covered by the employer. So, the last recommendation involves adding just a little clarifying language to remaining standards specifically 9 and 10 to add language to clarify that those Preventive Service and preand post natal are covered no charge and specified and standardized by aca and preclude unclarity people may have with their base benefits for any health plan so they wont avoid getting preventive screenings and seeing their primary care for those reasons. Minimum standards 8 and 1116 we got feedback to add language to clarify the cost sharing is consistent with the proceeding minimum standards and also standardized by aca rules and that is more on the employers side just to clarify how do the Health Benefits work and what does it mean for coverage. It was clarifying language to make sure that we can be as clear as we can right away and poor beverly gets a lot of email and phone calls about that as well. In unconclusion 30 percent of platinum and gold plajs are complinets and gets to affordable tension on the employer side so with the minimum standards that we recommend for updating, it would increase to 52 percent of all plans and that includes a good amount of silver plans become available and still pretty much all gold and platinum plans become available. Bronze plans are pretty much worked out of the consideration and so we feel good about the level of benefits that workers would be getting and also maker sure employers have a good range of plans to choose from. At this time happy to take questions or comments or foodfeed feedback. Before we do that we have two public speakers so will call them first. Debbie [inaudible] and speakers have 3 minutes on the timer when the buzzer goes off please know your time is up. That is follows by ema [inaudible] good afternoon. Did you say 3 minutes or 2 3. Debbie [inaudible] with San Francisco Human Servicess network. We are association of about 80 San Francisco health and Human Service nonprofits most och the member organizations have contractwise the city and conte of San Francisco and provide benefits under the hcao. I had the opportunity to serve in the Stakeholders Group since the very first group which i believe was in 2004. Nonprofits have very specific goals that we like to see come out of this process. First of all, we feel it is important there is accessibility to a broad range of plans and not limited to just 30 percent the plans that are on the market. We have the availability to shope shop and flexibility to taylor plans that work for our workforce and hand in hand with that, that our plans need to be affordable. Particularly in the Nonprofit Sector. We can not raise our praiss or put a little [inaudible] on the menus. Whatever the cost is we have to come up with the money to pay it and city and county doesnt cover all the cost and have to provide the same plans to all employees not working on the city contracts, so those there factors we think about. Also as nonprofits we do think about our workers. We need to compete. It is hard to get good workers these days because of the high cost of living here, recruitment and retention are very challenging so we want to have plans that are good for workers and want the workers to be able to see the doctor and want clients in low income Employment Opportunity to Access Health care. Those are all the considerations we have been through the process and want to say we believe those proposed standards meet those goals. Keep in mind these are minimum standards and it is common in our sector for employers to offer multimal plans. You offer a plan that meets the minimum standard where the employers pays one00 percent of the premium. Some employers also offer Higher Quality plans where the employees may pay a little bit but they can purchase something that is more akin to what they need. Maybe a lower premium and add dependents. These are minimum standsards and think this is something the member organizations can live with for the next fwo years and that it meets our goal squz increases the choice of plans that are available, which allows lower premiums which helps pay for the cost of the deductible to make sure our workers can afford to have those plans and access care. Just want to thank everybody for participating ibthe process and work wg us. Thank you very much. Our next speaker, please. Good afternoon. My name is ema gerold from [inaudible] 1021. A field supervisor in San Francisco and also over our nonprofit workers many who work under employers with city contracts, about a thousand workers. I have been part the work group, this is my third time. We also had other organizations there as well such as the labor counsel, local 2, 2 airport union, Living Wage Coalition and [inaudible] who also have workers that fall under this ordinance. Organized labor our gome is reduce deductible. This is biggest barrier for workers to Access Health care especially many workers are low wage workers in Nonprofit Sector so they dont have the cash flow to go to the doctor so having the option of hsa or hra the employ rb pays the 100 removed the barrier so that is our goal and excited we came to this agreement and think it is fair and think it is also fair for the employers if they have more choice and we urge you to recommend recommendation that the work group came up with. Thank you. Thank you. Commissioners, questions to our presenter orwe will have this item for vote at our next meeting, so Public Comment may come in prior to that vote. We are prepared for questions . Anymore questions at this points or is it very clear to everybody where we are going . Commissioner singer. Clarification and question. So, on the clarification, so a visit to your primary care position for physician for annual check up or vack seens there is no copay . Presentive is no copay. When would a primary care copay kick in . Say you break your arm and you need a referralit is hmo you go through your pcp andyou have tosee your pcp and refers you to a specialist or if you need a scan or something then you have to pay the copay for that. Did you guys think at all about with regard to medicine going to no dedectable or no copay for chronic meds the way some studies show . Yes, unfrch notly the plans we saw the way they were structured that wasnt a option. There were not enough plans that had the cost structure. That immediately push them to the upper tear of the gold plans and platinum plans. For minimum standard it wasnt available . Yeah, the affordable part would have been tough for employers. This is such a nuance byzantine area. It is hard to understand the impact on this. In terms of people. How many people, how will it change behavior and what we noticed in the past that would lead one to conclude that these reasonable things to do because behavior will be driven by this. I dont know how that came into your discussions we didnt have those numbers to pull from in terms of creating just backdrop to see what is the quantifyed impacts. I think what we heard consistently at least going through the minute and the reports and listening to steak holder stories over the last 10 years is that anecdoteally at least they notice the quality of employees increased, improved staff retention recruitment opportunity. It has really improved a lot of just work culture and expectations in terms of that way and some of that is probably not quantifyable in that way. The employers that have shared their point of view say that the [inaudible] has been a real boom for them in terms of the quality of their staff and can you quantify that . Maybe, but that is a great question. In terms how many people have been impacted, that is something ill do my best to research before the next meeting. We do this every two years, is that right . Yes, sir. The i think that is good to put energy to know because here is a concern just in listening to how this unfolded that i think is wurkt thinking aboutyou said the people who came and talked to us and thispublic policy can be an area where the squeaky wheel gets the grease and think it is very dangerous to assume and generalize from that. It may well be true, but i think that we owe it to everyone to really understand. Okay, we change this part of the deductible, what changed in peoples behavior as a result of that . We did this, what changed . Did they use less or more or what happened that we didnt expect because we can make policy decisions based on data of behavior of lrjer groups and not make decisions on who is on a committee or took the time to thoughtfully write you. Not that those are not legitimate pointf view but if you did that 10 years in a row you can end up in a place when you look at the data you said like, huhal that makes sense. It sound like we may work with the health plan and Health Network to get data. I agree that is something that we need to start probably putting a closer lens to to see what has been the impact over the last 15 years. If there is one lesson everyone agrees on about the aca is law of unintented consequences probably dominateed. J thank you. Thank you. Yes, commissioner pating. Thank you for the wonderful report. I support the intent of the hcao, but with that said, i might take a different track but the same track as you commissioner singer. My experience no two health planerize the same. Your health plan is your health plan and no one else has the same benefits anywhereyou think they would but not been my experience. Everyone is veryue sneak with their employer and situation. Also Understanding Health plans is like understanding how laws are made, the devil is in the details and the point you are making. I want to ask in the future with convenchlg on plans and benefits we see under the aca the possibility of simifying this and rewriting the hcao and saying align with the silver plan and looking more alike than not and federal government and the state is really done a lot of this can covered california rather than getting to try to do the mince meat of figuring out what the perfect pie should look like. We are buying good pies now off the silver level pies off the shelf and rewrite saying we mandate silver plans across as the minimum benefit for a contractor. Is there a possibility mubing towards that in the next couple of years . That is a great question and something that came up a lot this time around and even the last review session, where many members would brought up the benefits of indexing some of these minimum standards like out of pocket maximum and deduct limits. Should we link to the irs or aca limit. There was a lot of arguments it would simplify a lot of things and automate the updates. Allot of disagreement is because it is stillit is a very volatile political environment and a lot discomfort around what if we index this and whatever president ial administration win squz what congress looks like there is a lot of volatility around the political environment around the aca and around the general haasetility toward Health Reform. What would that look like and would that endanger some of the protections that the work group wanted to preserve. This time around the work group decided not to index any of these stand ards to a existing benchmark so that is something we may revisit. Probably likely revisit the next time we review the standards. Would that require legislation to do that indexing or do that within the confines of whatever the existing statute . Some of the enableling language in the ordinance may need to be updated for that purpose. Thank you very much. Could i ask you just walk me through about the medical dedectable and also the copayment on how we are goinga individual goes to a doctor and he is under his medical dedectable still of what you are recommending 2 thousand but this works at the current, 1500. The Employer Paid into hra rks does he get his cost back from the hra pool . So,debbie is much more versed in i just want the one individual answer. I have deductible and paid a hundred, now what do i do . What happens is the employer gets a card and doesnt to fully prefund it but any cost the employer entailed they pay off the card. They pay the doctor, the doctor gets the card and bills the hra . Basically that is how it works. At the end of the year if the money is not all used then it can revert to the employer. If it is hsa the employer and employee can put money in and it stays in the pool. Okay, one more question and it sounds like mrs. Chang prapsh you can answer this. Now i fulfilled my dedectable and now we go to the doctor and i have a 100 bill. Do i now pay my part the copay, which is 30 or 45 or get coinsurance from hra or hsa . Once the employer money is spent if you have a catastrophic need that exceed 2 thousand then you will start to be responsible for there cost up to that 6850 maximum or less dependent on your plan. Now responsible for the copays . Above that amount you are responsible for the copay for the appointment and responsible for 30 percent of the coinsurance if that is what youmay be lab cost or hospital cost or things like that. It is generally if you have a catastrophic need and most will not reach that amount inly particular year. The committees feeling is the plans have the 45 and what you do is expand into the plans but they have the higher copay. That is going to be a cost to the eployee and that is acceptable to you all . Yeah. The money the employer puts in is first dollar so the employer money is spent first and only those employees who have a more catastrophic need in a particular year would start to incur higher costs. So you wouldnt get to to that you dont think . We have a year or two in our life where something bad happens and have to come up with money to figure how to pay for it, but the trade off is we are not overinsureing people. If you buy plans that cover the catastrophic needs for everybody when most will not use that then you are over insureing. It is a trade off, a balance. Right. So, if i get this clear, up to my deductible i actually dont have to worry about this part. I am not paying 100 for the doctor but after the dedectable and satisfied and need to pay 45 for the visit . That is my understanding. What that is how the broker described it. Thank you. For preventative needs there is no copay. I understand that. Thank you. Any other questions to mr. Chang . If not, im sure he will be here to squr answer questions you have at the next hareing on this. Thank you for your time, commissioners. Thank you very much. Item 7 is dph 4th quarter revenue report. Mr. Wagner. Good afternoon commissioners. Greg wagner chief financial officer. We want to thank you for your presentation at the last planning meeting. Youre welcome. So, i am presenting today our 4th quarter Financial Report. We are in the process of going through the yearened close and some of this may still be revised prior to the end of the year, but this definitely gives you a sense of the picture of where we are. So, as you can see on the Financial Statement we project to end the year with net 103. 3 million sur plus. This is big difference from the Third Quarter Financial Statement and there are a couple of things going on. Total difference is 46. 3 million, of that about 35. 9 million is a number of balanced close out and changes we made. We talked about these in prior Budget Planning sessions, but as you know we have worked with the controllers and Mayors Office toward an agreement that is the extent we are able to close out dollars from within our budget that are one time in nature we can reappropriate those in the budget for one time uses such as our ehr project and Capital Projects so we have done that. Those 35. 9 are assumed in the adopted budged budget so that is good for us. There is 10. 4 million, which is kind of true change in the underlying Operational Performance on the financial since the Third Quarter. Also, well talk about this a little more in the presentation but the bottom line figure assumes deposit of 12. 4 million into our reserve that we established a couple years ago under the annual appropriation ordinance that allows us to put money away to protect against uncertain revenues in future years so we have a bit of a cushion for known risks in our financials year to year. So, again just summary table of where things stand by division and ill go through major variances by Division Within the department. San francisco general you see here as yoi have in past statements a lot moving around in terms of variances, but the bottom line is 5. 7 million sur plus. Part the reason things are moving around is the financing has changed for a lot of safetynet programs over the last several years as we have gone through the aca and this year change in the 1115 waver. As we have gone into the new waver, most of the those programs are funded by intergovernmental transfers so the city puts up intergovernmental transfer and igt, the dollars are matched and comes back and how we receive our payment. As we changed transitioned into the new waver, the structure of how those igts work changed quite a bit. In some cases we put up less money and getting more back or vice versa and so you have a lot of changes in our waver revenues that are offset by other changes in the amount of igt we have to put up so you see a lot of movement in the numbers but a lot of data is tied to non subsstantative underlying things driving the variances. Net patient revenues we have continued to see strength in the net patient revenues. As you will recall from previous reports, we had strengthened our commercial revenue and been able to sustain our fee for Service Revenues in large part boss because of the Eligibility Program which allowed us to draw additional fee for Service Revenues we thought we would phase out. Another big piece the nelt patient revenue alt sfgh is simply that we had a reconciliation of accounts receivable so outstanding accounts and how much income we need to claim. We still see a lot of mub mentd move nlt movement in that as we see change in the payer status on aca as more people are on medical and medical expansion. The amont of income we receive from our outstanding bims is moving quited quite a bit so had a true up in the 30 quarter that was net increase over 20 million. On our waver programs, i got a little summary of what is mubling on the next slide and there is also a table in the Financial Report that you can look at, but this is just a flush out what is mubing in our payments under the waver and how that relates to the saichbings and igt. You see in this table how things are moving, so for example, if you look at the third line down current year gpp variance, that is a new program under the new waver that used to be dish and safetynet care pool. We are receiving 14 14 million less gross receive new but have to put up 29 million less than we do in igt. It shows as a revenue short fall but that is actually a net positive to our bottom line. I dont want to belabor this because i know this is munesia but larger point is, there is a lot of movement in the numbers driving those variances but a lot is due to transition between wavers and we should be able to shake that out in the new budget years and get everything trued uch to the new waver and wont see the continuing large variances. At lugina honda hospital, we have significant positive variance and revenues. The biggest single driver is that we had a rate reduction several years back when we were in the dark years of the recession where the state cut the rate for Skilled Nursing facilities. Earlier this spring the state reversed that rate cut and reversed ret row actively so we had a lot of reserves on the books in anticipation having to get the money back to state and no longer do so take that into our income and that is about 31 million net positive. We got that back. That has aaloed us to fund through the budget a significant number of capital projeths on the campus allows us to fix the hvac system, complete the work differed in the scope of the original rebuild project and that include the loading dock and grading work and demolition on two of the wings of the Old Buildings and work on the administrative spaces in the old building. That will be a great pause tchb positive for us and unfunded projects we have been trying to figure out how to fund and we have this one time revenue and the Mayors Office agreed to alouse to appropriate that in the budget to fund those uses. You specified that to lugina, correct . Yes, that is laguna. Help at home has small sur plus in the revenue. Primary care 6. 9 million sur plus on the books. There is capitation revenue higheren thabudgement. We have been a little under stated in the capitation revenue at primary care. They receive a share of the cap dollars from the health plan and there is also significant fringe benefit savings. This is there for a couple of years as you know we budgeted for a significant staffic expansion at primary care as part the lead up to aca and beyond to increase capacity so we can attract and retain members to the system. Taken us as is somewhat typical longer than usual to fill the new positions so have a lag in the budget. We made adjustments in the budget for the coming two years and looking at the salary spending reports it does look like we are catching back up to budget and should have a smaller variance beginning this year. Jail Health Services is very close to being on budget. In Mental Health again a few things moving here. We are showing surplus of short revenues. That again has to do with the mixture of patients that are old medical eligible versus new medical eligible chblt we had a higher rate where we get reimburseed at the higher level under medical expansion and gives 100 reimbursement taper down to 90 but at a higher rate. We under shot that a little so see our income rise for short doyle. Also, salary and fringe benefit savings for the same reason as primary care and have done truing up of that in the budget also. A big number under non Personnel Services that is contract dollars. There are a couple things happening here where we have big one time savings that are coming to our budget and that are used to fund some of our one time expenses in the adopted budget. We had going into the past fiscal year 15squaen 16 made request for Carry Forward of appropriation which is brought the prior year savings to the new year budget and did that to drive expenditures to move the ehr program along and also some other priorities. Now that we have caught up and got fl to a new budget year we budget those into the ehr project and allows us to close out that balance and take it to year end frund balance and appropriate in the budget. We also have significant savings in this line, which is due to the fact that we incumber dollars on contracts until the cogest cost reports are settled and have a positive or negative reconciliation to pay out more money or less and this year we have significantly less than we had incumbered so that allows us to pull some of the contract dollars back out of reserves and into income. This is a big variance, but it is not a variance that we expect to continue on into future years. In the Public Health division, there is also variance in non personal services. This is really less in the phd Program Operations and more in central administration. Again, at the year end of 1415 we carried forward one time dollars primarily for the ehr program and we have in the budget closed those out and used those to fund ehr expenses. We also have some savings from healthy San Francisco, Third Party Provider payments that we cleaned up in the budget but we had had a year end balance in those dollars. Substnlss abuse 2. 8 million in saverings and salary and fringe and state alcohol revenue sur plus. Overall big picture in terms of where we are, it is a very good year for us, so we are happy about that. I think the most positive thing about where we are is that we met our goals but also where we have been able to exceed and pull money out of other programs, we have been blessed by the Decision Makers at city hall to capture the dollars and use them for big one time needs. That has not always been the case in the past. That is not the historcock president but think as Barbara Garcia always points out, our ability to manage our finances is what makes us be able to make a credible case to be able to do those types of things and so i think the history of having a few good years of Financial Performance led to our Credit Rating as it is where with the mayors and Controllers Office qu and so we are in a place to self fund a lot of the different type s of programs we would normally to ask a general fund ask for. 31 million of the balance in the year we just closeed is retained and budgeted to the program so that is the primary example. As i menshzed earlier, 12. 8 12. 8 million of Capital Expenditures at laguna honda hospital so significant progress towards those bill big needs. We also underneath the numbers that you are seeing as you recall another budget provision that we received beginning in the prior year was have authorization in the budget if we can make up to 25 million in surplus year end balance we have authority to transfer to the projjeth hit and made the transfer so yet another way we are allowed to direct some of our unspcktded good news s to the major projects. Under the reserve, which i mentioned beginning of the presentation, as you know, a couple years ago we were in a position where we had a lot of our dollars moving unpredictbly over time under the prior waver where safety net revenues were allocated under a formiuma that is very complex and difficult to predict so we see lot of big swings year to year in the revenues. So, we worked with the Controllers Office to add a provision in to the annual budget ordinance where we have surplus revenues but know there is a risk that in the future years our revenues could be short. It allows to money into management reserve that is managed by the Controllers Office in close collaboration with dph so it does provide us with cushion against fuper vulnerability if we have a big change in revenue allocations. This is important for a couple reasons. Important on the face because we need that cushion. It is not appropriate way to manage an operation of this to be hundred percent general fund on the margin but gives a level of confident because we have the cushion we can afford and the mayors and Controllers Office feel comfortable putting significant resources into the ehr program and other Major Investments knowing that those dollars can be appropriated and we still have some cushion if something goes wrong in the operating budget. We ended 1516 with 95. 2 million in that reserve. The year 1516 we added another 12 million currently 107. 6 million. The base frs the calculation of the rurfb and this is management reserve so requires judgment and projections about risks that may be out there, but we do know that we have a potential disallowance of historical payments to laguna honda for debt service on the construction and received from cms may disaplow 56 thousand of prior year payments and a vulnerability we reserved against here. We have uncertainty remaining how our realignment will shake out and also prior year waver settlements that could come down the pipe. Between those two uncertainties i think we got a good reserve in place that allows us to manage against that risk Going Forward so think that is a important priority for the commission and the department for the past several years to get us into a place where we have a higher level of comfort. So that is a summary of where we are. Im happy to take questions or elaborate further if it is helpful. Commissioners, questions . Commissioner loyce was that a question . Okay. Commissioner chung. So, im sure that this is just me not reading correctly because like in the memo you said the year end sur plus is 103. 3 103. 3 million and mention td is 107. 6 107. 6 million so was there additional money that want accounted for . Thank for the question. That was probably me not being clear. Two separate similar numbers but similar by coincidence. The 103 million, that is our operating surplus for fiscal year 1516. In addition to that we have another pot of money and that 103 million gets returned to the general fund and some appropriated for things like ehr and capital budget. There is oorths pot of munl money we have been feeding into for the past 3 fiscal years which is separate management reserve which sits on the general ledger outside our operating budget so distinth pot of money and that pot of money we have been as we have surplus dollars at year end but we have identified future risks in our revenues that are known we take the surplus and deposit into the reserve and reduces our operating balance and allows to build up that reserve. The balance of that has now grown over 3 years to 107 million so they are similar numbers but separate pots of money. [inaudible] yes, correct. A lot came from this year . 12 came from this year. Thank you. Commissioners ort questions . Y commissioner singer. Congrat ylshz to you. It a s hard to do in your line of work. Absolutely. Just to start on the reserve because that is where you ended, when you added 12 to the reserve did you have to reverse things in the reserve already that it turned out were either going to come out badly or there was resolution on it that in fact you added more to the reserve . Yeah, so the way that the calculation works, it is essentially quarterly when we put together a quarterly Financial Statement we sit with the Controller Office and look what is programmed in the reserve and new information that has come to be since we last calculated it and make an adjustment and it does move over time and what is factored into it, there are things that come and go, so for example, at the yearened last year we reserved dollars against a rate cut in our medical expansion capitation rates. That came to be true and we ended up factoring that into our budget. Because we are able to put it in the budget it is no longer uncertainty so factor comes out thf reserve. There are things that have come and gone over time. The net has grown consistently. Part of it is i thenk the risks known and part is how much can we afford to set aside dollars to mitigate those risks. Right. Right. Okay. On the sfgh in particular, but general, the kind of benefit we got from commercial payers this year is substantial at least in dollar terms maybe not percentage. How did we achieve that . What drove that . So, on the Patient Services revenues there are multiple things that are moving. On the commercial side we continued to see strength there but the bulk of coming in are people coming in through our ed for trauma because they are not contracted arrangements with commercial insures. That sh the next phase we are trying to get to and in the process of and that we talked about at our Planning Session at the last meeting. So, the bulk of what we are see is it is people coming in that we dont have a contract with and sending a bill out and receiving some payment on it. It is partially we are at the whim of what happens to us externally. Another piece of it though is and you have seen a couple of settlements come to this commission where we have been proactive when we feel like we are being underpaid sfr the services we are provided. We are proactive going out and making a strong push to make sure that we dpet reimburseed at a level that is fair. Weef had a couple settlements and both resulted enone time ret row active payments of commercial dollars and agreement on rates Going Forward. So, right now what we see in the Financial Statement it is a non contracted actirfbty coming in through the sfgh emergency department. In the future we are in the process of trying to build up commercial contracts so we would be able to generate commercial revenue through referrals and outpatient procedures, those type of services we have capacity for and somebody is sending us a patient not for a reason other than they need to come in through the ed. You also saw around 30 percent of Behavioral Health budget was that line item 2, right . 30 percent of . Revenue and behavioral. Could you speak into the micro phone, please . If i got it right, 30 percent in behavioral was that too. What is striking to mei was thinking about the Carry Forward. Sorry. It was 67the general was 67 million unexpected benefit in that line item. Is that adid we have a blip in the year or isGoing Forward. It is a good question and we will be working oson it as we go fl to this budget to try to reset where we are, but it is two things for sure. First, as we have done our last round of financial planning, we had a projection and that was done preaca with hma health ready ness form assessment and projection is over time as people settled into the new payer eligibility requirements that we will see a large portion of what our fee for Service Revenue was particularly in on medical get converted to capitated revenue sews o so as people enroll in manage care we see less fee for service and more payments that we would have to write off from a direct billing perspective because they were already capitated patients and so we forcasted that and budgetedpretty pessimistic about what we thought that would change. In realty what we have seen is the strength remained at a higher level than what we anticipated. I think part of that is because of churn of people moving on and off the program. Part of it is because we have this Eligibility Program that if somebody comes in who is uninsured and possible eligible for medical, we enroll them and are granted presumption they are eligible and paid whether they stick as medical and become eligible for medical in the end so that is a boom to our fee for Service Revenues that looks like it is sticking around to some extent so we need to reevaluate the extent to which that revenue is something we can count on Going Forward. And think part is and part isnt. There is another big piece which is i think a blip, and that is that i kind of described it hastily and probably not very clearly, but every quarter we have of our accounts receivable out so bills out in the world we make a assumption how many will convert to actual income and accrue as income even though we havent received it. As we have seen Peoples Insurance eligibility status change, we have seen swings in our accuracy about projecting that. For example, if you have just to be10 dollars of bills outstanding for medical eligible people you might say we think we will get a buck 20 in payment against those bills and that is about what it is. If that numbers go up to 15 percent, you have a big swing in your income and so what we saw in the between the third and fourth quarters this year, was as our Accounting Firm that does this analysis, they reran the model to project our income from those outstanding accounts and there was a huge bump because the asurchltions and analysis changed which allowed us to take a bigger proportion of that to income. That is something we also to look at but it is probably something that is accumulated over the course of the year in our assumptions that we use to calculate that income that resulted in a lump of income in the forkt quarter. Thank you, very helpful. I think we should be encouraged about your capacity to understand the details. Thank you. Commissioner loyce. I will try to ask this question in a way that one, you can understand because im not sure i understand the question i will ask you and two, you can give me a answer. Historically when there is a surplus there are two things i think i was aware and you said it differently today, if you had a surplus, when you proposed the next year budget you couldnt put that in the budget as the baseline and leave as a separate line item and the only way to spend the money is get approval from the mayors and Controllers Office. I thought i heard you say today with the surplus there is administrative Holding Place and the department can draw on the surplus Going Forward. That seems a bit different than historical relationship with the Mayors Office and financing. The question makes perect if sense and two separate things going on which i probably didnt pull out and separate sufficiently. The first is, on the underlying mechanics of the budget it is still similar. At the oned thf year if you have a surplus if we have a surplus we have no right to control that surplus so default is under the way the budget works, if we have a surplus of 10 million, there is reduction in the general fund coming into the deparchlt by 10 million and the benefit goes to the general fund. So, that process remains. What has changed on that front is that we have made significant effort and had a really Good Partnership with the mayor pfs office and Controllers Office not through a change in the ordinances or the charter but agreement how to do some of these things where we do have significant one time revenues or savings or good news, that we have been able to agrew through the budget process to use those to fund the big one time needs. The city has a policy of using one time revenues and savings for one time use which is a good financial practice, but we have actually implemented that policy work wg Mayors Office and budget. Nothing changed that gives the authority to do it, what changed is we simply had been fortunate working with budget process to be allowed to do that and that has benefited us in funding the Capital Projects. [inaudible] yes. About 2 years ago so why commissioner you wouldnt be aware of it since we prepared for the Electronic Health record. In practice that is a change. The second piece of it isrelated in some ways but it is differental animal and it is a change in the orb nns so the ordinance that goes with the budget that allowed us to create a separate pot of fund that is a management reserve so we can feed dollars into it at your end with a surplus and work the Controllers Office controls this and works with us, but we feed dollars into that reserve so that if in a future year we have a deficit and if we get notified by the state that we will have a reduction in our payment which happens with some frequency. A letter shows up one day and have 30 million problem. We have the pot of fund set aside so that if we end the year in the negative we draw money outd of that reserve and use to cover the balance. That is in the adman provisions of the budget and gives a mechanism to survive that instability and unpredictability. Two separate and related conversations of the mechanics of how those situations work. Thank you for the full report and being able to understand and decipher my question. Thought it was a good question. I think all these question have brought out the value that you have brought to the department in terms of being able to really put our department finances into a reasonable state where there is a at least somewhat comfort able reserve. Everything is returning back to general fund and had to go back. And i will say i wont take the credit for it because i worked on it but what allowed us to do this i think has been Department Wide commitment to our Financial Management and that is from barbara, it is from the staff and we got ourselves into a place i think where there is a recognition that we really are committed to trying to carry our weight financially and that is really what has allowed these new mechanisms to be put in place so thipg it is a change in Department Wide culture how we approach our Financial Management. Thank you. Any further comments . I just like to also thank greg. He will give credit but his ability to interpret because he was the mayors Budget Office director undering how the finances and i walk into gregs office and get a 40 million reserve coming back from a long time ago audit. Our revenue just flux waits so much that i think the Mayors Office also recognized how important that is for our ability to continue service and greg is able to interpret that and get the Mayors Office to understand our finances. [inaudible] deserves the cred it for what must be one of the best and clear reports we received. Thank you. Next items item 8 is other business. Anyone any old business or other business at this point . If not we can proceed to the 9th. Item 9 is joint Conference Committee report and commissioner sanchez can give a update. Laguna honda jcc met october 11. The Committee Approved the october medical credentials report and we had a full committee including our new colleagues who joined us. Thank you to the secretary bringing to the different committees, so we had a very good meeting and closed also adjourned in honor of memory of drz isaacs who passed away and that was part of our closing. Thats it. Unless you have any further comments. Any questions . Or any additions from members of committee . If not, then we can proceed on to the next item. Item 10 is Committee Agenda setting. The calendar is also before you, if there is comments and opponent out that the joint meeting with the Planning Commission is scheduled for november 17. Yes. In regards to the c prfx Mc Development agreement. If there are no comments on the Committee Agenda then we can proceed to a motion for adjournment. So moved. And i heard a motion and second. All in favor of adjournment say aye. Opposed . The meeting is now adjourned. Thank you. [meeting adjourned] all right. 2, 1 you innovation on or was on over 200 years they went through extensive innovations to the existing green new metal gates were installed our the perimeter 9 project is funded inform there are no 9 Community Opportunity and our Capital Improvement plan to the 2008 clean and safe neighborhood it allows the residents and park advocates like san franciscans to make the matching of the few minutes through the philanthropic dungeons and finished and finally able to pull on play on the number one green a celebration on october 7, 1901, a skoovlt for the st. Anthonys formed a club and john then the superintendent the Golden Gate Park laid out the Bowling Green are here sharing meditates a permanent green now and then was opened in 1902 during the course the 1906 San Francisco earthquake that citywide much the city the greens were left that with an ellen surface and not readers necessarily 1911 it had the blowing e bowling that was formed in 1912 the Parks Commission paid laying down down green number 2 the San Francisco lawn club was the first opened in the United States and the oldest on the west their registered as San Francisco lark one 101 and ti it is not all fierce competition food and good ole friend of mine drive it members les lecturely challenge the stories some may be true some not memories of past winners is reversed presbyterian on the wall of champions. Make sure you see the one in to the corner thats me and. No . Not bingo or scrabble but the pare of todays competition two doreen and christen and beginninger against robert and others easing our opponents for the stair down is a pregame strategy even in lawn bowling. Play ball. Yes. Almost. clapping . The size of tennis ball the object of the game our control to so when the players on both sides are bold at any rate the complete ends you do do scoring it is youll get within point lead for this bonus first of all, a jack can be moved and a or picked up to some other point or move the jack with i have a goal behind the just a second a lot of elements to the game. Were about a yard long. Aim a were not player ill play any weighed see on the inside in the goal is a minimum the latter side will make that arc in im righthand side i play my for hand and to my left if i wanted to acre my respect i extend so it is arced to the right have to be able to pray both hands. clapping. who one. Nice try and hi, im been play lawn bowling affair 10 years after he retired i needed something to do so i picked up this paper and in this paper i see in there play lawn bowling in San Francisco Golden Gate Park ever since then ive been trying to bowl i enjoy bowling a very good support and good experience most of you have of of all love the peoples and have a lot of have a lot of few minutes in mr. Mayor the San Francisco play lawn bowling is in Golden Gate Park were sharing meadow for more information about the club including free lessons log good afternoon everyone and welcome to the San Francisco board of supervisors meeting of tuesday, october 25, 2016. Mdm. Clerk these call roll call thank you. Avalos, present. Breed, here. Campos, present. Cohen not present, farrell, present. Kim not present, mar not present, peskin, present. Tang, present. Weiner, present. Yee, present. Kim, present. Mar, present. That president you have a quorum thank you. Please join us in the pledge of allegiance. [pleage of allegiance] thank you. Mdm. Clerk any communications width lunch report mdm. Pres. Colleagues any changes to the september 20 20 sitting board minutes . Seeing none, is her motion to approve those minutes . Motion by supervisor campos second by supervisor avalos. Colleagues, can we take the approval without objection . Without objection those Meeting Minutes will be passed after Public Comment. [gavel] mdm. Clerk but go to the consent agenda. Items 13 comprise the consent agenda. If a member objects to the these items be on consent and item be be removed and considered separately. All right. Be seen no names on the roster mdm. Clerk