Transcripts For SFGTV Health Service Board 113015 20151201

Topics and we will precede accordingly, i made a request of our City Attorney to while back over a year ago to give us guidance on one of the turns of reference that we approved as a board a little bit more than 9 months ago it was regarding our fiduciary duties around investments if you recall a representative of the treasurers did not come and explain how were a part of the large pool of funds and forgetting but still some outstanding questions at least from a board stand point i think that and over attorney will advise us on we may need to address in addition he wanted to you requested of the City Attorney to give the board kind of and then he hope the public who are here in the audience and those who might see that as a late point about the duty of the fiduciary and the multiple of that board sincerely does indeed guide our action and Decision Making lots of and lots of guidance from the Mayors Office from City Attorneys office how to behavior and not have conflict of interest and so on and so forth annual letters around that stuff some core fiduciary requirements this board has that is unique to this board and its role administering the trust fund for the members members of the city and county of San Francisco that are part of this system with that introduction ill ask my worthy council eric please come forward and the secretary will read the first agenda item. I want to make sure that sfgovtv is recording us we cut you nine out of ten. Eric will straighten his tie and adjust his glasses and all that stuff. Were okay okay. So item one. Item one discussion item the fiduciaries standards and board roll in adapting the plan for sf trust fund assets and applications of pursuant person standards and the need to adopt a policy and a sf policyears. Eric. Okay. Hello. Were here thank you eric. Should how do we get oh, there that is Good Afternoon Health Service Board this is my first time my first time doing a presentation from this side of the podium. Does it look any different okay laughter . Before i start today, i want to go through a couple of caveats to this presentation i think the legal presentation without caveats will not be much of a legal presentation at all first when we talk about the roles list in the agenda it is not meant to be an exhausted list i picked 4 basic roles to talk about the board decisions that the commissions make from fremont and also i dont mean to say youll be engaging in one role and not more at the same time ill briefly discuss all 4 roles today, the primary presentation it the boards roll in investing trust fund assets second this is not intended to be a fiduciary review of the Health Service Board Investment obligation what im hoping today is to begin answering two basic questions first what is a fiduciary standard that applies to the Health Service board oversight of trust fund assets and second is it appropriate for the Health Service board to continue to lead the trust fund assets invested with the San Francisco Treasurers Office and finally id like this presentation to be more of a general discussion were not here today to review the specific decisions in the past more of a forwardlooking discussion and, of course, hypothetical questions you want to ask thats great lets keep the questions truly hypothetical and not based on a specific decision that board made in the last couple of years. So let me briefly review what im hoping to cover first the charter language establishing the Health Services as a trust fund and providing the authorization for this board to invest trust fund assets and second go over the board terms of reference specifically the Investment Administration policy other board adapted in april and have a brief discussion how we got here today and next go over briefly 12 fiduciary standards and then answer the question specifically with respect to the boards obligation regarding the assets that are countering have found that the San Francisco Treasurers Office and switch gears again and go over the other roles listed in the agenda the boards roll in adapting the plans as part of the raising benefits the boards role of setting policy and overseeing the administration and the boards roll in hearing appeals. Okay first chart section chart section 12203 i niend the key language the charter language that established the trust fund and identifies who the fiduciaries are specifically the active and retired members theyre covered dependents i think when but read this charter section in conjunction with the rest of the chariot fair to say in general the of primarily trust fund is to negotiate and approve the rates and benefits every year to make sure the Health Services are based the employee employee and employer contributions the next charter system is charter section a two 49 the first sentence the board has control of the Administration Information xhivenlgs of the Health Service board board and system to invest the trust fund assets you see the priority that all the investments shall be of the legal for Insurance Companies in california aim in the process of following up with outside council regarding the limitations but at that point no depreciation this board contemplates making bumps up against the lirmgs this language was adopted by the voters in 1937 i think so that in the early 90s a lot of other funds moved uaw from the language all still used in other parts of country and others limitations. Just a moment. Sure. Just so were clear im clear it says the character legal for Insurance Companies does that suggest that there is a more conservative view how we should be behaving in terms of how we invest in terms of find the faster growing thing in the marketplace to do whatever it can to increase the corpus of fund in our charge. I dont know that this was a limitation that the voters established in 1937 my understanding in 1992 other trust funds probably adopt the standards more likely but regardless of whether it is this standard or another standard i dont think that anything given that the Health Services will consider is a bump up against this standard. Director dodd. I think the reason it keeps referring totions is because in 1937 person completely selfinsured we paid our own claims and since city plan was born so we had to ply with any Insurance Standards now contract that administrative part out assume our vendors are complooilg. Thats and helpful clarification. Ill followup to the an area im personally familiar with so the next the next charter section a 423 again, this confirms the Health Services boards Investment Authority and the Administrative Expenses related to the Fund Investments can be paid from trust funds investment. I know your highlighting we know youre there it is informative to look at the other aspects of this particular charter precisions it talks about a lot of the things we make decisions dissixth amendment information a wellness program, supporting the cost of our actuary all the components we find we spends months and days on here if in chamber doing again go ahead. Thats correct so outside of paying for premiums a question arises from time to time a certain expense out of trust fund assets and generally not until a specific allowed expectation in section a 243 is the actuary expenses and Wellness Programs and communication expenses. Okay. Now id like to briefly again switch gears slightly and talk about the Health Services board terms of reference that were approved on april 9th so specifically id like to gave us context up until a few years ago not that much money in the money in the refers i understand theyre under 20 million and that means that the money that came in pay premiums went out relatively quickly with a more robust policy combined with the city to flex the blue shield funds the reserves grew and thus, the board asked our office what the fiduciary obligations over the trust fund assets in april of third year upon the governance consultant tom do you mind a Administration Policy which was included 2, 3, 4 did boards terms of reference ive copied on this slide and the next slide for your reference that the boards august meeting of this year pauley marks the chief treasurer with the office made a presentation made a presentation explaining how Health Services and trust fund assets are currently invested that the Treasurers Office so as you can see. We didnt have an investment policy the board didnt center a policy. Thats correct ill get to that right now you have not formally adopted an investment policy right so this but essentially im refer to an investment policy if you look at the combined this what you have newer your board terms of respect not a formal policy but the language you youve adopted duo to date so this Investment Administration language first as you can see the section 12203 and 09 we discussed and then it goes ton and theyre taking this requires the board to adopt a written policy statement and taking those out of order the current terms of reference require regular monitoring and ongoing review of Investment Performance and having qualified managers appointed to manage the Health Services assets but a key part of policy requires the board to adapt a written Department Policy statement i guess were i know take apart words is that the policy that requires an investment policy that is what you do you mind today and the bottom 3 bullet points are depending on the investment fair to say why the board has by default adopted the treasurers policy to date the two policies were here to discuss what the fiduciary standard it applies to the Oversight Trust fund assets and should the board formally adopt the treasurers policy as the Health Services policy or in the alternative consider some other option. And while beer at this moment of pause i want to reiterate for the record this not about fingerpointing and not about what has or hadnt been done or should not by the Treasurers Office this is rather take into account the duties this board has regarding its role if in area. How well decide the outcome of the next steward step it a matter for another day. Okay. Thank you. So, now again, this is switching gears slightly we want to briefly go over the various sfefl fiduciary the california constitutional standard for Pension System not a Pension System this standard doesnt legally apply to us i wanted to read it so you can get a sense of the standards look like requires that the board of a Pension System shall discharge their the United States with respect to the system with the care and skill and prudence under the circumstances that a pursuant person familiar with those matters will use in the concoct of duties this incorporates this constitutional fiduciary standard for the retirement system again, were not a Pension System it doesnt apply to us when we look at the other trust in the city are there the recommend system were talking about the hfrs system a standard that applies to the Health Care System and a state standard which is the uniform pursuant investor or the upi a a standard in probate or the fiduciary obligations for terrorist fee managing a state that standard requires that the fiduciary the manager trust u trusted assets as a pursuant investor by look at the requirements and other circumstances of the trust and satisfactory that standard the fiduciary shall experience reasonable care and skill and caution i think the next standard that is relevant this the arise standard it does not preto the Health System but because the arise law a law that cantonese cases related to multi Employer Trust from there were are a litigation or a court to review trust standards in this context it is highly likely the parts will look to arise for guidance it requires the fiduciary to act solely in the interest of the participant and benchmarks of the plan and with the care skill and prunsz and diligence under the circumstances then prevailing that a prudent man acting in a lick capacity familiar would use in the connecting conduct of a enterprise with lick character this is similar to the upi a that the california constitution. Sure. The words have somewhat familiar but in a legal sense not some of the standards use the words caution, some prudence are they enter challengeable how does we begin prudence. Right today ointment going to specifically advise this board adapt a specific standard i think that is a discretion for a later day and so hold that question is it so r it is a legitimate question weve started to engage in a fiduciary review as part of progress i think the board will windup adopting a standard on that note i just added the next slide is the standard that the retirements Health Service board adopted in their terms of reference and the trust fund is the third, the lastly trust fund is designed to prefund the citys obligation to pay for restored health care and like contributions from employees it was adopted in 2008, and requires the employees hired after january 10, 2009, to contribute 9 percent to the fund and in prop c in 2011 amended to the employees hired before january of 2009 will have to make contributions in 2016 and their matching employer contributions as well the retired health care ive pasted it right there not going to read it but prior to the standards and i would envision this process the Health Services duplicities a standard at this time well talk about the differences between the different language so the next slide is in a sense the one i dont want to say give us legal advice the answer to the question should the board formally adopt the policy as the Health Services or in the alternative consider other options i think we can answer this question without having to pick a specific standard regardless of what standard this board picks i think our advise is going to be the same and so for this one ill read this one allowed fiduciaries acting in correspondence are the upi a generally find that appropriated to remain outside expertise with the fiduciaries dont have the expertise to address the question in managing of managing the assets it is common more Plan Sponsors and others to remain Third Party Consultants or advisors to advise them on the policies recommending an Investment Program for on Employee Benefit plan this expert could advise whether it is to be rained remained are ray retained in longer investment strategy. To put a pin in this to be be clear our council on this topic regarding the roll that we have as investors under our investment terms. Right we can advise to the Legal Standard is were not here to provide specific investment advise the idea that consistent with the fiduciaries obligations it make sense to consultant. If we determine because we were too busy in other matters wiener we dont want to address this gay would we be acting as good fiduciaries as well save that to the ends hopefully, well see what happens i mean, hopefully youll follow the advice. Okay. Well not there it have to answer that question. Now switching gears well discuss the board role as oversight role for managing Health Services and assets and investing overseeing assets i want to talk about so the other 3 i think major roles this commissioners play on a yearly basis the central with an in adapting the rates and benefits every year set forth in charter second second a the board shall have the power and the majority vote of the heart and soul to adopt the plans or plan for rendering medical care to members of the system i think this arguably the role of this board the one sort of. I would footnote everything there are a number of people that play inside baseball for years and years a Standard Committee on rates and benefits would the change in our terms ever reference last year, we decided to do you away with that committee ultimately that is the responsibility of every member of this board and so rather than having a two tier kind of thing going on we we have a Committee Meeting and the boards meeting youre here and voting on the same thing twice under the leadership of cesarean and others in the governance area we decided to make the board act as committee as a whole it is consistent now with the charter section. The only thing to add about that process and role the adoption of plans that on the shall not be fiscal until the board of supervisors adopted by 3 quarters of its members weve had one Carbon Monoxide the board of supervisors did not approve a rate and benefits sent it back to the haelts so in making those rates and benefits decision obviously something the commissioners have to take into account the charters they make the benefits will be approved by the board of supervisors. So again the next role he wanted to discuss is in a sense the role of the commissioners on this board policy as a policymaker and making higher level decisions verse providing administrative oversight to the Health Services the Health Services board makes the decision for the day to day operations are left to the Vice President head for example, the board votes on expending the wellness a contract for Data Collection and approve the budget every year but when it comes to administering the contract or promoting the wellness plan that is an administrative function of the Department Charter section 4 point one 02 lists the schaerpt section the last forgave so i didnt include it in the that time but the powers are evaluate and approving the goals and objectives and plans and programs and setting the policies consisted with the overhead city objectives with that said, the distinction between a administrative decision is not clear regardless of how we characters the decision charter section 4. 102 go through the Department Head with administrative matters in the Department Works with the vendor to implement the contract and if it comes to light the board has concerned how the contract is implemented the process to contact the Vice President head and try to work out in the past and this is happened the Commission Gets the binder with the agenda and flip that open with a budget you can call the cfo with a question im sure and thats okay Orange County communications to date that takes place between commissioners and Health Services and staff it is fair to say those conjectures are done within the explicit or candidate content of the director if you look at the bottom of the slide there is this while you have to each commission has to relatedly being fair to the department shall deal what the administrative matters of through the Department Head nothing should restrict the boards or Commission Hearing an inquiry as provided in the charter the point those powers are formally powers of inquiry i just not going to spend any time gopher this slide just to point out a whole charter section that outlines the former powers this power of inquiry is not cart blank for a commissioner to call up a staff member with a question he or she has b a decision to engage in some sort of investigation or have a hearing he was really to trying to think of a holy know that Member Services a great Member Services team for some reason complaint about the member serves to contact the director i assume theyll be able to work it out, however, for some reason noable the board felt the director was not resolving the concerns then you could invoke this power of inquiry and engage in a more thorough fact finding investigation. Can i. Oh, sure. Related to that im new to the board it was a little bit of a surprise i got emails from enreels exclaiming about the errors and their medications were not available and sent to hawaii it is something related to those kinds of complaints how they get farltd in terms of coming to all of us and get forwarded automatically we dont need to respond individuals would it be useful to have a statement guarantee im not the right person by charter or whatever about once a week or every other week. Thats a great question part of the reason were having this discussion here today i dont get those emails so listening to you is tells you two different categories of emails either way both of the categories should be forwarded to the Health Services system generally, if their emails related to administrative matters not related to an individual Health Services member you know claims process or medical issue again, this should be forwarded directly to the director and let the director handsome that the director is a could respond, however, but you i think this would be the better way to handle it with respect to members proven commissioners regarding their own claims experience lets get to that the next slide thats this late board member role if you go through it and you have questions well talk about and finally the commissioners play a unique roll in member system appeal in this case, the commissioners are acting as pifks method of operation forgive judges youre putting on a hat like a court of law one of the principals of the court of what are you be fair to both parties both the Health Services system and the Health Services member so Health Services member role you has the member appeals and grievances is on the Health Services website requires a member to go to the Health Services system before filing on appeal with the board therefore by the time the Board Members file is an appeal it is obviously if they go to the Health Services it will get accounted and realistically in a member files an appeal by definition the Health Service board has 250b on the opposite side when a claim is filed with the board the boards needs to insure the get is revolved after a levels the Playing Field and it is critical no x parliaments or Party Communications before the staff or Health Services board commissioners and the Health Services member about this specific members colleague by exasperate a existence with one party the other party is not privy too for the levels the Playing Field for the member i as General Council for the system cant represent both the system and the board at the same time with respect to the member appeal that is in the fair im advising the Health Services system on appeal and then the member comes out with an point out and turns to me for advice this would be a conflict and be more than just unfair it would be illegal and a problem for the city for them to have a legitimate hearing on the issue therefore the City Attorneys office set a think ethical screen and if the Health Services board needs advice the attorney from the City Attorneys office that will representing the Health Services interests the team with work with the dpw they have extensive expertise in to the area of raw and the office made and policy call that make sense to represent the board in those appeals i think that is just easily logicly the Health Services didnt need a legal advice to resolve those if i was he representing the Health Services we need another taxi driver attorney now weve tried this that make sense for me to continue to represent the boards for Health Services appeals i could see a situation as long as were having this discussion for some reason, i provide advise for a member appeal so from the Health Services system ill switch for that one case and the office ranges for another attorney to represent the board that has not happened yet and hopefully wont with respect to all Health Services communications had be other Health Services secretary and effects the clerk under those set of circumstances so when i guess ford respect to a communication send auto a out a communication it goes to the member and the board their copied on all communications to answer over question if a conversions is contacted by claims i think that is okay to provide the member General Information whether to the website look at the member guide, take into account the you know member rules regarding appeals but direction them to Member Services the southern if a commission interacts with the Health Member with their claims or issue and it didnt get resolved the person is fooel on appeal depending on the fact it is conceivable youll have to recuse yourselves with a 7 member board and now recuse a 6 member board and a 33 split i dont know it is con sebl well say the Health Services decision is uphold because not enough to turn offer the boards decision is it so ironic if the member went and the board member not able to vote for the member it would be just a lot easy if a you are contacted regarding a specific member colleague or medical issue you just you know refer it to a Member Services i think youre fine to refer it to the head of Member Services or the decoration to handle that appropriately that has happened consistently in the past. I have a question. Okay. We have now on email directly to the board so in some situations the people that are writing in complaining about the director are we supposed to ignore that we canned put a box around the board with no contact with the members it sounds like so information from the board so we should have some kind of a policy would say going to respond to the emails at our directly to the board would probably be the president of the board and it is to the board and i dont think it is proper to say ignore them all especially, if theyre complaining about the person our ref them back to we have to get that about some of the direct emails. These are benchmarks and working solely for their benefit; right . And thats over and over again, it says it to ignore those emails and say someone else will take care of that i agree an appeal in the nature, of course, but rounded things someone is complaining about somebody does something and send it back to that person i dont think that is right of. Well, i think again lets keep this conversation at a higher level without specifics i think there is going to be i guess i dont receives emails who general complaints about Health Services from the administration and then specific claims about member claims again, if it didnt get resolved the member can file an appeal and the member has the right to have a hearing on the merit i understand that every member probably a First Amendment right to approach the board on what we have topic by maybe we can do Going Forward in the next couple of emails get forwarded to me and workout some kind of appropriate way for the board and the Health Services system to respond to these emails to balance all interests insure the members right to appeal is not jeopardize by communications between the commissioners and the Health Services. Those were not necessarily appeal issues. Right it is not an appeal issue well look at it and figure out what were going to do about that but again to the extent this board has issues about the administration of the Health Services from those issues these ordinances have to get worked out with the director that charter section 4 if the 102 no way around it if a member is unhappy with senior staff or the director it is going to have to get worked out the only way to communicate the way to do that is get the board to the director to resolve those ordinances. The communication could be the power of inquiry process we referred to earlier. Correct if i have a series of complaint not able to account with the director ill point out every issue has been worked out not aware of a single issue or with bart ever came up that the director and the board were not able to workout but for some reaps a assessors of complaints and a systematic problem the board can have a hearing and testify and answer our questions. I think the work premises on this particular point we have created on a email addresses okay. We have a phone number attached and so weve invited people to share with us their concerns but we hadnt been as to process those things once we get them thats the point that karen is making we need to give thought to it the ones ive seen commissioner breslin i know i couldnt respond to someones open enrollment issue ive had to rely upon someone sending that to the person that knows something about open enrollment i wanted exchange the assurance that that is attend to by that member of the department i assume it was attended to primarily or the person would have sent another email no. You didnt do it right of we have to exercise a little bit of judgment not only because the charter tells us to but it makes sense the person is writing trying to get a response or clarification or whatever i may not be in the position to do that or may not have the clear information we have to rely on the director and their team to do that but again, if we think something is reoccurring or pattern starting to develop or what have you, we have again, the authority to make the kind of inquires from the director not satisfaction and take a more formal direction it is a matter of coming up with the process understanding about how were going to respond to this channel of communication i think rightfully have created ill talk about it i see a situation 80 percent of the inlaws or a specific member claims issues we could come up with a formal response ill send out to the extent not failing into a category of noncomplaints or an el serve member we have a brown act not having everybody for emails we have a meeting a nonnoticed meeting. So one person. What what. Im assuming. Yeah. Well talk about that and think about it and come up with a way for hotchkins emails well put our Heads Together to come up with a way it works. Well expect our that guidance and council to assist us i think there is another yes another question. Fiduciaries who is the fiduciary ive had a lot of material on this and has there been any Supreme Court decisions that refine fiduciary not just us but the director or anyone that is investing and the staff to some degree. Right those are all good questions at the beginning of this presentation that was my second caveat not a secondary caveat review the commissioners are fiduciaries i understand the someone at the Treasurers Office acting in a fiduciary with respect to the assets what what we havent talked about the con turns of that relationship with respect to decisions other than the disbursement of trust fund assets the international Employee Benefits affirmation along with my having attend their meeting in june sent me an article called the Trustees Handbook that thick too inches worth of stuff the first 90 pages is about the role of a fiduciary the fiduciary relationship and talked about the pensions and multi Employer Health benefits as well i dont think that is one theme that come out of it, yes we as fiduciaries in this plan can peck others to do thing on our on behalf audit and investment all kinds of stuff doesnt relieve United States i us of the primary accountability of experiencing judgment and prurnls and reasonable are person standard that person is doing it and let it alone we still remain some of the accountability in our role and a as fiduciary i recognize not a clean depiction for the Health Services you but that types of itself 2, 3, 4 the fiduciary role. I dont want to put the cart before the horse one of the reasons were having this decision is a question of you know is that appropriate to leave the assets with the treasurers if you windup taking our advice get an expert and it is appropriate that is a different world than if you tried to choose some other option so when you read that to treefts law or kwhaefr the Supreme Court cases are it is much more complex set of decisions the retirement system faces or the Health Services system is taking their sole purpose to invest the trust funds assets over a 40 year horizon what i think this board needs to do build a sensible fiduciary policy around after hearing advice from you know an expert explaining what we you know and after this board sort of adapts what is appropriate use of trust fund assets again, after consulting with the experts the boards decided to stick with the Treasurers Office and adopt the treasurers policy as the boards policy that is one depreciation and we can continue a fiduciary review bans that depreciation if for some reason the board goes in another direction there will be issues that arises from that decision. Our containments to the governance policy is saying you should have a policy not change what youre doing but a policy that says what youre doing we say dont have anything in writing egging writing i dont think anybody wanted to get involved. In a sense you have a policy by default youre investing your money with the Treasurers Office they have a policy you heard in August Pauline came up with a detailed policy how the trust funds is being invests you raise the issue are a fiduciary standard that approaches any of the fiduciary standards weve talked about is that a pursuant way to invest the trust fund seats assets thats the question im not an investment expert i wish i was this board has the opportunity to answer that question if in due season. Any other questions. Yeah. You answered the question about other trusts within the city system. Yeah. Is there overlap between the retiree care so they are a different fiduciary board and so theres no over laptopo so those funds for Retiree Health care. Yeah. Their two different trusts this trust gets money in every year and used to negotiate the rates and benefits assume your 99 percent of the money a large percent of the money gets spend o spent on member premiums every year the city in 2008, through prop b because the city a had been going as a pay as you go and over the next couple of years you know the Retiree Health care costs are close to 6 percent of payroll probably to 10 percent over the next several years theyve decided they negotiated with labor. Way to prefund the citys obligations to pay for Retiree Health care so they created the hocking trust fund and have a mandatory member contributions and recently they adapted the last Charter Amendment with some exception any expenditures is not projected to be fully fund until 2044 we have time and there are no again get back to the policy you know obviously you know it has to what is persistent has to take into account the obligates thats why i was confused no expenditures until 2044 presumably. What they start. Not impact the decisions you, you make you get the money from the employee and employer im not saying you dont care but the money is regarded in the collective bargaining and the county and through the charter with the Health Care Trust fund formula you hiring the Retiree Trust Fund height they get the money and invest it at some point through the Controllers Office write a check or Wire Transfer to this fund. Thats the question. At this point in 20044 when the money keeps from the Health Care Trust fund. We look at the rates we look at retiree rates on medicare not on medicare 34ek we look at this come out of funds that are paid or is he exclude the other funds. Commission. By default we use this as a a result for the fiduciary investment thirds party to invest the funds theres a defensive between the retirement and the Health Care Board and ours ours is outside of the reserve pretty much what we receive is what we pay to the provider so it is mostly in and out i like what the retirement does it maximize any fortunately for any proofts there is a later on as far as investment i think except for thirty years but a big difference but going back to the recommendations by the governs committee what no other be to likely one forgave were we use the office as our fiduciary third party to make the investment autopsy on that point. What the Governance Committee is lacking for just photograph we use this as our Third Party Investment thats the investment for us. As a one commissioner reserve any right to make that depreciation at a later time im not prime the outcome today to what we will finally do as at board maybe the intent of the Governance Committee that maybe what whether happen and ultimately but not done the Due Diligence to reach that depreciation thats where we are and well take that particular point up at a later meeting any other general questions about the fiduciary role . Okay. My council i thank you for ceasing us with another question and opportunity. Thank you very much. Thank you hearing very much ill request we take a 5 minute pause. Now that cigarette of our agenda was in parenthesis was populated to be 20 minutes long its absolutely the reason were here and not pacific because of presumed timeline there is some of the topics we want to cover and in indeed we dont get them all covered theyll be carved offer for other moments on the future agenda the point a range of topics and issues some near term and some fallout out to make adjustment well do that but at the end of the day this was supposed to be an education session for the board and public well be diligent about this and okay. So now well move to item number 2 item 2 discussion item internal investment near term 12 months and longerterm 24 months and public and private segments nationally california and the back and forth issue h s f state taxed and transparency bay area 9 county analysis transparency abc president scott. Ap cd. All claims database. Just for the record well have the representatives from heating come forward to talk about trends. Thank you if you pull our microphone it will stick in our face speak into it. Ive been known to have a soft voice. Speak into the microphone. Thank you for having me. Ill try to keep it to 10 minutes. Your name and Juan Anderson from heating. I want to start off what is happening in the micro investment. Still cant hear. Okay. Is this better okay. Great id like to spend a few minutes of the michael initials and how it relatively related to benefits as the next 12 to 24 months the prospective from the public segment prospective and public prospective and where their minds theyre planning for the next 12 to 24 most and focus on some of the external things in the marketplace as it relate to the carrier a competition from a aboard prospective and periodically to the bay area. Okay. Thank you. The clicker so many macro things 4 key things happening in the marketplace we think will have down stream prelims and everyone is talking about the tax and well be that but i want to make a comment most plan passports about twothirds have the x us tax in 2018 irrespective of public or private segment the real issue for the plan supports in general another huge area especially we feel it from the bay area around the Venture Capital and the Health Technology i think about impact not only Health Insurance but how the employers delivers the benefits and we as consumers use health care that is an area we cant ignore the other piece is around the changing would it be fair to say we think again 2020 we have 5 different generation in of the would it be fair to say thats across the board so the Value Proposition for the different generation is very different we know the millennials is coming into our workforce the expectation of the employers and what they expect under the benefits package is different the employees are thinking about what that means for benefits and what their value is to the employees and the other changing would it be fair to say factors we need to consider about the benefits the fact that well be the majority in the workforce as well as much broader ethnicity within the population so right now 18 percent of our population of different ethnicity growing to 37 percent by 2020 how do side that impact our benefits to the organization and then well got the access to public exchanges and as large employers have ceasing access to say those vehicles it changes the values and proposition as now we talked to our clients from the public and private segment they feel that is a core part of their proposition to the employees not a mass exodus at this point the next few pages a survey results of the survey we do every year and it is a huge database that includes Public Sector as well on page 5 we basically asked our clients and Plan Sponsors what are really the key challenges their faced with their benefits program and as you imagine it is around engagement and motivation and providing tools for employees to active understand how to use theyre health care and make changes around that when we think about some of these challenges their faced with there is basically 5 key areas we see planned sponsors moving towards not a Silver Bullet to fix the Health Care Many of the 5 things ill talk about things that the boards all right considering and often about as we work with our clients those are the areas theyre focused the opportunities of wellness a much broader prospective of wellness not only the physical but social emotional and physical aspects of wellness something the employers are talking about the holistic and the engagement the board is talking about transparency so engagement and other is critical and as i think about the programs designed Going Forward theyre really focused on customers and the other or shared accountability the other area we see significant opportunity from reducing the waste in the system is around provider reform im talking about that in more detail the two key areas again seeing a lot of trespassed and Energy Around this the context consider management and serious to the quality providers for Better Outcomes in terms of the questionnaire you gave us the top 5 how many challengers were offered to all those you know government providers number one and what the regional difference some of the midwest see the challenges definitely than in the far west. No about 12 to 15 different answers ill say there is similar responses across the board irrespective of geography and only in the industry as well size size it a little bit different smaller employers feel the cost pressures more significant than our business but consistent. And i think to highlight those very quickly one of them in engaging employees with which one conditions and disease programs requester put a check and motivating people probation officer make behavorial changes scope and so on the government regulations and weve within grappling with that access to price and quality education weave been concerned about that and ceased with the unpredictability of costs it seems like on eternal condition with the trends im in lien with those concerns. Yes. The next page is how employers are responding to the challenges this is an area that seize detests between private employers and public employers so i also many of the private employers have been tweaking their plan design and costshare strategy the course of last 4 to 10 years running out of room to manage their costs on the other hand, where Public Sector Plan Sponsors provide generous benefits and cost subsidies definitely more room to move in that direction so when the responses to the survey for the Public Sector was you know what are the 3 key things their looking at inc. Copay changes theyre doing that and expect to do that in the future they have room to move from a design prospective the area around adult dependent coverage in the private sector an employer has treated that adult dependent category definitely maybe a lunch reduced subsidy for spouseal you, you want to cover your spouse other employers plans those things happening in the private sector and the the Public Sector thinking about 6 percent of the Public Sector that do does that day and today and the third piece in terms of health plan 15 hundred deindict before the plan pace anything has been popcorn in the private sector not the public but is that the direction we want to go as you can see currently there folks that are doing that today and another 25 percent thinking about that in the fire chief whats been interesting on the survey weeping weve been doing this safer for 20 or thirty years asking what change when will you make over the last 10 to 15 years with the looming Health Care Excise Tax the changes that are disruptive to disruptive change so were seeing a lot of incremental changes ways to create more druchgs in the marketplace and the Health System to create better quality and outcomes and better placing so i on the several items ive mentioned earlier around the disruptive change page 8 so this is around reducing waste and moving away from volume to values and this is really an initiative around provider payments there is basically provider payment reform it is around a hive qualify involving the paeshlt and prompting costefficientness as you can see this angle area well take an opportunity to increase coast efficiency and increase Better Outcomes and quality and innovate leave movement in this area for a number of arenas around the Care Organization and collateral Care Organization and patient in homes additional infrastructure needs to make that happen as you can see based on the survey a third of planned sponsors are thinking this has to be part of overall strategy when is interesting about that particular area the fact that i think over the last 10 to 15 years move forward to one onesizefitsall even though we know that health care is local thats some of the dynamics it is coming back to where health care is local very different and variations in zip codes and geography and opportunities to leverage that localness of Health Providers asia Health Systems to deliver Better Benefits to the employees in terms of assess. Could you speak into the microphone please. Is this better. Someone that did primary care i was impressed about the support for primary care go i dont see that in many laundry lists of ways to improve some of the perimeters youre talking about. Yeah. I dont know what that means support primary care to an employer or whatever but like to see it. There is direct implementation every research has shown a primary care physician youre more likely to engage in our primary care system so a lot of the plan designs focused on making it cost fiscal to the primary care through the prevent care is it is free a loose we can promote things that have positive impacts. So with Provider Network super change those are area were hearing a lot about and the progressive things aco and Patient Center homes aco tell are very public in the bay area as well as the northwest and groermz of the u. S. We have over seven hundred and 50 acu over the country that increased over the last couple of years and the accountable Care Organization will be pardon the Program Benefits as they go forward and the same with medical homes 7 thousand across the country and growing there is a lot of discussion around directing care so once we actually have the information that you know certain provides providers and certain paradises have better clinical outcomes how to get the employees to use those so there are benefit designs around degree of care the care to the right place and right time so a lot of discussion ill stop there and see if there is any questions. Can you explain what a medical home is. A medical home is basically centered around the employees a primary care that are correspondence the quality of care and facilitates their access to a care it is a coordinated care model does that answer your question. Yeah. This is a really busy slide but i wanted to make a few not as we think about benefits and benefit delivery in the next couple of years so if you look to the left side of the slide where the force that are changing for employers again, he talked about the millennials and the generational defensive that is interesting based on the Consumer Research millennials care about Career Development and less worried about retirement and Financial Wellbeing and financial welfare you have the women that are of the majority of the workforce that point more allocation of benefit dollars to ppo or life balance and differences in either slarld population or Union Population for example, surveyed population valued with the Financial Wellbeing if you have those different would it be fair to say in your environment how this changes the way you offer benefits and deliver the benefits so again, it is more questions for us to you look at but some things that are happening on a macro basis for the employees as we move into the next 56 years their out of pocket costs will increase sixth so they bear more costs at risk and more flexibility and chicagos choice and control over they are benefits program wear marrow empire centered and some dynamics in terms of the things youll talk about a little bit further youll skip the next page we talked about the force the next several pages around things that are happening in the market terms never mind of vendor consolidation and with some of the explosions that are happening with the signifying in a and others providers the carriers expect their outcomes from the consolidation and certainly the market share will deliver the values and value from cost prospective and an ability to leverage it is going to be interesting that will refwharl ability to leverage with the provider and Hospital Systems so it is almost like theyre back in the drivers seat i think that carriers will say that you know having bigger market share will create the ability to analyze the data a district 5 district 5 and consolidation will help with the products with the public and private exchanges within over carrier format so there is some hive expectations of consolidation will deliver but based on the history all the consolidations that happened in 1990 and 2000 really has been not fruitful from the cost prospective. On that point. Its been about two months ago there was trevor involving the ceos of etna and another company and a key kwae key questions from franklin from minnesota at the end of the day will 24 consolidation reduce costs for consumers. And im still waiting for an answer to that question two most later i have absolutely no belief that will happen all the description are selfserving for the company the costefficientcy and leveraging the market and sfoefrth i dont here hearing to the care shares im waiting for the answer ill pit everyone on 90s notice those companies with those planned relationships ill be asking those questions as we go through renewal. History shows it hadnt and maybe comment on the role of government part of problem many of the carriers have for profit arms and not nonprofit arms i cant keep them straight is there Movement Direction and in terms of you know the amount of money going into delivering health care so the overhead is not 50 percent to investors is that factor into here there are differences between you know for property organizations verse in time and certainly from a nonprofit several tasht what actually goes to expenses i see differences and more consolidation observing in the private sector the for profit. The for profit. Organizations. Right. The next couple pampers has kind of talk through the lens and impacts of those consolidations open planned sponsors and provider and Customer Service center consumers on page 15 what does it mean for you say a planned sponsor that will impact our choice and competition thats the biggest worry with the consolidations with the mega Health Organization from a constitutional 125u7b89 im hoping it goes back to the 80s and 90s providers come together for example, aco and the teaches models from a product nomination will come into the market to critique that competition but this point i have big carriers coming together you lose a choice to leverage the market it youre a huge employer in terms of member count it is harder to have a leverage with those organizations. inaudible . Sorry. And then in terms of lower admin fees that will take a while before you see it come to fruition. On page 14 Research Shows that consolidation railway reduces costs and improves costs efficiency are you trying to say reduced costs productive of proves the efficiency and right all the negatives. Also moving on the provider back to the medical home a trend in the bay area for providers when we come forward come down to some of the issues the carriers are reducing their disbursement this . Not reducing the medical car care and question see the fees imposed by or requested by provider of their patient say they have to you know, i know one set of providers is 17,000 a year to get with a medical home so those two providers actually accompany their patients to specialists there is to hear with the specialists is saying and twitter thats with the medical consider doctors are joined at the hip thats not possible did that factor into this i mean shouldnt should be thinking about either ways to encourage members savings accountant. Great question from the medical home prospective a whole gambit of reimbursement approaches that carriers have today and we are moving more towards pay for performance it not like theyre cutting their fees to the medical homes theyre providing ways to do the right thing and the population their severing they have enough few minutes we see a full gambit not to take the services way away but pay for values we see that request carriers and the medical home in terms of connoisseur services we see that more in environments their offering a much higher deduct out of costs so they can kind of supplement the deduct i dont see that where but have robust plan designs with low costs. Were on page 16 in terms of the implementation to the providers again, i think that is impacting the providers from a leverage prospective with the carriers but i think that will accelerate them actually coming together so hospitals and medical assistants coming together around developing those products we think there will be innovation in that regard and i think it will accelerate judge what were talking about the drive to payment by insureers to manage their business about more appropriately. From a consumer prospective that will be diminished competition and choice for consumers and they will be feeling a lot more increased branding by provider with Provider Exchange offering in a consolidated manner. Okay in terms of some key events market events and were focusing on the ones happening in the be sure so sutters is their hmo with their product competition both the marketplace and a lot of affiliations and partnership with areas across the west providers are coming together and their desire to contract directly with the shoppers in certain groups where we come together and Product Innovation and competition in that marketplace. The bottom bullet their quite a few of the here in the bay area we continue to have not only provider groups but health insureers rolling out in the bay area in San Francisco and the south bay and obviously have several aco through the benefits program. Ill actually move im going to move to page 21 well talked about the mergers in the investment. One quick question. And a at the aco youve been around long enough see it theyre working a few of them pulled out one of the ormz. Thats a great question and ask neil and page to add to that their relating now noting new not a lot of data yes or no definitely but rationally going in the right direction in terms of the potential cost savings and things that are related to clipal outcomes and quality care not around long enough to say that is working. My understanding there was some hope that the government will help this transition and offering supplemental funding if their experienced in the year two or three or 4 was adverse that is not come to past organizations are facing financial challenges because of adverse selection or whatever when your small it becomes a big factor. You definite need the infrastructure to manage our risks. Another comment please introduce yourselves and im hewitt ill have to say success is it is still evaluated and somewhat of an impact of the utilization and still not impacted significantly costs yet but you know as the times going on they keep trying to finetune and some things are working but still way good early to tell. Yes. Director dodd. Blue shield has given American People analysis of the aco utilization and costs to our same population through the nonaco members in that small analysis aco were making a difference and neil will attest to the fact when you what is key in the aco the hospital commitment we havent had one particular hospital committed all right. Would you, please continue. 41 fox ucsf the enrollment is commercial body most of businesses are fully insured that is different in the mini market Kaiser Permanente has the market share by a. M. Anthem and fwluld from the market share prospective in this area opportunities for the additional consolidation and certainly that dynamics is curving marketplace o ocurving marketplace curving marketplace curving marketplace ucurving marketplace curving marketplace icurving marketplace ncurving marketplace gcurving marketplace urving marketplace rving marketplace ving marketplace ing marketplace ng marketplace g Marketplace Marketplace Marketplace Marketplace marketplace ring marketplace the network are one of the largest go health and brown and outside the ive listed the aco activities here interesting related to the cost issue and not born by my any data but significant savings ive heard numbers as high as 10 percent it had been interesting to see the data once we have that pertinent information. Again for i think those are pretty consistent with a what weve talked about in terms of impacts to the San Francisco eco system is consolidation will impact the market and some of the leverage will shift back to the providers hospital and to the carriers there maybe additional competition for Kaiser Permanente which obviously has the significant market share with the consolidation we do so continued decline of Plan Sponsors ability to leverage for the consolidation here in the marketplace. And then in terms of just specific to San Francisco and the two blue plans merging it is yet to be seen what that means from a math prospective. This is a very grim assessment but i thank you laughter for taking your castro oil i suppose one the will bring out spots we have for which were falsified with the civic group on health katherine represents for large employers we know that will take that kind of collaboration to kind of and in any way be robust to the what the assessor is telling us all right. Were taking those in order who is up next by the agenda . Issues statement taxed and transparency katherine. Thank you im handed out today, i had our cfo put together a list of federal taxed so youll get a sense of the size and enormity it we review this when we review the actuary letters by the supervisors but the fee went up from 2. 08 to 2 plus and granted that is on this 220th century 200 and 65 thousand dollars a fee on top of the premium the transitional insurance fee moves down in 2016 but that is constitutional close to 4 millions and the c tax 2 percent of premium is nearly 15 million on top of our premiums hasten and then well hear about the expertise itarted to say on top of this rule recall the lunch break of legislation when at the tried to agree on a budget a practice for sometime the state impose a tax on medical managed care plans are the medicaid and medicare said you cant tax the medicals provider you have to tax everyone many manages care we were looking at a managed care at the end of the last closed session and the way it was written in the governs budget they were increasing every year to cover the medical shortfall no perimeters on this and essentially it becomes a tax on a tax or it adds to our excise Tax Obligations so apparently that is tossed out for this year and their deciding it was mentioned across the street he saw this ive not been introduced but it will have to come to some conduct by april of next year and it would be tragedy if we interest have to pay tax on top of taxed and we will work to change that prop thirty was passed several years ago a move to extend that that is a Ballot Initiative well have they not to make that permanent that charges the tax on people individuals can make more than 200 and 30,000 a year so hospitals and the units b will come together to put anything on the ballot for that whether or not that solves our problem being taxed on top of taxes is not clear people at the table are not employers their hospitals and units who want to solve the medical problem but not necessarily worry about our cost of our premiums so that is what i have to say about takes and call on marina. Before we do that im to declare a 10 minute hygiene break marina youll beyou. Okay. Were going to thank you for that recess were going to now take up the question as presented by madam secretary. Yes. This is a issues h s f transparency marina. Marine Health Services and data manager i was off to provide a quick Transparency Initiative you all know that it is our mission to certainly preserve and improve the sustainable quality benefits in being able to assess the value of the care were ref and have it access to the quality information so to that end in our continuing efforts to, of course, have the database heretofore ap cd as part of strategy and weve just recently completed the Implementation Phase and have a europe and looking at how to incorporate that into the tranlt strategies we had a meeting on october 1st here at city hall attend by supervisor farrell and in attendance commissioner scott and commissioner breslin joined us for part of meeting we had members from the cal reform and aon hewitt in terms of transparency, of course, and our executive director Katherine Dodd and other members of the team and some other experts we have off to attend a panelist members from pg h on health as well as policy individuals from usf that came and had several hours long conversations in terms of reviewing where we were nationally around legislative initiatives as well as talking about specifically the landscape that h sf faces in our Northern California market and the make up of our members and our plans and what we can do with that certainly one of the comments in the room that day was one of the tools that has been most helpful in moving forward transparency has been the databases and we certainly have a number of states with them were operate active over 50 more like 20 states those days but we spent sometime delving both possible how to leverage our ap cd you wont go into that update the other take away no uhhuh hazard we know we face in terms of what we are and not able to do here in our market subsequent to that i attended the center for Health Care Transparency they have an Innovator Forum in San Francisco and the focus of that meeting was really trying to identify regional and statewide entities in a goal for insuring meaningful information on a relative cost and quality of Health Care Services available to 50 percent of the United States by 2020 and so in that room were members from many different states i think about new york and massachusetts and wisconsin and colorado and oregon and a number of states that already have mcds and certainly legislation are reporting theyre doing and it was a variety of other some people that focused on quality and some people that were focused on the providers side or the purposes or consumers there were technical people in the room the focus was in terms of 24 strategy around the 2020 goal trying to establish regional data in a intermediate to collect data for the people and Work Together to put into the public says that a National Public reporting requirement information around costs and quality as well as clinic information and instead of you know trying to build top down solutions looking at a grassroots integration bring people together and be able to by each regional and intermediatey vice chair a responsibility could we get to the 2020 goal certainly the Health Services system we continues to look at how ways to take our action and driving the goals were in the process of evaluating for 24 meeting if we could apartment and looking for elements we dont track only a certain piece if this is a value and will that work to do that we explored that previously this goes back to late 2013 we looked at integrating the chip the California Health care Information System that is administered by dpw there are different teaches chips and at this point we looked at that integration there i know we hit into some difficulties in terms of satisfying the Business Association agreement with the City Attorney and the other party so we did moved in 2013 it is pursuant we visit that here especially with the ap cd up and running we look at again to deriving to that actionable. With that point marina. Yeah. The Business Group on health and investment you say it maybe is that a signal we can expect to hear from you how youll be doing this and what. My first step to go back to our City Attorney contact to revisit what we had pementdz and see if there are opportunities to move that Going Forward calirnia is certainly one of the states that has been ragging with the statewide database and should it be closer it will continue to expand and certainly with our longterm strategies being able to interact you are data youll start with a conversation it looks like we can pursue ill bring back for details. You have a graphic at the october 1st meeting i think that would be useful to insert to the record of that hearing the cc investment this document youre not supposed to flash anything the public cant see if we could get a copy of that to be integrated it shows with the transparency begins and so it is always at the Health Care Providers door thank you. Thank you very much. Thank you. Are theyre questions if you would remain questions by any of the other commissioners august yeah, im new to the board can i begin transparency and is it transparency of outcomes to the transparency or interaction what exactly are we talking about. Its a great question. Sorry to ask at the end of your i think if i had the answer i wouldnt be here but on white house i wouldnt get around the cost or what is is talking about i know that even like this Health Care Center for Health Care Transparency there theyre looking to the regional intraerdz to help begin some of the terms what were trying trying tee drive to to the cost of care and interact p segregate terms of Patient Experience not only our provider prospective or our health plan or perspire, you know, to get the full picture on this so what we know die that i think that will evolve over time we dont know what were paying for not the the value can we sit here and tell you he assure the quality is what we expect im pleased the ac d. C. Gives information about the quality and preventive skewer and big deal to do other assessments our agency for Health Care Research and quality i know is looking at creating a standard hopefully, will be released next year but lip into 2015 to create standard quality for the ac d. C. So there is no easy answer what we mean by transparency other than oh, the question what are we paying and getting for what we pay. Other questions from the board. All right. Thank you very much. Next were going to move to the 10 bay is that right. The bay area 9 county analysis and yes. Marie murphy. Hello marie is this our first time. Yes. It is good morning. laughter . Im the Research Assistant can everybody hear me in the back. Apparently youll hear otherwise. I dont diego dousht it so we created this survey of the 9 bay area communities to enlightenment the 10 county survey youre quite familiar to getting a sense of the neighboring counties in terms of their benefits to employees in order of most to at least populous the 9 areas a Santa Clara Alameda contra costa pr San Francisco san mateo. Solano, marin and napa we collected data so all the health plans for employees busing plus one and two the plan design so what they cover and at what percentage, etc. We collected data on the premiums with and without medicare for retirees plus one with or without medicare before we go further it came to my attention you received multiply copies of document well talk about in your folder so if youre looking at a few Different Things well clarify just now im providing overview we looked at vision and dental and voluntary benefits i know im forgetting things hospitals and county and whether or not counties provide coverage for adult disabled children that was a bit more involved than the 10 county survey the document well talk about today fortunately is a summary of the data the key utilities heave post the awe pension fund peculiar online over one hundred 50 pages at final count we didnt make paper coops. So. Just to reiterate then even with the data that is part of our board today, youll saying a expand volume. Thats correct. All it is posted online. Thats correct and assessable to everyone. Thats correct online as we speak. Okay. Thank you. So if youll turn to page 2 of the document you should have ill ill scroll the way to tell whether or not our looking at the correct version by looking want bar that represents marin county you should see the bottom number of 800. 08 by he won hundred plus percent by one thousand 30. 94 and zero percent he at the top of the bar and zero. Zero not 100 percent. Correct. Correct as long as you have that in hand ill precede yes good so what. Looking at the averaged monthly medical costs for employees only for each county youre also looking at the average employer and employee contributions to be premiums by county the percentages you see represent the percent contribution for employer and employees those averages are not evaluated for many factors it would be considered important like plan design and covered lives per plan the demographics is as with you know the rest of this document weve provided this effort represents the significant step forward in terms of gathering the population on gashthd tends other things we meet want to think about should we conduct that kind of study in the future take those numbers with a grain of salt the activey analysis by ann might yield things but with the caveats directing your attention to the fact that the averaged employee costs with highest in alameda and contra costa and santa clara then napa then is a loan be then marin and san mateo and San Francisco from marin 100 percent covered by the county not a typo every plan designs is absent different for marin the employees get a cash rebate speaks for itself in the planned premium museum it under one thousand dollars plus moving open to page 3. Can i ask would be question and, of course, of course. A Health Coverage you know my understanding started during world war ii when employers outside of military industries couldnt compensate the employees can those adjusted for what the employees average income if we look at guaranteeing this county looks at generous their average salary for the same you know absolutely. Is that a stupid. No a terrific question. Do you have that data. No a preliminary effort by the way, as a pilot effort that provides a usable starting point we didnt previously know but looked at into the future. Commissioner lim. Just a clarification for marin the contribution for employees is over one thousand the difference is is an incentive. Up to one hundred dollars they give back to the employees. What well see as we go obtain on the employee plus one and plus 2 the county contribution is set at a certain amount id have to look at the appendix the way for employee only premiums if the employee choices a plan theyll receive a cash back rebate correct. Moving on to page 3 and very similar representation here except this time were looking employee plus one premiums so weve averaged by county and averaged the county contributions, and again, we see that Alameda County premiums were the most expensive and followed by contra costa and napa and is a last night and san mateo and then San Francisco and is a not only. Move on to page 4 that takes us to employee plus 2 premium costs and average county contributions to the county costs. Same idea and caveats not adjusted so interest not question questions im sorry to viewers at home. What page page 6. No page 5. Page 5. 5. So, now the retiree premiums on page 5 the average monthly premium costs for retirees only that have mefshg parts ab so again those afternoons are not evaluated adjusted for the covered lives, etc. Id like to point out those amounts are not adjusted for the variance in criteria for eligibility for retiree coverage mover over as you can see we dont have data for many of the counties we dont have the employer contributions to the premium for san mateo and dont have any data for santa clara so ill say more about the difficulties later but for now getting the retiree data was difficult one of the reasons for that the divisions within the county that administer the Health Benefits for active employees dont necessarily administer the Retiree Benefits sometimes the people we get data didnt have answers didnt get them in some cases no questions page 6. Okay similar to page 5 were looking at medical premium costs and county tricks with employees with medicare and dependents that are medicare parts ab were taking o take into account the fact those are not adjusted San Francisco contributions are generous not the most generous of all itself counties but we stack up well against the others then we move on to page 7 we look at the premiums and retirees that dont have medicare we see the most difference for San Francisco excuse me. So looking at page 7 were talking about the average monthly medical costs and counties tricks for retirees 0 both dont have medicare and even though we take into account go what your data didnt account for we see that San Francisco contributions are the most generous. Moving on to page 8 this is a continuation of explanation of premium costs and county tricks for retirees without medicare this is for the premiums for the employees plus one without medicare. So again just as i mentioned for retirees with medicare those averages dont account for Eligibility Criteria one of the big ones oh, there we go. One of the big things without medicare is years of service most counties had some sort of requirement of years of requirements to be eligible for i retiree coverage some have complicated formulas that has to do with sick time remain and the number of years worked, variance things that werent account to the difference we dont account for those this is a guide rather than an exact measure but again given this information in San Francisco the benefits esteem to seem to be generous in this department and in terms of 9 counties that were surveyed can we assume no data those counties not one Service System that administers or reviews plans like in San Francisco how could monotony know what mraung not know this. I mean, were talking to the right people. Correct there isnt as i said earlier every county has a way to administer other Employee Health care benefits in many instances in the access not been able to get the information and not knowing exactly why not and well talk about towards the ends some difficulties within the Data Collection effort you know wouldnt be generous of me to assume the worse Case Scenario so the short answer not case of San Mateo County a system to the premiums it is about bit con equivalent i couldnt get numbers to represent their data. Commissioner lim. Or. The san mateo cover retirees. To an stent to an stent the extent to of they do is unclear im not comfortable or confident giving us more concrete answer and there is sick pay but the last i checked thats been a while. It may not amount to much. Commissioner lim. For the retirees and the agency. I dont have is fine grain daily. It didnt include any thoughts retirees they have definite and we couldnt get to that level of detail. Thats small theres a presentation for next time it will change eventually 5 or 10 years after the premium they have retirees depending on the number of services assume more of the costs. Overwhelm to ask i know we have a serious or series of charts that is counter to the first pass were traeg to do this is it your sustainability to receive or refine to come up with a summary of some kind of major themes that run across the graphics your shoukz. Youll with to ask director dodd about that. Director dodd laughter by i mean it is useful information yeah, he recognize you can go back if and do our magic with the adjustments given planned and demographics thats all interesting by once we have these data delayed is there a theme youre trying to get at in doing the project at the out set. The goal to look at how we compare to the other counties and included retirees when we do the 10 counties analysis which we set over mandated contributions to active physicals there are represented by retirees those are counties that are not anything like us so to compare to San Francisco to la county is like commissioner Vice President mar apples and pin apples similarly and i think neil can atte the School Teachers have that i think our 10 county analysis is as inaccurate as this is to the intent was to kind of give us a per of were there similarities or not as you can see that there are a couple of places where we are off the charts but for the most part were similar to the county that explicit sprees us we looked at the utilization data from cape and they ran the counties and allowed us to look at our data were similar to the bay area county it not surprisingly our costs are similar do we intend to go back to piece this out this is how many months of work 6 . We congressmens this in july it has not been a full team efforts but as well as say more towards the ends the labor that went into getting 24 was not ensignificant thats not just my labor and the labor of katherine and rosemary the communication manager i was extracting and in some cases x tracking this data if benefits representatives and have any things they consider important to do so you know the level of detail i was trying to get required you know lots of nominees e emails we contacted the chairs of the board of supervisors which we should have contacted the h. R. Directors but we need that and it is useful to you, too no incentive to give us data and so let me say for the record some of the benefits were trembling on top of and very responsive giving of their time as and could be and some of them there is a tremors generous of them but the up shot viewing this is not a hop skip and a jump if he were to consider that. I too want to know the goal that takes that much time weve changing the 10 county survey whats the goal. All are have to ask director dodd. See how different from the 10 couldnt to see if we could make a cost to see if they hire in cancel to give you a sense of how much other counties were spending on premiums and how well or not well, we quarry think that it is pretty clear we do well at norwalk premiums given our size when you look at the another counties that was the goals. Questioning egging questions or comments. Thank you for you will this data and getting to the counties the cost of the 10 counties is different from the 9 counties the cost of living is similar amongst the different areas of counties so thank you for all this data it is helpful when will you have the data on the number of members and lives it would be more helpful how many members are dead to San Francisco or let me see what my fellow commissioners have to say and contra costa. We didnt analysis for those differences in the appendix we have the number of covered employees per plan youll see inform each county within the appendix. Thank you. Sorry. Just have to add. You have to look at that but even within that covered number of employees i mentioned we dont have the excuse me. Per county and for lives per plan getting that would have been monumental. Good word. Our presentation people go to our website and get this information we have far more transparency than any of those other 9 counties a contribute tribute to the system h sf was detain we did the demographic reports all along and the county board of supervisors didnt want to see that it is kind of surprising. Yeah. We want to reiterate while were on that point i was wade through the counties presentations of the benefits information i can say that our presentation of information is head and shoulder above that of other counties we present more information and in other same place places than other counties do that is something we should all be very proud of. Your referred seechlts ill be saying that later were at the point of later and unfortunately are fortunate. Lets talk about page 9 we spoke about. This relevant to ann presentation a little while ago it is the plan deduct for employee on this coverage within the plans we had planned designed information the 9 bay area counties currently over 67 plans and out of 67 plans we have plan design information for 53 all detailed within the appendix if youre interested in looking at it. But we see the majority of plans were excuse me. Planned deindict were 500 or lower 87 percent of plans had relatively deduct they have a deduct of zero dollars and level of 11 percent have annual employee detublts over 1,000. Okay moving on to page 10 we start to look at the employee only dental plan maximum and ill discuss well see on the no objection page some counties have dental plans not plan year maximums those maximums are for the plans that have maximums and the range from 14 hundred excuse me. One thousand 200 plus to 3,000 for dental plan maximum again, this doesnt adjust for plan design and the Provider Network we collected data on dental plan and i suspect the wide range this the depth if youll turn to page eleven you see that we had 8 dental plans offend by the 9 plans with not a year maximum this is interesting but we dont know exactly if they have one one half dentists or may be one hundred we dont know that moving to page 12 math preference, etc. In bay area counties. Now this dynamic shows of percentage of licensed hospital beds you do understand by sutter if each bay area counties i want to caution that is meant to be a guide and interesting starting point but number one getting the number of licensed hospital beds was not a straightforward endeavor as one might imagine the counts i have could be 100 percent accurate ill not try to sill that with you know on the honor of my kitty cat and everyone else i spoke with hospital administrators websites and drew on other sources sometimes two experts of same hospital will give me a different count for the licensed by these those are the kinds of things we dont know this time around and important to keep these in mind licensed by these are the beds for which a hospital has a license to operate it might be ill have to look at available beds or staffed beds so with a grain of salt this is the math resource of sutter. Yeah. I have a question within this a little bit for example, for San Francisco im assuming you excluded the va hospital they dont a license the beds. Correct. Its the federal number one and so certain institutions like laguna honda that has the most licensed beds in the city and sfgh which if not two or three are they included theyre not commercial beds in the search warrant someway that civil right e. R. Charity. Those are include in San Francisco is count so the percentage is available for example, to Health Plan Service is contracting maybe higher i mean 19 percent maybe underestimated because a lot of the beds are not assessable to us the laguna honda is not Offering Health plan options. Right if we want to get more precise what question count as a bed that is accountable we need to set the criteria more specifically correct. Okay page 13 is glossary and pages 14 and 15 how the nittygritty what the limitations and weve gone through many of the things here i caution that further analyze should take into account the time and effort that is involved in such an affair and what is not listed it is the matter of timing the other counties have their goals of work throughout the year open enrollment makes everybody busy but prior to open enrollment they dont know what is rates are figuring out what best to conduct that kind of a survey not a simple thing to establish thats not to say it wouldnt be worth trying tee create a work plan that is more systemic that was a pilot effort im sure that would be reif i understand in the future for now it is xfrm to point out the perplexity those numbers should be available to you know the inquiring minds that want to know each community presents their information in a different way some presentation of information are more assessable though the intersect than others and more complete than on the information is available throughout the year, and so forth. I for one thank you for your work and effort in doing this we may consider that i know we like to know this every year this might be in every other year or 3 years and refined you know well assume this is baseline all of caveats youve outlined thank you for your work. I want to point out the caveats i feel it is important to do but emphasis this is a starting point more than we knew about more of months ago and let me emphasized if you want to know more go online with the appendix and detailed information as we could get and dont print it. Right. Thank you very much. All right. Were at a Decision Point unless everyone brought lunches or diners im going to take the pro romantic of the chair and we have a series of emerging topics were going to discuss and when i see. I think this will take discussion. I believe beven duffey was going to present hes not here yet so. Im going to suspend on that one all right. Id like to had had pharmacy and the excise tax okay. Then we can get internal like katherine and mitch that are ready to present theyre always with us were not losing them and say oh, my god we got out before dawn to page come forward. The person from the xhoiz wisely is here. I it out that was you not you katherine defendants deposition well have that person choosing wisely where are you so any of the guests their speaking on topics make sure we get them done out of courtesy and the team members well beg over dloenlz so pharmacy benefits. Player and members of the Commission Im with hewitt and today id like to spend. Few minutes talking about pharmacy tearing and i think one of the things we talked about in may was the fact that there is a big procuring on pharmacies the trend is increasing as you can see at about 25 percent of the costs now relate to speciality and that increasing the speciality costs are increasing at 20 percent a year clipping that is sustainability is becoming an issue as we Going Forward and we have 3 health plans theyre struggling how to manage the specialty costs within the parliament and within the rates they substantially offer to you so tiering i i he giving different types of drugs and costs structures is one of the attempts that people are using to balance the Pharmacy Program so if you look at page 3 let me see you will see your current pharmacy share this is for nonmail orders youll notice that blue shield of california has four different costs they can apply to they are different pharmacy pharmaceuticals depending on the type or what their formula is and city plan has 3 and Kaiser Permanente 2. And so well come back to this page are, if you will, just keep this in mind that is a good Reference Point when we talk about the issues that surrounds speciality drugs so first start but out with blue shield im not going to you would like to acknowledge the health plans are supportive presentation providing the information, and, secondly, not focusing on the commercial populations at u h c it is small were looking at the two Largest Health plans of blue shield and Kaiser Permanente so for the data period january one 2014 to december 31st youll see their speciality drug was 26. 2 excuse me. Would you give me a number on that rough number how many Million Dollars at hand. Well get that and the percentage is two small to know but the issue at the end of the day when you tell me that is 20 percent more than last year 20 percent of 2 million is one thing but 20 percent of 20 million is a big chunk off money so it will be helpful to have a. Very good point i dont have it deck but i said to point out if you look at what i would call the more common curtains that is your rheumatoid arthritis, your example s and cancers that is that represents about 44 percent of their specialities spent and hepatitis c one is cancer. Right i was going to the next page and talk about that youll find that really represents point zero 5 percent of blue shields population is spending that 26. 2 percent were not talking about a large coholster but talking about diseases that you are all probably familiar with ms, cancer and you know, of course, hiv and hepatitis c. And so as we go forward i want you to remember here for blue shield for speciality drugs theyre paying 20 percent of the costs up to one hundred dollars. Is that per year. Thats per prescription. Then for moving on to page 6 and ill catch up here we have Kaiser Permanente experience ill point out here this is slightly different time period from its at same 12 months but rolled forwards six months sorry it represents 31 percent of their drugs spend it in speciality drugs 35 percent is spent on hepatitis c and others and 51 percent of their additional costs are spent for cancers, ms and anti aikt reiterates you, however, the first page two tiers with 4 or 15 so right there in and of itself presents the challenge that we have before us with speciality drugs how should they be placed and where should we go what is a speciality drug weve talked about this before but basically, it is a drug where manufacturing is very complex and requires special handing and usually a different root of administration through the mouth, it is very high per unit here on behalf of the appellant and on your page 6. Yeah. The specialty drugs 31 percent for Kaiser Permanente you know what is the prescriptions on blue shields is 8 percent, 36 percent of speciality okay. Youre saying point zero 5 percent was the specialty drugs but what prescription does thirty percent e. R. 34 percent for cape and ill photo i didnt ask for that when i got the status ill make sure that is in the final presentation very good question thank you. Then again, we have clinical that gets that is required and currently about three hundred speciality drugs with 6 hundred in the pipeline of course, you know most of them are related to cancers this is why speciality drugs is a focus of cms but you have a Significant Impact of hepatitis k c on the medicare population it is on everybody elses focus one of the things as a result of speciality drugs you used to have the benefit managers that were working together i mean that is causing tension because now the pharmacies is taking money from the medical side that is a difficult pie is only so big. So id like to. Commissioner has a question and he was confused by one of your statements on page 7 it may require a Health Care Provider everyone he, he was matt haney the Health Care Provider is required in order to administrator it. Okay. Not all drug requires a Health Care Provider to administrator. You might want to clarify. Any other questions before i move on. Im skip slide 8 and go to slides 9 in effort of time so i went to blue shield and asked him what are your current considerations you have 4 tiers their security tier structure is one through 4 with a higher tier with a higher coshare and wrrment based on the drug effectiveness and that speciality drugs are placed into tier 4 are they were considering for 2014 a fifth tier and it would be available for all groups now i can say in the literature i see people going to 6 tiers i asked Kaiser Permanente they were very nice enough to talk about their approach and they feel it is presenting a challenge to the whole u. S. System and i bring that up because you noticed on page 10 their bottom bullet is theyre advocating for lower prices with pharmaceutical manufacturing and working with at stakeholders to that that katrero park has a history or working with other shareholders and been effective to make it a efficient move forward so when Technology Come forward it is adapted unformly the fact theyre at the table working with other advocates to try to address this means we at least have strength in numbers at that in that political process and like blauld has position exert panels reviewing the speciality dug use make sure that is working, they make sure they use others nondrug theefrpz when available but really the issue is what is parties in the marketplace . They currently have two tiers for that system they like that if youre only paying 15 and Kaiser Permanente and 50 at blue shields if anyone needs a speciality drug what plan that might you choose is that making you will say you know xafshl i mean blue shield a fifth tier theyre looking at adding an additional tier for speciality drugs in 2016 and what offer to us if we choose in 2015 at this time u h c currently has a 45 copay on their third tier in the middle 24 7 Kaiser Permanente and blue shields they are no plans at the present time though in the backroom as theyre one the largely palmer suicidal benefit managers to add an additional tier or a copacing pay but not in the plan now in conclusion you have to remember the population that is using speciality drugs is very small but theyre using a great percentage of pharmacies and the estimates if a number of different sources is that speciality drugs could steeped 50 percent as early as 2018 one of the issues not none the table and this may be aware bio similars are out the first for neutrogena is available people with not automatically switch for a generic and other advancements like the area hypertension looking at pharmacy tier from the area what is reasonable and compatible will be a critical decisions point are there me questions and additional questions i want to thank you as a physician in serve practice with one carrier giving me a last time donated cards with 5 formulas just for medicaid in the 90s, the medication for upper religious pretrack infection this is an evolution of what is for a long time and there are all these gimmicks that pharmaceutical companies that offer documents and theyre being challenged by the federal government and the attorney general because theyre providing the staff to lie about enter criteria i dont know how that fits in this comment that is a huge deal in the drugs are getting direct Consumer Advertising as someone that has to watch tv but the modern value to those companies a implementation advertising for multiple sclerosis not in the top 5 groups but advocating to the consumers on tv it. It brought id like to document the research but basically only 6 percent of the population uses the coupons stays on a brand drug for a year along a person that didnt use it and gets trefrdz to the generic lower costs a significant issue as you may know not loud in medicare and medicaid not all physicians and members understand they cant use the coupons it is a challenging problem. My good wife said when she sees an ad did you listen to the side effects would you take that. laughter . Again any other questions . Okay thank you very much all right. Neil island ill ask you to understand the head can only comprehend what the hand whether endure laughter . Good afternoon youve heard much of this before this is an update. There will be that is my cue to be extremely succinct a wlat afternoon commissioners im here to update you from january 8, 2015, the impact of the excise tax for ill briefly describe wear were talking about the expertise dont describe what were talking about does anyone need a brief education what an excise tax is. Weve had that. Whats the bottom line we have on pages one, 2, 3, 4, 4, we go through all of this and since we did the assessment used the premiums and went through the cycles some of the premiums went through a rigorous experience to lower that that was generating a tremendous amount of expertise so we went through a subsidy presentation and subsequent agreement at the board and so those premiums and what is projected are lower so lets go to page 4 and see where we are actually page 6 for 2018 one number went up this grid is blue shield early retirees as you may know we increased the rates for 2016, 11 and a half percent for blue shield took a recreate increase a that increased that rate and therefore that plus what we see in 2018 have made this number higher the number is pretty much where we were with Kaiser Permanente and the lower number it bans the fact that the city rates have been brought down as we did in the january meeting we shared there are rules we finally overhead in the early part of 2016 that for those you can blends early retirees which we saw were expensive and the medicare well blend the numbers we need guidance there are terms last week similarly situated plans the exact same benefit of that and so forth we are really not trying to make major adjustment to blends how to be able to blend so page 7 says if we can blends all of our you know assessment of the expertise for 2018 is for early retirees we have early retirees we basically eliminating all of the tax for 2018 which is a fantastic situation for us we want to blends thats what we want to do and when we know exactly how to blends hell come back and say that is what it looks like i want to say as we do rates and benefits when we present the numbers in june we present then bear what we determine and what it means excise tax wise and i will suggest when you go we do that just to give us the context on the basis what that would be if it were blend and not so we see both numbers. Glad to do that a subs recognize that is the way to go it will be useful to document okay. Had this not happened this would have been the higher. Well do that after the guidance pickup truck. So with that, because the rigor the board we document everything understood. So the policy decision done by i mean by the blending because sometimes there noticing there is no final giles. The people the experts in the companies have assured me the best understanding is the best quarter of 2016 were ankyawaiting this information and lots of people dealing with hethd and the other people that do this kind of work we want to know about blending this is a lot of money and looking at other ways of dealing with that sending the early reertsdz to exchanges they dont want to do that so theyre waiting no final guidance. We have to remember the nature is a tax that means revenue to the government when they see a dramatic shift of millions of down to a shift that may influence the outcome. Question, sit here 3 more hours why theyll consider it or not but they are considering it hopefully guidance we like with that, i want to say one more thing and well move on we need to turn to the awe pefrngs peculiar weve conducted the regulations youll include those we went back and actually took the sense excess and added to the project calculations so with that, it is slightly increases the tax so we have look at it as a first task would we eliminating this too much of an impact to the tax youll have to do that and my understanding is that discussion should not and most likely will not be had were goito eliminating the h h a first, the assessment put the maximum amount we didnt get the elections in time to present that material we caveated and say a percentage so we did that so what did this mean at the end of the day where are we with what we would like to be our realty turn to package 13 on page 24r7b if we blend and you have to be determined the stementdz path for 2018 is 4 hundred and 65 thousand dollars thats it. So if we accomplish those goals otherwise cant blend through s f s a the tax tsa is 11 million plus if the things turn out to be which maternity happen not within that kind of range blending has a profound impact on our excise tax assessment this my most current update any questions. Questions or comments. This is very clear to me appreciate that i actually thought that was very helpful. Thank you, sir pleasure. A topic that will be. Yes. Commissioner lim. Bring back previous to marie as far as the subsequence were better off than the others 9 counties because theyre way too high than us excise tax point. 100 percent agree and it as an awe up to the time objection, sir well done. Were now going to go choosing wisely and katherine come forward and identity 50ur name and affiliation. Rebecca. They brought up choosing wisely and the California Committee on reducing waste and excessive cost is using choosing wisely measures i thought that would be helpful well be electrical want to include them in our contracts next year not all of them but 3 main ones but this is an incredible all of this is available to the public online it is remarkable so. Hi is this on. No youll have to use the other one pull it way down and in front of you. Thank you for having me. I know were overcame ill try to keep this brief and to the point for those who are not familiar with the choosing wisely caption campaign to get patient and Health Care Providers to talk about the use it can be harm and excess costs for over use of italy biotics and religious picture and low back pain, etc. Ill talk about the choosing Wisely Campaign what customer reports and the materials you can use that are covered and the covered benchmark are the employees of the city and county of San Francisco and that it you choose to adopt that ill talk about the 3 taefkz that the california statewide work group on overuse is using those 3 tauvengz you might want to consider looking at so to get started overuse a huge amount of over wastes millions and this is a combines of the providers Offering Health care not needed and, of course, due to cultivate norms of turfs on television the patients are getting this information choosing wireless from the american boards of external medication foundation it is a knock it out of the park to promote conversations will medical overuse between patients and providers to step back the reason the Consumer Reports is involved is similar how did reports are known helping people make important decisions what refrigerator to buy were helping people make decisions by asking questions and what the safeties item to search is it the safety or the one that costs the at least expensive and similar with protecting is it is the right and safest and something that will turn the best investment thats why it Consumer Reports is involved weve worked on the first article in 1996 we worked on ac slefr people think we jumgdz into that weve been working for quite a long time the way that chillies wisely work the america board of Foundation Went it out other societies to the professionals, etc. And said we propose each of you come forward with 5 medical tests are treatment over eve doing within our society and come up pubically and put them on a list as you can see those are the lists everything was well documented and in april 2012 when the Campaign Began the 9 society that came forward and said pub say the tests that are overused it is quite bold the over 70 parents and also some nonmedical like dentists and therapies over all 4 hundred tauvengz the societies talk about overuse and as Consumer Reports weve been hammering away at a hundred of them ill say talk about 3 of them the california statewide working group has worked on. So as you can see here a Consumer Report weve created collateral you can create with all available with no costs unlike the Customer Service consumer prescription all of the Public Health is in front of the the people where no pay wall it is for free weve been willie brown work with the medical societies with posts posters and Public Service announcements and volunteers you were hundred people use when they talk to the doctor do i need this treatment what are the risks and the costs we believe that by asking those questions the providers and patients will really be able to engage with conversation about overuse i want to talk about 3 areas for example, choosing wireless openly petroleum is a overuse the state of california is working an two greeters one in Northern California and one in Southern California currently and opium is one were looking at if you were to go ahead at the board and adapt choosing wisely one you might want to look at go is if sync request what the state is looking at this flier is for all the topics on the Consumer Reports two page easy to read brochures in english and spanish starting to consider others language likes korean and chinese theyre talking about what the risks and harms and costs why you may want to think twice and on the backside the blue box if you break it fix it were saying for example, dont out openly workshops heres other techniques the second topic area is the low back pain medications for someone that as a garden variety of low back pain and for 6 weeks it is unlikely they need tests that whether leads them down a long path and exposure to radiation and the final topic overuse of c sections for pregnant no risk to the mother and baby dollars the c sections again, i put up this example here. Choosing wisely ive had a huge pickup in the mainstream and medical journals as you can see in nine out of ten usa today and voltage and mens journal, etc. Weve got a huge reach across the country Consumer Reports work with 70 pardons like aarp and other Smaller Health care acholic beverages in addition to the grants that are working on choosing wisely there are 7 grants two in california they have a minimum have to Health Care Systems within the grants anytime 14 across the country and in each one of them must within the next 3 years decrease overuse by the choosing wisely by 80 percent from baseline all of them are working on italy boefkz and respiratory attachment treatment and some chos choose low back and etc. I wanted to pointed out the los angeles counties of Public Health theyre part of the grants and doing fantastic work in reaching folks in Los Angeles County and finally he wanted to say we have a campaign within in choosing wisely an app a special website and video series if Companies Want to roll outburst choosing wisely to the consumers that is a way to do that quotes of Lessons Learned from using chulz wisely ill be happy to answer any questions. Rebecca give us our full name. Rebecca rocketing child the Senior Leader at consumer workshop. Your proposing we use this all online is that the ideas. You can use it openly we can build you a micro site for all the information that is cobranded we can roll to employees or work with the specific plans we can give us tefrlz so that pds and posters and videos so a huge mulch the tells ill recommend if you consider it pick a topic or pick the overhead 5 questions areas that i talked about with the posters that generally works better than accept and expend outer 4 hundred topics that is ooechlg. You send members email and ask them about that. You can send to members newsletters and materials hardcopy or emails if i work with particular clinics or Doctors Office or the hospitals find the materials hanging thatll whether it theyll pick up the materials online and offline different ways wearable to work with you directly to think about how your members month benefit from it. I think the thing im struck by a rather Robust Communications Police Radios with the members there are ways Something Like that if we decide to proceed will be integrated into things were doing wellness stand point and things online so on other questions for the boards otherwise well make a recommendation to katherine. I think as adult abuse ive seen this process evolves it is brilliant because one of the impedes is the physician themselves and the focus fact it comes if the society and the rapid acceleration such a i persuade this ive seen adds for a bio long for my condition i get reports and the aarp and all that so it is not enough to me it is put it out there in a once a year you know memo toe members remember so how do you actually what kind of recommendations from our 0 program can we think about that is real dont go into seeing your doctor for low back pain how do you see that. It is a good question the campaign is shifting the Culture Bureau or for the providers and general consumers to that maybe going into the tests and asking for the italy biotics is not the best thing to do get people to been shopping youll never go randomly buy a car or washing machine why are you taking this medicine so get people to think about this from a consumer prospective and actively consumers ill note that while i and consumers reports the fupgs foundation is wlookt both angles were trying to change the culture. I read a presentation on this on the committee to reduce the over use many hospitals know how to assess their Electronic Health roared one physician if south side cindy sgifz to any facility wer