Transcripts For SFGTV Health Service Board 41317 20170418

Now have your secretary call the roll. President scott, present. Lim,print. Breslin, here. Farrell, expected. Ferrigno, here. Follansbee, excused. Commissioner sass, excused. We have a quorum. Thank you. Well now take action item number 1. Item 1, action item approval with possible moud fiication oz thf minutes of inmeeting set forth below regular meeting of march 9, 2017. Im ready to entertain a motion fruproval the minutes. Move that we approve the minutes. Second. Hear second. Any edits clarification or comments by the board . Any Public Comment on the minutes preceding meeting . Hearing and seeing none, we are now ready to vote. All in favor signify by saying aye. Opposed . Motion carries. I do have discussion item. That is item 2, discussion item. General Public Comment on matters within the board jurisdiction not appearing on todays agenda. Is there any matter in the boards jurisdiction any member the public wish to comment on it . As it relates to the Health Service system . Not the general environment or other concerns we might have. Hearing and seeing no Public Comment we are now ready to move to the next item on the agenda, which would be the rates and benefits committee. I am going to claim the privilege the chair in doing two items. One to move item 12 to the next item, which is dealing with the executive director search for the Health Service system for the city and county of San Francisco so well move that item up and take it for consideration after we have this particular item. Im going to ask acts executive director griggs to please comment on the recent staff issue with the Health Services system, please. Thank you, president scott. Greg, director of Health Services cystism. Manch was a tough month for hss. We had a employee pass away and that is [inaudible] henry. I want to thank our eap team who really supported us during this loss. It was unexpected, it was very difficult for the staff but very lucky to have them as part of our agency. Vedy was hired by the city in manch 1980. She worked as a claims processor when the benefits were under department of Human Resources. Became a claims process for the health plan when hss admidgestered claims for the plan. During that time he was interrum supervisor and became a Business Analyst working in Business Service as. When vedia passed march 24, 2017 she working on 38th year of services. She had Excellent Customer Service skills. We received so many compliments about her from our membership by phone or email or letters or members loved how patient she was work wg them and making sure they fully understood their benefits and spending all the time it took to make sure they were clear. I worked with her on several large issues including medicare as a secondary payer. These are really messy claim jz she was our subject Matter Expert on that topic. All othf staff enjoyed working with her and since she had the most longivity we work would her every day. This is a great loss. We miss veda. Thank you very much actbing director griggs and in honor of the life and service of vedia hechbry i like to ask the board and those in the audience to please stand and have a moment of silence. Thank you. As i indicated earlier, we are now going to move one of our items up from the regular board agenda, which is report on item 12. Thank you. Item 12, action item, report and possible action regarding evaluation of such firm rfp respondents and possible recommendation of a finalist to the rfp for the position of sfhss executive director. President scott. Thank you. We have been engaged in a process since our last meeting regarding an rfp. I asked christina to come whos is a representative of the dhr department for the city and county of San Francisco and working very closely with us on the project to give an update of process update and well comment on what well do next. Yes, so the department of Human Resources issued a rfp for an executive recrument for the position andsent the rfp to had recruiters on the prequalified list. Department of Human Resources received 3 roposals by the deadline and those were forwarded to the board for review. Alright. We received the proposals and christina, please say your last name and position with the department for the record. Christina bresocka Senior Administrative analyst with department of Human Resources. Thank you. I received the proposals immediately got in cablth with my council to be sure that what we were getting ready to do is absolutely in compliance with the requirements from had brown act and what have you and with his guidance i asked commissioner breslin who is serviceing as the share of our governance commitee to join me in the task of reviewing the proposalsism we set a time certain this past tuesday to come back with any follow up questions to both christina to be clear what we should or should not do reviewing these proposals and got clarification of some of the detail squz services described. Following that, today commission, breslin and i did meet to discuss results of our scoring and what recommendation we might make to the board and to the department of Human Resources as to a next step. After review and discussion over a very nice lunch and one of the favorite dining spots in the city, call thd city hall cafe we came to had conclusion we identified one firm which we want to refer to the department of Human Resources to begin the contracting final steps of the contracting process and we need the authorization of the board to do that, so im going to offer a motion we make that referral and without publicly today disclosing the name of the firm or any of the cost or any of that sort of thing and the council to the committee will explain why we are doing it this way. Okay. Generally it is being done this way because during the process for negotiating a contract through a rpf process, the city keeps these negotiations confidence until a contract is signed. Once that referral is made and in a offer is made to the applicant and if they accept, then the documents with respect to the applicant that accepts are made public. Compligzer breslin and i are in unanimity in termoffs the recommendation to the firm so the motion is as follows we recommend to the board that we refer to the department of Human Resources the name of the first candidate for thecandidate we reviewed and scored to begin the search and the executive drether of the Health Services system. We are further instructing the department or requesting the department to begin the finalize the Contract Negotiation squz proceed in the process as outlined by this particular respondent. So, that is the sense of the motion. Do i have a second . Second. Alright, it is properly moved and seconded. Is there any discussion by members the board or questions or comments by members of the board . Hearing none, is there any Public Comment . Hearing and seeing no Public Comment we are now ready to vote. All in favor of the motion as offered, please signify by saying aye. Those opposed . The motion is unanimous. Thank you, christina. Alright. We are now ready to resume the regular order of business, which is the convening of this board as the committee of the whole for the purposes of rates and benefits, action items and discussion items. I keep reminding everyone that doesnt play this inside baseball month after month that this board about a year or two this is the second year disbanded and individual rates and benefits committee and because so much of these issues needed to be discussed by the full board before being voted upon that we decided that the board would act as committeeads a whole of the issues so that is how we take them up at these meetings, so we are now acting as the rates and benefits committee. We look the same as the board, well be talking the same as the board but are the rates and benefits committee. With that, well start with discussion item 3. Iletm 3, discussion item. Prezendation of aetna Life Insurance and Long Term Disability insurance, rate guarantee for 2018 plan year aon hewitt. Good afternoon. Good afternoon. In front of you will see a short deck and ill keep it brief. With aetna you have the basic and volunteer life as well as the Long Term Disability insurance. Last year we entered into ain the renewal cycle for this current year we entered into a three Year Agreement with aetna for 3 year rate lock on premiums which you will see on the next seval pages. I will not read those to you. Because of the three year premium guarantee, which approved last year at the april 14 Board Meeting no further action is required at this time. Any questions . Any questions by the commissioners on this item . Any Public Comment . Hearing and seeing no pub luck comment, we thank you for your excellent presentation. Insightful and prokbound we enjoyed it. Youre very welcome. Thank you. We will proceed to item number 4. Item 4, action item. Approve gender dysphoria bfts for 2018 lan year. Acting director griggs. Good afternoon Mitchell Griggs acting director of Health Service system. Last muckt we had discussion item in regards to gender dysphoria update of benefit said and aligning them across our plans and applying what we were stating as medical necessity for these benefits. During the discussion, there was several questions by the board, so the purpose of this particular part before we gelt to the recommendations is answer those question. The first one that we want to respond to is some idea of cost of these benefits over the years. In our prior presentation last month we gave two or three years or so in the beginning of some information on how muchclaims were costing and how many claimants so asked to give a high level idea of the numbersism in order to do this we now and the past 3 years had our all claim payer database so gathered this information from our all claims payer database and on page one of the deck is a general description of how we looked at the criteria and pulled these numbers. Basically based on diagnosis codes and also cost include facility, inpatient, outpatient, laboratory. On page 3 we are talking about sometimes when we couldnt find a particular diagnosis code there were certain procedures that we were able to look at and get that information to. So, on slide three, all Payer Claims Database these are the numbers we came up. With 2014, 2015 and 2016. On the left hand side we are showing the costclaims cost and the payable cost. Thats in the green bar . So the green bar is the allowed amount and the orange bar is what was paid on those charges. In 2015 is a slight increase and that because we had two climeant during that year. As you can see where we are inend ed up in 2016 as well. On the right we provided numbers of the amont of claimant per year. So, in 2014 you see the number is 26, 2015 it is 46 and 2016, 55. Now, the numbers or individuals included in 26 could be included in 2016 too in the visuals will be having claim s more than one year for some of those services. We want to give a general idea of what the costs are for the transjnder benefits. Any question snz any questions by members of the board on this asspect of the preezen sentation . There is none. Another question that came up in the discussion item last month was, what is the medical incessty applied by blue shield and the current benefits that they offer for gender dysphor ia. So, that was the question that got a lot of debate on the board and also internally in theophorous as we try to respond to this question. We were able to speak with blue shield and ask for a representative of blue shield to come and speak to you and answer the questions of the criteria they use for medica nusisty within these benefits. I will have him come up at the moment but want to give a brief bio. His name is dr. Anth an van gore and senior medical director of policy and technology at blue shield. He served as Regional Medical kreckter and pharmaceutical director at health net and Group Medical director of sutter health. He also is a veteran of the military for 28 years served in the United States air force and had several positions within the military including chief of staff of numerous medical facilities and retiring as fum colonel. He is board satisfied in internal medicine and Board Certified of medical management and holds a masters degree in medical manage. Dr. Van gore. Just as a pray lewd to this, doctor, two of the individuals who raised these questions as we were looking at a comparative chart of criteria what was medical necessity are not here today. That was commissioner follansbee and commissioner sass. I think i can reflect what their concern was. There is variation among the provisions of the plan but also the question is, if you use Something Like medical necessity what are some of the factors that play into making a determination and i think that was the core of the question that was previously raised. Thank you, mr. Scott. Ill leave a copy of the medical necessity criteria for you. What i will ask you to do, you have to look like you are eat thg micro phone so you have to lean into it or point it up to where you are speaking. I am short challenge d. Thank you. I first of all i like to compliment the board. I watched the video of the meeting last months and the concept of medical necessity isnt a easy one by any stretch of the imag nation and think the board recognize and there is input to the efeath there is no cook book approach to the coverage determinations made. Avenue wn is different. Everyone has different needs and there is a problem with respect to providing surgical benefits to a Certain Group tat may not be available to other groups as well. Those are very challenging problems and those problems need to be address bide a responsible health plan to make sure all been fishiaries are served. What ill do is ill give you blue shields definition. I can compare and contrast with the other s that are out in the field. Certainly the ama has theirs from the code of ethics they have and [inaudible] has theirs that is a addapitation. Would you say the last group wpath, the organization involved in working transjnder issues. Their criteria are essentially a restatement of the ama criteria. To read what our criteria are, we call med shrae necessary a treatment procedure or drug is medically necessary when established as safe and effective for the particular symptoms or diagnosis is not investigational or experimental, not provided primarily for the convenience the patient or the provider and is provided at the most appropriate level to treat the condition. This statement of medical necessity is a lot simpler than the ama statement and the wpath statement, but i will tell you that essentially the basic elements of the ama criteria are present in these. Essentially speaking, medica necessity criteria involve assessment of the need of the patient, the safety of the procedure that is contm plated and effectiveness of the procedure contm plated. Those are consistent throughout all the medical necessity criteria and statements. I think it is a challenge. It is challenge for me over the last 4 years i have been deal wg medical necessity, to understand how to apply them to individual cases. I think medical necessity as a concept is very very well adapted to physical problems and illnesses. You break your leg, you have a need to ambulate again. The procedure involved resetting the leg or perhaps pinning it is a safe procedure and numerous medical article said came out and studies show tg is effective over time. All those elements are present. For physical condition medical necessity work well. Not quite as well when we deal with a social issue, when we deal with a professional issue or personal issue, when we are dealing with acceptance in society. Sometimes we thought in the back of our mind maybe we should set up a solesly set of criteria to recognize the difference. The difference is this, in terms of medical necessity for a physical procedure, the health plans certainly i have over the 4 health plans where worked with look at medical evidence bethined and usually speaking , there are reproducible results that build into clinical trials, that build into a body of evidence which says this procedure is medically necessary and do what it is supposed to be doing. For a number of different conditions, these medical necessity criteria dont work as well. I think one of the primary ones is assessment of pain. Probably the reason that we have a problem the opioid epidemic, is pain we can look at and objectively measure . Well, we can try, but its very very subjective in terms of the impact of the pain on the individual and the amount of pain and how it is perceived. There are elements of motivation, there are elements of intent that go along with a determination like this. The principle benefit to transjnder surgery over course over and above the recognized knowledge that this is a procedure that helps with a persons identity, helps with a persons being. The concern is that we cant measure, we cant reproduce the idea that there ishow best to say it . How much pain and suffering is going on. How much psychological impact there is. How much emotional impact there is. We can certainly estimate it and studies have been done to do that, but the scientific inquiry into medical necessity depends we have data and evidence and something objective to look at. That isnt quite as easy work wg transgender surgery because the impact of the surgery is not only physical but it is emotional, it is spiritual and it is psychological. So we have to deal with that and it is not as easy as determining medical necessity for a physical condition. Not a straight forward and certainly fraught with difficulty in terms of assessing the impact on the individual thats going to be encountered. But we try. We try. At blue shield of california what we do when we get a request we have a certain process and believe there is a question about process that we follow as well when we get a request like this. Intake receives these requests. A nurse review takes place, but we have specified that requests for any type of transgender surgery be it the gentle modification surgery, the ancillary procedures of concern last week go to a medical director for review, that always happens. The medical director gathers all the information that is available and with the transgender requests, there are quite a bit of medical Information Available that we can look at and gather. We seek help. These questions are com plex. What we do is if the medical director for a ancillary procedure cant make a determine ation him or herself, we have of course our internal Plastic Surgeons that can assist and can go outside and do to a independent reviewer and Plastic Surgeon and independent specialist to take a look and help and advise us. If we are still stuck, what our procedure is to air on the side of the patient. If sthra tie and cant make a determination the blue shield policy is air on the side of making sure the procedure is done. I think one the distinctions brought up in the discussion of last month, was why we review these requests at all when other plans may or may not review them. One the principles of blue shield of california that we have been trying to live up to, we are trying to really really walk the talk on our culture of diversity and inclusion. I think that is something blue shield is known for, something we are striving for. Looking at these requests seemed very very consistent with the cultural we are trying to establish. There is another issue too and that the california Reconstructive Surgery act of 1998. Now, the california Reconstructive Surgery act passed essentially said and i got a copy ill leave for the board, that if a medical condition is caused by disease, is caused by trauma, is a congenttle defect, the health plan will consider either one of two characteristics in terms of making a medically necessary decision on that. One is appearance and the other is function. Before the california act of 1998, either appearance or functionboth appearance and function were necessary making the determinations. The california Reconstructive Surgery active very monulateal changing that mentality. Also the department of managed healthcare and believe in 2014 came up with a policy saying that for the purposes of the california Reconstructive Surgery act, gender dysphoria will be considered a disease. That wasnt to derogate the idea of jendser dysphoria, that was to fit into a category for either appearance or function is considered. Because the california Reconstructive Surgery act is difficult to interpret and there are many elements, any request under the Reconstructive Surgery act go to medical director for review. I think in looking at what was presentsed last month, particularly looking at what our colleagues as kaiser are doing with respect to review, i see very little difference or theoretical difference to what we are doing against what they are doing with respect to considering Reconstructive Surgery for transgender patients. I think the processes more than likely in my experience are the same across all boards or all medical plans. I think all of us at this point in time really do look at these cases very carefully and also consider the implication of the Reconstructive Surgery act and our own culture in terms of adjudicating them. As far as that is concerned my feeling is first of all, you folks have taken on a monster with respect to looking at medical necessity. It is a monster we struggled with for years and years and hopefully come up with a better answer. If we can only generate some way of getting an objective measure of pain that is reproducible across the entire pop ulation and get measure of motivation and intent to get the evidence use frd physical activities, this process would be much much easier, but all i can say to the board and all i can say to those listening is that i believe blue shield of california is making a honest effort and looking that case squz doing the best we can. Thank you for that. Are there any questions from members of the board . Just curious if you had requests for medical necessity that are turned away for gender . I dont have that data with me, i know we are talking about probably two Different Things here. The modification of genitalia and lower abdahmsinal surgery we get quite a lot of requests for those and my understanding is they are approved. The amount of information that needs to be provided, the willingness, the persur veerance of the person getting the surgery is incredible to get that done. We found the documentation to be superior in terms of getting that modification surgery done. That evidence may not be as available for the ancillary procedures we are talking about the tracheal changes and the liposuction and filler or procedures that are done. We have to look at those very very carefully. I will tell you blue shield doesnt get a great number of these. I talked about the medical directors about it specifically and what they said is well, we are seeing at the order of maybe one or two cases every 6 months with a request for these secondary characteristic modification surgery, so we are not seeing a great deal at this point in time but what we are doing is subjecting those to scrutiny. The is criteria like any other procedure like heart surgery . There is a cruteria for the surgery so for the most part thats good enough for most patients, right . Other than the criteria themselves, please understand in terms of looking at doing procedures, heart surgery and others, generally speaking we look very closely at the medical evidence to not only justify the procedure, but to predict the outcomes of the procedure and to predict the efficacy of the procedure. That sort of information hopefully eventually will be available to the ang laer procedures in gender reassignment surgery. They are not to the extent that we have them in other areas presently. We hope to add to that as time goes on to really predict the true impact, the true meaning of these surgeries. Just to be clear in the interim period while that evidence is not available i think i heard you say that core of your presentation that you are trying to assess these on a individual basis and youre inclination is air on the side of the patient. Thats correct. I recognize thats a variable within a variable. Veer very clear on that point but one that i think as we hopefully move forward with this policy and this action of this board today that its not just to be left alone, that we do come back and collectively with you and the other health plans assess how this process is working, what is happening to our members, how have we responded to put a policy on autopilot and not look at it. Im not talking aboutit may not be a year, but maybe a two year cycle if that made sense is to me just not doing the fiduciary think i think we need to do, andio it is not just make agpolicy decision and saying we are done with that, lets move on and good bye and well take up Something Else because this is a area evolving we commonly say and need to stay abreast of it so i accept and thank you for that non databased inclination. There is a science to medicine and there is a art to medicine as far as thats concerned. We do our best to practice the art if we kronet dont have the science but in terms of reproducible results, in terms of being able to predict outcomes, science is a very good thing to have. I understand. Thank you, doctor. Are there questions from the members the board . Alright. We have no other questions of you at this time and thank you for your presentation. Look forward to incorporating the materials. If you turn those over to the board scaert secretary and well make sure they are part of the record for this presentation. Well go back to director griggs to help through the rest of this. I also want to mention commissioner ferrigno brought this up which is important part about taking services that are exclusion and making them covered based on medical necessity. When you do that and they are denied as a non covered service because medical necessity wasnt found, that allows the appeal process. If they are a exclusion there is no first level appeal process with the plans. I think the good thing about this if we move and it is approved, that if there are inconsistencies between the plans on the criteria of medical necessity there is a better appeal process for the member. Thank you for that clarification. Also, i have another smeeker that i want to present right now and that is theresa sparks. I have just a little bio for her. Senior advisor on transjndser initiatives for mayor lee office. Prior was executive drether of the Human Rights Commission, president for the Police Commission and lgbt advisory commission. She is a effective 5d voicate for trands gender community. Taken on issues such as aforeable helt care including the champion of our current city transgender benefits. Last meeting i had opportunity to meet mrs. Sparks at the Mayors Office for a ceremonial raising of the lgbtq flag kicking off the june pride sknlunth it is working with individuals like this is one thing but feel happy about having my job so i like to turn it over to theresa. Thank you. Welcome back. You were with us last month. I know that you haveif you got a extensive statement we absolutely want to incorporate it into the record. Y i do nolt actually, but thank you president scott. I will try to be brief. I never heard presentation as complete as the one just given by blue shield. I heard advocates talk about medical necessity but that was very well done and just to address a couple issues he talked about, particularly the one about science versus art is 15, 20 years ago when the board first adopted the non discrimination policy for transjendser healthcare, there was all most so science and very litm art but it was based on the concept that other City Employees were given hemth care based on their medical and psychological and mental needs and that this should be considered under those same criteria and this board and then the board of supervisors were very progressive back then. I had every other jurisdiction in the United States to approve this. Some of the cost considerations back then were way over inflated as we found out two or three years later it was substantially less expensive when the city was pay frg them directly out of a trust fund. Then we moved to blue cross and kaiser and at that point health net and found the cost was very very demin ms compared to what the expectations were. Moving forward i had never seen the numbers how many people and how much money the city spent because it was very difficult to get. But i was impressed and what is interesting is this is only half of the city program for transjndser helt care, the other half are people uninsured and it is under healthy San Francisco which we put into place two years ago. Last year under healthy San Francisco we had about 70 people who went through the process for primarily bottom surgery, top surgery and those types of surgeries. Currently, they are considering exactly the same procedures now that you have on the table before you. In addition, you see San Francisco as a Transgender Center of Health Excellence in the parnassus campus and they participated in the same surgeries but also are doing more research. You see childrens hospital, you see benny off childrens hapt in mission bay has a gender youth clinic now and last year counseled 350 different families about gender dysphoria with childrens between the age of 6 and 12. So, this iswe are getting science within this discipline. You see systems now are going to have a International Forum next year on scientific presentations on this issue. You see systemwide not only the college and unistrrsty and student servicess include these servicess now so they are being more progressive. Let me just go through some of the other issues other than the science but maybe the art and human rights side. Number one is, there is a lot of definitions in this and this issue isnt intuitive. We are not expecting anybody to have a light bulb go off and say i get it, this is something learned and something you have to digest and understand. Two issues, one is the sex you are assigned at birth. A stranger who you have never seen looks at one criteria and says this is a boy or girl and this is the label and the sex that follows through your entire life. No other criteria. Second, isthat is based on physical appearance only. Physical jen tailier, they dont take chromosome test and this or that tast, it is physical appearance. The other one is gender identity and what we are finding now is that children as young as the age of three start saying between the physical sex at birth and how they feel about themselves and there is a lot of documentary and lot of publicity and a lot of personal stories on television, you tube around showing how Young Children and gender identity is really developed at a very very young age and so what does that mean as far as how they can live their life . What we are finding in the gender dysphoria youth clinic and benny off hospital is finding the earlier you recognize this, the less a dysphoria is, and b, less problems the individual hass they go through life. The physical characteristics of a individual develop around puberty. It is muscle growth, growing breasts and facial hair and all these things that can be recognized. If in fact you can deal with this issue prior to puberty, then those changes donts happen and so the incongruity between how someone feel squz how they look is lessoned to a great extent and that is what the science is looking at now, but that isnt what we are looking at. We are looking at essentially two primary issues that are relatively costly. One is facial feminization surgery. Changing the physical characteristics of a individual particularly in their face to better match that of their gender identity. So, they can live their life without continually being confronted if you are a boy or girl and that happens every day. I have been doing this 20 years and a muchckt ago i was in star bucks on fillmore and thrown out because she says we have seen people like you here before, and we are not going to serve you. It is very seldom im speechless but this was one case i was but it happens to people all over San Francisco and we are the easiest city in the United States to be a transjndser person. 26 states over 100 different state legislatures there is over wn00 bills arounds the United States now going through the process to restrict transgender people from going the bathroom from children in gradecool to adults. North carolina was a example, texas is very very close and this is going forward. What happens if all the bills pass . Say i geto the oakland colosseum to use the bathroom and force today go to the mens side. I probably wont come out and thats a realty. That is not speculation. In north car linea there are children beat up trying to use the bathroom associate would their sex gender rather than their gender identity but there isnt one chaild harmed when children going into bathrooms associate would their gend identity. Those are facts. Not one reported incident and that is across the United States, not just in north car linea. The concept of facial feminization isnt a psychological or self esteem issue but it is becoming a safety issue and that is something San Francisco needs to consider as part the art and part of the impact on real people over and above the scientific information which is evolving very quickly. The other one is Breast Reconstruction surgery, those are the two big ones. As director of the Human Rights Commission we talked to the Health Department and filed a complaint against the helt department because they provided Breast Reconstruction surgeries based on criteria for women who had cancer and for women who had lost their breasts for some reason or another but not supplying to transjnder people. The lawyers of the sit aef of San Francisco saw this was a discriminatory policy. If they supply for one category they should sploi it for the other. The both based on self esteem, they were based on physical appearance and how a woman felt about her. I ask you to fall though citys criteria we fallowed for people who are not insured, to follow for people who insured because it is a criteria that is gaining influence across the cuntsry. That is really all my prepared statement is. Im here to answer any question you might have. Im happy to. Im the first person in the United States that has been put in a position directly advising the mayor and board of supervisors on this issue specifically. Im probably not qualified and should probably have a medical degree but on the other hand happy to answer any questions. Any questions from members of the board . Thank you for both your Statement Today and at our prior meeting. I think it has been very additive to the Public Record and your own living experience is a testament as well so thank you for coming today. Director griggs. With these two guests i wanted to make sure you got your questions answered about medica necessity and putting context into the reason why we need tees benefits paid by our helths insurers and employer. The last question that was asked in the last meeting was how prepared are the plans are to come up to thiscover the items if it was approved by the board and i wanted to say that hss if approved if these recommendations approved hss will work closely with all the health plans to make sure that we are all on the same page and can it be done, when it can be done as well as any criteria and interpretation of the criteria. We have done a lot of work already but will continue to the work and hoping we can make a comment maybe in the directors report in may of the preparedness for 2018 for when they can be prepared. Just to be clear on the recommendations that are up for your consideration, recommendation one, approve the San Francisco Health Services system gender dysphoria policy statement. That statement was included in the packet laest month and including this month. Recommendation two, eliminate the 75 thousand life time cap for fully insured health car plan and the recommendation is eliminate the life time cap on the active plans or any self funded plans. M ap drfx was removed the Affordable Care act. Last recommendation is require all plans to adopt the approach taken ply blue shield for gender dysphoria benefit. Plan offers for each service by requiring the Services Reviewed for medical necessity rather than excluded and those are listed. Insure consistency require all plans for review for medical necessity treatment and not limited to and there is a additional procedure there. So our recommendation is approve. Alright. To members the board you heard the recommendation, is there a motion . I just say basically what we are doing here is making it uniform among the plans, isnt that that is correct. That is what the intent was. Blue shield already does these things. It does all these with exception of one and that is the last listed on the third recommendation . Which is that . Other than the one listed in the third recommendation but the notion is bethined staff recommendation just to be clear that we do get a level Playing Field among these benefits both in terms of how they applied and processes and those type of things and the system will work with the plans to try to achieve that outcome ovtime, is that the intent sth that is the intent. Alright. Mr. Lim. So, did you make any initial discussion or with kaiser and United Healthcare . So, since my involvement and discussion in march yes, i have been in discussion with kaiser, blue shield and United Healthcare. Does kaiser and united have a review iew process or doing benefits related . They do cover current gender. Not necessarily with the Health Service but doing benefits outside of outside of the contracted benefit levels, that is a question im not 100 percent sure of. We can come back in may with that information or we can have any the plan representatives speak to that now. Out to kaiser and united and they haveinitial discussion with kaiser or is there any [inaudible] are there anydo we have discussion with them rather than just implementing it right away and will have a throwback coming from them . So, the discussions that i had particularly with kaiser as you see in the chart that we provided before, there was excluded items on there not excluded by bly blue shield because of medical necessity. I talked about the timing. They are reviewing all that. We are also in the middle of rate renewals and know kaiser is looking at these. We dont have a definitive answer but will hopefully in may is what can be done between implementing all of these for 2016 or quarterly. There is a close conversation every day with the plans about how to get this done for twnts 18. Thank you. Other questions from commissioners . Hearing no questions, is there a motion . Accept the recommendations mpt. So, i like to approve the gender dysphoria benefit plans for 2018 as recommended on 1, 2 and 3. Is there a second . Second. It is properly moved and seconded that we adopt the staff recommendations 1, 2 and 3 as outlined in the presentation with the clear intent that these benefits be harmineized by the hhs staff going forward. Any comment s from it board . I like to acknowledge as my comment to the board before we go to Public Comment that we did receive a letter from the union of American Physicians and dentist addressed to us and distributed to the Board Members and they are very much writing on behalf of physicians dentists and pudustrist to express the strong support the plans updated and standardized to fully covered medically necessary treatment for gender dysphoria and the letter goes on and will be part the record but want today acknowledge we received that communication. Any other Public Comment on this topic . Seeing innumber of people rising, i would ask that you be focused in your comments so that we can give everyone due consideration this afternoon. Please identify yourself and then make your comment. Icate kessleraria vise president for Kaiser Permanente Public Sector account. I want to invite dr. Plouts to join us. We appreciated the discussion today very much. It was a pleasure to be able to hear blue shield address this and hearing what they deem medically necessary and their definition is helpful as we cont plate the topic, a vore important topic so dr. Plouz is prepared to address that today. Thank you, sir. Would you please give your name and your Organization Affiliation and who you are. Im fill plout, im a physician at Kaiser Permanente emergency physician working this morning and just got off and also the Health Plan Physician Advisor and involved in our Transgender Program and decision about benefits on that. I very much appreciate the comments of the previous two speakers. I think they are much in concordance with Kaiser Permanente. We are providing to compassion and quaument care for transgender members and built a program throtraining several of our own physicians. Sometimes training at International Centers excellence and hiring where we lacked expertise and i believe we are now in a position to provide comprehensive care within our program in Northern California. In fact San Francisco Medical Center is the Referral Center for our complex transgender surgeries and also the home to our jnder pathways multidisciplinary clinic. We acknowledge and practice according to the d wpath standard. Our practitioners provide any and all treatments when medically necessary by the definitions presented without discrimination with respect to race, elth nisty, age, gender or jnder identity. Thats as required by the Patient Protection and Affordable Care act section 1557. That section is in suspense now due to legal action in texas but kaiser is committed to practicing according to that provision because it is consistent with our organizational values. We treat patients with dysphoria with Reconstructive Surgery with medical necessity for those procedures that are reconstructive being the Reconstructive Surgery statute presented here today. That standard applied to the transgender populations indicates patients will be treated to the extent possible to create a normal appearance for the gender that they identify with. So, it is specific in this area and thats how it is immediateical necessity is interpreted in this realm. These decisions are made by our physicians and to the extent that we have achieved all most completely the standard to internalize the services there is no prior authorization process for referrals by permanenta medical group clinicians for transgender procedures but to the extent there will be i would be involved to applying the criteria and i similar discussed by the speaker from blue shield. It needs to be acknowledged patients request in our practitioners offer procedures meeting the Reconstructive Surgery statute definition of cosmetic and thest that is procedures to enhance a normal appearance. We offer those on a fee for service basis. These include treatments for the normal effects of aging, which is considered cosmetic under that statute so we have a clear standard defined in the state of california by this act and its applied consistently at Kaiser Permanente. Of the listed procedures in your prior deliberations, there are a number in our experience at Kaiser Permanente not deemed medically necessary for patients with gender dysphoria. There are many provided on a routine base squs there are a few that may be provided to patients with gender dysphoria but based on other conditions they have besides gender dysphoria and a example of that is fillers for patients with hiv related lipo dist profee associated with a disease with a similar appearance due to aging may not be covered. It is complex interpreting these but our Reconstructive Surgeons are well aware the standards with we work to inform them and consistenthy apply the standard to all populations from the medical population to medicare population to those who received the care through covered california. The commercial patients. Our practitioners apply the same standsards across all groups without discrimination. If you have nor of your statement you would like to enter into the record we will be happy to receive it. Have just a couple more statements here. My role as the Health Plan Physician Advisor and sit on the Oversight Committee for transgender care and i also par tace pate in a statewide member issues resolution calls for transgender patients. For the last two years i heard all the complaints, the issues with the care that is provided and there are cases where members have challenged the decisions arounds procedures like facial feminization and the timing of procedures and so forth and i find through this process that our practitioners are consistantsly applying the standsards and have oversight mechanisms to make sure members concerns are heard when they disgrie but in the end we are fairly applying the standard to all patients. Having listeninged to the prior testimony, i believe that blue shield is applying the same standards as kaiser and believe the practitioners in our case the front line practitioners caring for the patient are applying the same standard they apply when they do medical review as presented today. So, we support care in this area. We foundi found had list to be a little bit challenging, because it is a menu of procedures whereas the decision about these are a hol istic approach by an evaluating reconstructive surgeon with a effort to use the techniques available to provide a normal apeenchs appearance to the extent possible. We continue to track the research and innovations that are occurring and incorporate that into our practice so this is not a stable but a moving target to a certain extent, but it is relatively stable at this point and we are well tuned into the innovations and changes as they occur. Thank you for making this statement and we look forward to working with you to coming to an evolved common view as it apply tooz the members of the helths Service System under this policy if adopted. As i said, this isnt a thing that will go on to autopilot. You need to be active and engaged conversations with practitioners like youself as well as the members and look forward to those conversations so thank you for coming today, doctor. Are there other Public Comment . Yes. Ill be brief. Commissioners ema urb balk from local 21 one of the employee organizations that represent employees who access healthcare. On behalf the members accessing these procedures for themselves or dependents we thank you for take thg issue up and broadening the range of options available for them to discuss with their doctor if it is deemed medically necessary. This is a huge step forward. I also want to make a point that we continue to talk with the city about being a employer of choice and we always want to work with the city to make sure even if San Francisco cant offer the highest pay check or greatest you know, of one aumgz option or the other city is inclusive. San francisco as a workplace is somewhere people can choose to come and feel like they will be respected, they will be valued and the more that we do that for our transjendser employees the better we serve the people of San Francisco and better we have relationshipwise employee ez so thank you for taking this up. Thank you for what i hope will be a yes vote on this. It is great to see San Francisco continuing to uphold our well deserved reputation for being a city that is not afraid to stand up for what is right even when other parts the country are not doing the same. Thank you for your comment. Other Public Comment . Hearing and seeing no other Public Comment, we are now ready to vote. All commissioners in favor of this recommendations as presented please signify by saying aye. All those opposed . It passes unanimously. We are now ready to go to item 5. 5, thank you secretary. Discussion item. Presentation of Vision Service plans buyup option. Taking instruction, eating the micro phone. It is helpful for avenue wn here and also the recording, so thank you. Terrific. My name is lusoneda ward a regional Vice President with Vision Service plan and appreciate being here. I like to thank you for the Long Term Partnership with hss. Weef truly enjoy that and enjoy serving your members. One of the items that have been a point of discussion over the past many years with hss and arounds the opportunity to provide choice around the vision plan as far as a enhanced or buyup options a at the contribution level from the employee or the retieee so that is what im here to talk about. In the market place, we see many Many Employers offering both their basic plan that is similar to what you offer today where it is Employer Paid and what we would consider a premium option and that is what this is. Hss would have a opportunity to provide additional choice at the member level to be able to provide two different plans, one that hss pays in full and the other hss continue tooz contribute the same they contribute today but the employee that chooses to buyup will pay the difference. The cost to hss in adding this would be neutral, there is no additional cost to hss. The administration of this has been bun of the areas that has been kind of a stumbling block so we have come to the table with two options, one hss the administrator as the plan and vsp to administer the plan. I will share with you that we do this for many many clients but sfgov tv, we have a presentation. Thank you. It is on what page of the presentation . Im still on page 2. Page 2. Licate. Sorry about that. Moving this right along. What i was sharing with you is one of the parallel client that offers a base and buyup where vsp does the buyup is the state of california so do for the active and volunteer retiree population. The next page, page 3, i just wanted to highlight what the different plan Design Options would look like. On the left side where it says the current core plan, that is today your current plan design. In the proposed buyup plan this is the plan offered to in open enrollment. In red are the key differences. So, the key differences as far as the frequency is instead of frames every year you get framesevery other year you get framed every year. The material copay is zero instead of 25 so just have the same exam copay. The frame allowance instead of 150 is 300. I will share when we look that frame selection for hss over the past 12 months if a memberif we had a 300 allowance that covered 80 percent of frames selected thmpt contact lens is 250 instead of 150 and lens enhancement, today members get a discount rate for progressive and antireflective coating. Those are top lens optionsism progressive will be coved in full with 25 copay. Today the average members spend about 123 so a significant savings. Antireflective coating is covered with 25 copay and today members spend 75 blending the different brands. Those are the highlights of the differences. Page 4, we share some of the rates that we shared so on the left side is your basic core plan, which i will share is generous that you still pay 100 percent of core benefit for all your core members. The next has two different options, one as i mentioned before is hss does had administration the plan. The other is vsp does the extra administration for the buy up so there is a cost. I will look add the vsp one so you can see. The city would spendhss pays 395 for all hss members and the employee only that chose to buy the buyup spends 10. 86 a month. I think we can read the chart and thank you for that. Terrific. The core question is which och these 2 options we will be taking . Right, it will come down to what hss the additional work or if they prefer for vsp to do that work. I like to have you pause there. Sure. Are there questions from the members of the board . Is this just for actives . No, it is offered to active and retiree. This says employee and the pretax we can correct that. It is for all actives, these proposals active and retirees. Alright. Other clarifying questions from the members of the board . I would prefer to see the you dpoo the Administration Just because i think our staff has plenty to do. This will add work for the staff which in the long run is more money for us. Remember again this discussion item today. Thank you for expressing that preference. If i also might add next month when we bring this as a action item there will be a staff recommendation of which of these roo we ask to approve. We will present both but there will be a staff recommendation whether we administer or they admanster. I will skip to slide number 7, just the other slides are around who does the adminivation so this should be vsp do the administration what that looks like. Y i will hold you and think we can read the portion of it when we bring the recommendation back. We know you scaexcellent call center and thank you for the presentation. Thank you very much. Any Public Comment on this item . It is coming back for action next month so if you would like to hold that would be appreciated but if not please do. Dennis crug, active retired Fire Fighters and surviving spouses. Two questions, one regardless who administers this plan, will the money be deducted from their checks or will it be money that has to be billed and sent in . Question one. Question two, just for my own etfiication, why is 300 frame allowance only 165 at costco and 150 is 80 which is present. If you are allowing 300 for frames shouldnt that be across the board . Thank you for those questions and what i would like to ask they be incorporated the response incorporated into the presentation when we bring the item back next menth so we have the context of it. Any other Public Comment . Hearing and seeing none, well close the item and move to discondition item 6. Item 6, discussion item. Presentation of risk kores, Marina Coleridge marina i know you have done a great deal of work and every bit is important, but please be conscious of our time today. I understand perfectly president scott. Thank you. Marina coleridge, data analytic manager presenting the risk scores for active and urmy retiree for Health Service system. Just a couple notes here. We of course used all payer claim said database. Using the diagnosis and using all the diagnosis available to us on the claim to present that information. The other thing i like to point out that is just a change from when we brought risk scores last yeari think we presented them in june and so we had the complete time for full run out for the 2015 calendar year begin wg the presentation today and go Forward Strategy is have this nrfg available as you go through the rates and benefit cycle so we moved up the time period of when we calculate the risk scores so now they are done on a rolling year from october of 2015 through september 2016 and the Previous Year for comparison of current year to Previous Year we also recalculated. Just moving to slide two is the summary level information looking at it by each of the plans and so the numbers for Previous Year are going to look a little different than what we brought to you in june last year because we are now calculating them on a sligetly different time period. We moved them back a quarter so why you see the difference there. We have concurrent and perspective risk scores and as we explained previously but for the benefit of those new, the risk scroreerize a tool to predict cost in healthcare so the concurrent risk scoreerize looking at your cost based on item in the current year and your perspective is really doing the Predictive Modeling of the future costs and these take into account age gender and diagnosis. Ill let you read the numbers on slide two and just to say without go nothing into them all over the next two slides we are able to run additional cuts so the next few pages just take by each plan and we break it here by gender as well as by the age group jz we do it for our actives and early retirees and that takes you through about the 9. Sound good. The signth page of the slide. Slide tenl we are doing other cuds we havent done before and here we are looking at first for our actives taking a look that concurrent and perspective scores based on relationship. Spouse to children and with our actives the spouse and domestic partners have a higher risk score than the employees and only the next page for early retirees doing the same thing here and we see a little difference here. Here it is the retiree member with the higher risk score versus the spouse and i believe what is driving a lot of that in the early retiree population is disability reteermt. Then we get into our slide 11 on this presentation, which what we have done here which i think is fun, but we risk adjusted the allowed amounts so we have rescaled information and looked at what was paid as a amount pmpm and if we do risk adjusting taking into account the diagnosis and the age and gender, what did we pay which is in the allowed amount and adjusting what we should have paid and by doing this anal ysis we see blue shield allowed amount were 17 percent higher when we do those adjustments. For city plan 13 percent higher and kaiser, their cost on the allowed amount is 16 percent lower. In conclusion just to say that on the whole this is good news. Our perspective risk scores did experience a slight improvement so a little lower than we presented previously and added younger lives to the risk pool and the covered lives are over 117 thousand. Any questions . Just like a general comment to this question. Why is this important to us . Why should we be concerned with all this statistical stuff . For us it weighs what is brought on the rate renewals. The plans look at utilization andologist looking at inrisk as a predictor of how costly our population are going be and so when they present to us what we need to be paying they look that claims experience and of course our [inaudible] present thd claim experience before so these are enter related so instead looking at it by dollars it gives to the number of the risk the population. The higher the number the more costly we will be so it is important as we try to level out our risk pool and try to mitigate costs is look at what direction it is heading, are there programs and thinks we need to do to bring that down. This is also rhetorical questions . Right. This is also to bring some level of transparency and understanding of what we understand the risk to be in our population versus having a third party tell us what that risk is . Absolutely. That is correct. That why it is important, right . Yes, sir. Thank you very much. Other members the board that are questions . So, what are these scores be compared to . Our population compared to . We compare in the case of the dynamic adjustment what we did is compared to ourselves so we went and recalculated where we talk it from individuals and made it one big pot looked at the risk scores and recalculate compareen one plan to the other and how they perform. We also have available to us in our all Payer Claims Database where we can get in california curious how we compare to say other group . Are we really high risk or lowequal . Say we compared to pers or any other group . I dont know what pers risk scores are but i can bring back in the report next month is the california benchmark using the market scan database. That will be helpful. Curious to see how our population is looking compared to perfect. Thank you. Other comments from members of the board or questions . If not, is there Public Comment on this item . Hearing and seeing no Public Comment we move to the next item. Item 7, discussion itedm. Report on Specialty Pharmacy trends. Aon hewitt and hss medical providers. This is where we can have a brain cramp, i understand that, but this particular aspect of healthcare spending is a key driver of overall costs and we have been looking at this in dismay and in lightenment given aons good work keeping abreast of this. This was a major topic at the november forum and if you want to go back for members of the public to take a look at what we were talking about about general trnds in this area and so forth and this is a Second Chapter if you will to that commentary, so we thank our friends for bringing this matter back into focus for us. Thank you. Thank you. [inaudible] as been referenced i have been here many times on this subject but very pleased to say im joined by Dean Fredericks from kaiser who is a pharmacist and bony hayes from United Healthcare who runs pharmacy operations as well as genet loans from blue shield and so from that perspective your questions probably can be answered by an expert as we go forward. I will be very brief both from the fact that i have brawn kites and have nor information to come. A brief overview, specialty medicationerize typically bilogic and compounds and require special manufacturing such as cold temperatures, sterility one would not find in normal medication. They are very high cost. They can average 3 thousand a month. We have one drug that treats a heredity disease that can run a Million Dollars a year. They also have significant side effects and so therefore they do require Clinical Management both manage the side effects and also to manage adherence and persistency on the part the member. What makeatize is a problem . First of all, it is high cost. Only two to three percent of wrour members use it. It is expect today approach 50 percent the pharmacy trend come 2020. Could you pause . We have a presentation today if you can bring that up. Sfgovtv. We have a presentation. Thank you. Thank you. We are on page two. Please continue. And lastly, really at this point in time there are no replacements for them. The bio similar market while it is in process is slow to get approved. It will only represent about a 20 percent decrease in cost once they come online. So, some the strategies that you see on page 3 that employers have been implementing are trying to reduce and appropriate utilization and make sure the clinical guidelines that are being applied are appropriate. That, the medication is administered in the appropriate site. Typically they start out being administered in the hospital setting or office setting. They have now been able to move home. They alsoSpecialty Drugs are hidden 13450i78s because some of the Specialty Drugs are found in the medical benefits about 50 percent of it and 50 percent of it is fon in the pharmacy benefit and i see a frown and by that i mean someone that goes in the hospital and has cancer or oncology drug it is billed through the medical claim, but whereas once they get outside and continue the treatment on a outpatient basis it comes to the pharmacy side so that is why you dont fully capture all the cost in the pharmacy side. We also have employers have implemented a different tier for Specialty Drugs as well as ambulmented partial fills at the initial start so you get 10 days of the drug because as i said earlier the side effects are quite ramped. Talked about the clinical side when i talk about who is appropriate to receive the drug. It is highly recommended that if there is a step therapy be applied and all the drugs prior authorization. The two points i really want to make and then ill turn it over to Dean Fredericks from kaiser, if you look at the history of the pharmacy spend what you see in 2011, 2012 that it is relatively stable in the sense that it is hiv, oncology, a few antiinflammatory drugs but in 2013 that is whether the fda first approved two medications for system fib roses and the hepatitis c drugs came online and so what you see in 2014 is a incredible jump to 30 percent. While it has slowed down a little bit, what we are afraid of if you turn to page 5 is that you continue to see increasing costs for areas such as inflammatory diseases, such as debeaties, ancology, ms and hiv and the problem here is this isthese diseases there are a number of individuals not one or two, but a number of individuals that will be required to take these medications and as that number increases either due to age, demo graphics, lifestyle perhaps, the cost will only keep ballooning. With that, ifem im going to turn over to kaiser. Thank you, page. We have a presentation, sfgovtv. Good afternoon. Ill eat the mic. Thank you. Im challenged as will. Dean fredericks pharmacist with kaiser, director of drug use management and my partner here is good afternoon. You have to come over, scott. Good afternoon. Scott yoma gujy, under writing for Kaiser Permanente. Thank you for the time. So, we at kaiser are not immune to the rising drug cost and concerned and pay close attention in all the settings, hospital, clinic setting, outpatient drug area as well. I will tell you that we are ue nukely positions to address this and what we are doing. One thing i try to describe is that in kaiser we can act as one unit. We have the medical Group Physician and hospital and helt plan and pharmacy and contracting people and benefit said all lined up. We meet together to try to solve the problems to deliver the highest quality most Affordable Care for our members. That is what we are striving to do. It is you describe that on page 3 . Yes. 2 and 3. Ill go to 3 in a second. I want to note our process is physician driven. That is very important to us and our members and our angle is three things. I trito describe how we manage is appropriate care, second is adherence, making sure the patient is taking the drug for the investment we make with that medication. All those to lead to the best outcome and we want to measure that outcome and make sure we deliver on that. Slide here, here is detailed approach and want to highlight a couple things that tie with what page mentioned. In the upper right section, basically we start with experts internally to development the evidence and guidelines to apply what is called step therapy to figure what is the best way to treat our patients. Then in situations where we have opportunities where drugs may be equal efficacy we can hand those to the Purchase Department to nolesh negotiate the best price. We are able to shift market share so when we say we use one help c drug, har voney we use it at a high level and get negotiating power with manufacturers to negotiate with best price and that is what we do on a ongoing basis. The other point is around rebates. Our philosophy is we dopet want to get into had rebate game and prefer transparency and want the lowest price at the beginning. We have very low level of rebates at this point in. Time. The fact is you have volume . Our volume isnt our volume that is the biggest contradictor, it is shift in market share. If we say to a manufacturer we will move to 90 percent of your product or competitors product that is when we get their attention. Market share that the typical thought. We are only 3 percent hof market so it isnt really volume so thatthe other piece we tied to is benefits so we have a specialty tier which you adapted and we use that to remain competitive in the market as a strategy as well. And then we internally do a bunch of work to basically what i call control the message. Eliminate the manufacturer message to physician message and go with what the experts describe as the guideline jz best care and communicate to the doctors and that is what gets used in our organization to manage our patients. We also at the very bottom involved in advocacy arounds rising drug price jz we have physicians and other team members going at the government level and coalitions and voicing our 34esage which is three fold. One is we want transparency in drug pricing, second, competition that drive priceess down, and third value which means if a manufacturer brings out a new drug we want to see added value if all is a price increase. We dont want to see drugs continuing to rise in price with no value. In slide 4, these are the tools and will let you read those. The one i want topoint out is bio similars. These are the gunarics for the bilogic drugs she mentioned. Kaiser is being very active moving that agenda forward. We adopted the first bio that came and brought into the organization moved market share quickly and demonstrated it is effective and want to continue to show over time we are irk withing on the second now to do the same thing. Those are the strategys we applying at this point in time. Thank you. Thank you, dean. Commissioners, we also want to share cost information and here we have on slide 5 the picture of the historical costs and cost trends for the hss membership conched with Kaiser Permanente. The top half of the page lays out the cost and presented on a per member per month basis for each wreer between 2012 going through 2016 and this is for your non medicare membership, so actives and early retirees but doesnt include the medicare membership. And then the bottom half of the page lays out the chaichck in cost so it connects to the bar chart above and shows the year over year change in each of the categories. We have broken the cost out between the medical cost, the non specialty Prescription Drug cost and Specialty Drug cost in the charts here and just a few comments. You can see in the bar chart the Specialty Drug costs are still a relative lee small piece of the total cost, but have clearly been increasing at the fastest clip over the time period. At the bottom of the page in the trnd table we have shown the comp pound annual growth rate so average increase for the time period. Average annual incraes and Specialty Drugathize grouth rate is 16. 7 percent compare today a 2. 7 percent overall compound annual growth rate. It isnt broken out in the slide here, where would note that the medications to treat hepatitis c were a clear driver in the Specialty Drug trend and if you remove the hepatitis c medications the grouth rate for the Specialty Drug component would drop to about 8. 5 percent. You would have moved from 8. 52 sent in specialty to 2012 to 11. 81 in 2016. That is the impact the Specialty Drug hepatitis c drugs impact. You have one additional slide. I sense urgency here. Just to sum razz what you heard today, specialty medication and pharmaceuticalerize a challenge 23r the entire system and industry. At kaiser we have a comp rehensive program that demonstrated results ovtime. That Program Continues to expands squevalve to help keep up and manage the Specialty Drug challenges. Our strategy around Drug Management and Specialty Drug management is broader than the clinical component. It cont plates benefit design, procurement and puchs purchase and advocacy role but the Clinical Management programs and our clinicians are at the core of all of that effort and we believe that our ent grated model and integrated culture within the model are a key dif rinch knraiator. Thank you for your presentation and what you are doing in the area and working with reporting on this i would just add in some detail. I attended several meetings regarding utilization so thaupg for the efforts. Page, can you remind how many dollars per year we spends annually on Specialty Drugs as a top level amount for the system . How many millions of dollars this is . Can somebody answer that . If page cant i know our actuary can. I may not have it off the top of the head. It is quite significant. If kaiser represents all most half of our 40 percent of the membership and paying 16 a month, it is quite significant. I just like to have a ball park. We will get that for you. Round for all of it not just kaiser. We have another presenter i believe. Good afternoon. Bouny hayes with optm rx. Where are the pharmacy provider foru hc. We have a presentation. Just our slides are very similar and start out differently. But kind the same story you heard throughout the presentation. While we are wait frg sth slides you spend about 6 million for total pharmacy through about 7 million total pharmacy through optm rx and all most half is on specialty. Thank you. So if we look that 4 year trends very similar, on the top is total per member per month cost and about 201415 is where we get the big hitter in and in the specialty, the blue bar is Specialty Drug jz primarily the hep drugs. Very small membership but about 30 thousand a month. Typically the members are on for 4 months so for the plan it is about 100 thousand per therapy, however, one thing i like to point out is there is a offset of the cost on the medical side because these members are getting treated through the pharmacy and the great news is these new medications dont have thedoesnt make them as sick as it used to as well as there is a Great Success rate with them, about 95 percent. It is very expensive for the plans but there is Great Success with it. We are also seeing a decline in the use of the hep drugs. When they first came out doctors were anticipating they were coming out so so a big rise with them and the costs were really going high. We are seeing a drop now. Not to say it still wont continue to happen. The other thing on the slide is just to point out the 4 year period. The non specialty diabetics and high cholesterol there was a negative spend on that specialty is higher but for a 4 year period it was 4. 3 percent trend. Next slide breaks down excuse me, is this specific to our system or is this kind of generic . This is specific for your plan. Alright. Absolutely. The wholeall the presentation is specific for this membership. Thank you because the headers wouldnt seem tosuggest that and want to make sure everyone understands this is our experience. Thank you, next time ill clean that up. On slide 3, i like to show you this just because it points out the differences in the cost so much. So on the left side is the utilization, the blue graph is your generic and the drugs around for quite a while. They are less expensive drugs. 80 percent of utilization is only driving 18. 7 percent the cost. When we do our strategies and Clinical Programs we like to strive to get you over to the geneter drugs. They are 36 for generic versus 340 for brand so a lot of strategies are inclined to drive the member to the lower cost drugs. It saves the copay and the planism the other thing on the slide is only 3. 4 percent of specialty utilization is driving 45. 1 percent the cost. A little higher than what we see for other plans. Most the plans now are about 35 percent. We do expect with a industry it will be 50 percent 06 the cost in the next couple years so you are right there right now. I am seeing a little lower costs, so far at this point, so we are keeping an eye on it and have a lault of strategies and help in place to help with the costs. The other note on here and i didnt point it out, but just as a fyi, the generic utilization the drugs are lestz costly, your plan had a 1. 9 percent in theginateic utilization which equate s to about 485 thousand savings so kudo tooz the plan to dribeing the members to the lower cost andnishatives you adopted. When we talk about the Specialty Pharmacy, i just want to quickly tell about brio. It is our Specialty Pharmacy and we dont only try to provide help to the members because when you find you have ms or cancer it is very very concerning, very frightening and scare so have material available for the caregivers and family so there are websites they can go and get educated with that. The biggest thing is brio to life and that is you can face time as you getd your medication, you can do face time with a nurse or pharmacist that walks you through everything in the package and helps you understand how to inject it if it is a injection and helps you understand it and walks through it so this is a new offering we find very very valuable. Then we also send if they need gauze or things we send that with it as well. Just wanted to share quickly what we have with that. Also when your members comcheers call in because we have medical and pharmacy data if they have a need fl fr Behavior Health we can get them there. If we see they havent had lab work done we can help with that as well. We do mujtly outreach to make sure they can compliant because when they start a medication you dont want them to not continue it. We also do outreach to the physician if we cant get a hold of the mb and do outreach after two outreaches. Also, i talked about how we have medical and pharmacy data because United Healthcare is at risk for over 8 million lives we want to provide benefits that provide the best care and support at the lowest cost, so we do. We do have some of the Specialty Drugs through the pharmacy as well as through the medical side. Usually if it is influgz in the Doctors Office it is through the medical side. Those numberbs are just strictly pharmacy. The slide is rebates. We always want to negotiate for the best rates for you. The top 3 are the top drivers. There are no generics in these categories now. We do expect this to be changing because we there is new bio similar within the diabetes category called [inaudible] so we expect we will have movement there so next time when you see these numbers you will probably see a difference there. One thing i need to point out is a error on the estimates for rebates for 2016 i have a error. My apology. It should be 893 893 thousand that is a substantial notation. Not 89 thousand it is 893 thousand. This is money coming back to us, is that correct . Exactly. Any questions . Any questions by members of the board . I just have a comment. I recently tweent a conference where they were talking about prescriptions and the number one thing is they need transparency in all employers need to be a Critical Mass to demand it because the data is not there and they cant get it. Another thing that came up is rebateerize a game. They just dharj charge your more and give money back, so we have price setting on the pricing so we try not to play that game and we do not put the highest cost drugs on the pdl for those rebates. I know that it is a tricky situation and there is a lot of discussion about it but we do not with our formulary pdl we do not put the drugs on there that drive the rebates. Are you participating in Public Policy forum snz always involved, yes. Thank you. Other questions from the board . If not, go to the next presenter. I attended that same conference and will make detailed comments in the president. I happen to be meeting with a representative of the National Pharmacy benefit exchanges and he says there is a lot of stuff coming out and employers and people are going to be absolutely thrilled and pleased with these new drugs. We got 10 of them in the pipeline and every 1 of them will be 100 thousand per dosage. I said, i want you to know im absolutely thrilled to hear that. He upset my breakfast terrible. Within the next two years he said. You are . On that note, i am genet moan with blue shield. Thank you for having me. Delighted to have you. Can you hear me . Yes. Much like my colleagues, scott and dean from kaiser, blue shield subscribes to much the same philosophy and practices. We have a presentation. Thank you. Thanks. Thank you. So, im going through highlights. You heard a lot from two other vendors who we regard highly so dont want to review the same information you already received but will call out the item said that may differ. Thank you, we appreciate your efficiency. Sox on page 2 of the presentation i wanted to outline the similar patterns to what you saw prior that the 2014 a huge uptake in prescription trend. 23. 93 percent with the largest tick we saw occurring in 2014. I wanted to also point out that of the specialty medications that were being administered, 3. 59 percent occur in inpatient hospital setting. So that being reflected in your medical trend only, the 3. 95 percent. Moving to page 3, you can see the bar graph, you see the upward trend year over year from 19. 61 to 27 27. 56 to 34. 82. The right is a bench mark and to the risk scores and how hss compares, there is a significant difference between the risk score at least the risk score with blue shield of california, the population there compared to similar employers and the corresponding cost. A few statistics, the average for Specialty Drug is 6, 350 per month. The cost share is 20 percent but has a cap at 100 so that means the member cost share is 1. 57 percent of the true cost. Again, relate today there benchmark, hss cost is 14 percent higher than the benchmark for similar employers and hss specialty costs increased 26 percent year over year. We see a lot of this with the aco partners specifically brown and tol end and the major focus is ancology medication and hiv and hepatitis which everyone saw. On page 4 we have our specialty prescription programs and much like kaiser, we are not focus on the rebate but the net cost and trying to avoid that game. We also focus like kaiser on ends to end integration where we are integrating our objective on the medical side with those of the pharmacy side so everything is related to the member and treated hol isticically. One difference i didnt hear mentioned yet and it could be based on the different models but there is a interesting phenomenon in the medical community there are many incentive and bet you learned about this at thefernalacy Pharmacy Forum that some medical practitioners are incent vised to use higher costing drugs so we had to work with that and we have given incentives to use the low r costing drugs that we have tiered professional fee schedules and that is something notable. Much like [inaudible] we have significant member intervention prioring to receiving medications there is a nurse support and practitioner support in advance of fills. The last item is short cycle program, often our members or patients are unable to take the entire course of a Specialty Drug prescription, so what the practice we started instituteest is first scripps are 14 to 16 days, the members copay is prorated accordingly so there no waste and the poor patient isnt continuing on with something that is being rejected. Does anyone have questions . Questions for members of the board . Alright. Again, thank you for your presentation and the perspectiveoffs blue shield on this topic. Thank you. Page, do you have wrapup comments you care to make . Just in closing, one of the recommendations is we continue to look at developing a specialty formulaary and look how you want to tier if you should given the discripancy between the total cost thf drug and member out of pocket. One thing i highly encourage is you do partial fill frz the initial prescription. Alright. Thank you. This issue will come back to us as we are dealing with renewals as we go forward. There are several conflicting items at this point i want to do. I know that one of our members may have limited Time Availability with us and wondering if we should take up the action item on the investment policy before we take a recess. The end can only comphand what the mind can inder or vice versa. I like to take the board action item on the investment policy as the next item. Interruptingwe are now the board not the benefits committee. Thank you. Item 13, action item. Approve San Francisco Health Service trust Fund Investment policy. This policy came to us after a lot of work by our chair commission sass a lot of involvement with the treasurers off with city and county of San Francisco. We commend the work effort of our council eric rap aport leading the legal review to get to this policy statement and now here in our sweeping activity to get it down, however we left one phrase in the policy and what we are proposing to do today by this final action is to remove that policy provision. So, that is really its one edit in the policy is what we are making as a change. Im ready to entertain a motion. Move that we approve the investmentpologist as written. Alright. As edited. It is moved. Is there a second. Second. Properly moved and seconded we approve the investment policy as finally edited. Is there any questions or comments by the board . Any Public Comment . Hearing and seeing no Public Comment we are ready to vote. All in favor say aye. All those oppose snd . It passed unanimously. With that, i would like to take a 5 minute recess. A 5 minute recess and we will reconvene as the rates and benefits committee and discussion itemsment [meeting reconvened]. Having stretched our minds on both end we are now ready to proceed with discussion item 8 which is the rates and benefits Committee Meeting discussion itemfelt item 8, discussion iletm. Presentation on Kaiser Permanente multiregion plan. Kaiser permanente. Good afternoon. Cindy green, Senior Executive account manager, Kaiser Permanente. We have a presentation. Just lean forward if you would. Thank you so much. Thank you for the stretch break by the way. I have been asked to present information about the possibility of exploring Kaiser Permanentes addition of three con tracts in regions outside of california for the capability to allow early retirees and medicare retirees the ability to keep kaiser if they move outside california. Today ill provide General Information about what that could look like. San Francisco Health sunchs system receives many requests and have for years for kaisers members moving outside california and wanting to keep kaiser. Kaiser is in other regions throughout the state and country so when someone moves to the the region and sees there is a kaiser there they wonder whey they cant keep it and still be affiliated with the city and count a. In order to offer Kaiser Permanente outside of california hss would have to look at adding three separate contracts on behalf of the regions we are interested in participating in. On slide three, those regions would be washington, oregon and hawaii. On slide 4, i list Key Statistics about those particular regions. We have existing member sp in those regions currently. I wont go through every detail because we are tight on time but it gives information about the hospital, medical office, Outpatient Surgery Centers and physicians in the areas. Washington which is our newest region, we are affilicated with 49 hospitals in that area. On slide 5, are the amount of retirees that live out of the state of california in those specific regions. If you look at the top of the slide they are enrolled with united 198 members that live in oregon, 171 in washington and 55 in hawaii. The table at the bottom of the slide are individuals that live in the region where there is a kaiser service area but have waved coverage. They are not receiving any medical coverage currently through San Francisco Health Service. 54 in oregon, 36 in waux washington and 21 in hawaii. What the considerations would be in order to move for ward this process and the benefit to the member of San Francisco Health Service system would be it allows them to have another insurance option outside of california and allow them to keep their kaiser coverage. It also would allowexcuse me, allows another choice for the retieees when they move out of state. In this situation the california based account team would remain your sole contract for any administrative contract needs and eligibility needs in the other regions so we would be your point of contact. It is not that you would have to deal with other account teams, the California Team is your sole contact. We are currently out to the bid process where we have taken this census information for these particular individuals i shared on the slide before and we are currently asking for rates and benefits, which we do not have at this time but in the bid process for that. We would be asked to align benefits as close as possible to the home region thrmpt are nuances sometimes in the other states based on the department of insurance in that area, which may prohibit from matching benefits exactly with the state of california under this arrangement, however the goal is match as close as possible. The retirees would need to complete ago ahead. On the previous page allow members to keep insurance as a active employee. Is it active employee or letireee . It is early retiree. We can correct that. This plan im talking about is for early retirees and medicare eligible retirees. Thank you for the clar ification. A retiree or early retiree would need to complete a new enrollment form if they moved out of california. They will not be able to continuously keep the same enrollment arrangement so that is the process that needs to be worked out on behalf if the new contracts were offered. Could you explain why that is . Under the cms regulations and guidelines right now the Northern California region is considered your home region and so someone moving outside of the home region to another state is a requirement they need a new enrollment form. Alright. Part of this arrangement is if it is decide to move forward is we are focus on the three regions to also evaluate the Administrative Burden or impact that such adding 3 additional contracts would have on San Francisco Health Services staff and kaiser account Management Team and want to make sure we deliver the High Quality Service so there will be a evaluation process if we move forward on this. Slide 7 listed some of the step squz nuances that need to be considered. Again, i had already mentioned we will look to match benefits as closely as possible with the home region. The california account base team is your sole contact. You would have a separate eoc and custom contract in those additional regions. We do have the capability for electronic billing in the home region and it is to be determined whether that same capability is available for a much smaller population in those additional regionsism we are also looking at the impact that would have on the current eligibility file, so currently all of the eligible employees in the state of california are transfer today kaiser electronically on one file. There needs separate files from those different regions. You also have Different Group numbers so now there is a group number for the north and south. There would be Additional Group number frz the regions we are referring to. As i mentioned the rates and benefits are determined. There would be different rates because we look at a different population in different state. There is also potential impact to the timing of rate availability. There is a for instance in our oregon a longer lead time to release commercial rates than in california so there could be impacktd in the area as well as being able to meet your timing and that is one of the things we will look at and that would be applicable to medicare and early retiree. Open enrollment occurs at the same time. No problem there. Then from a data reporting i think kaiser currently provides robust reporting and Data Analytics on the california population and there is no reporting available on the small populations based on the size of the numbers that you saw earlier. Based on that size we wouldnt be able to report on those specific populations in those three regions. Our next step in this process is to continue the rate and bid process to provide that information when we gather that to San Francisco Health Service system, answer questions on the previous slide on more of the process, the timing and capabilities. This would be for the jan 1 Effective Date of 2018 and once we provide that Additional Information that will give them San Francisco Health Service system the information they need to make a informed decision. Thank you. Any questions . This is a excellent idea. For years members have been asking totransfer to other areas. I notice other areas like colorado, do we have members there that yes, there were members in all the other regions kaiser offers but we chose the three most populous regions and especially since this is something we want to evam wait the administrative impact we thought it is more fruitful to look at the three more popialist areas first and make sure we have this finetuned before we expand cht anyway, it is great. A long time coming. Other question snz i have one more question. Now, members who already in these areas and have say United Healthcare, Medicare Advantage because they had to sign up this year, they can transfer to kaiser . At open enrollment kaiser is a medical choice option for them. Great, thank you very much. Thank you. If no further questions any Public Comment on this item . Hearing and seeing nonewe do have Public Comment. Dennis. Sorry. Dennis crurg active retired Fire Fighters and surviving spouses. This is great. Commissioner breslin, basically piggy backing because my two questions she asked them. I like to add if kaiser could see expand to any place they have kaiser where we can accommodate our members that is a wonderful thing, but this is a good first start. Thank you. Thank you. Other Public Comment . Age before beauty. Um, actually i you are . Clar zuzonsky representing reccsf. Im happy to see this. There are rumors about it and have been approached all the years i served on the board and all the time im serving with retirees im asked this all the time so these regions are critical especially hawaii and oregon. I think the numbers will increase over time and just recently got a inquiry from someone moving close toor the carolina area and asking about it as well and we had questions for members moving in georgia as well, so i think whatever we can do to help with this. Im also hoping because it is a small population that is mubing into a area kwr we are urmy retirees and retirees and tend to be looked at as a higher cost if there is some way to have our few members rated in a larger group, or as some like large group book of business kind of rating to keep those rates down, because those members are moving there because either families or the cost of living is different for them and lower for them and making this affordable is what is really important. If this becomes more expensive than for exampleu hc it presentss a significant problem and may in fact deter members going into kaiser and maintaining in most cases a long history with kaiser. All most avenue wn who asks has brin all most a life time member of kaiser and i think we need to consider that and hoping that kaiser does as well so they realize that this is a continuation and those are patients who have already been well cared for by kaiser and they have a healthier lifestyle. So, that would be my addition to the comments that were made. Thank you very much. Thank you. Any other Public Comment on this item . Hearing and seeing none we move and thank you for the presentation. Item 9, discussion itemism presentation of healthcare Value Initiative which compares blfts cross governmental and prive lt private sectors. Aon hewitt. Ann thompson andin front of you you have a presentation on the health Value Initiative. We look adit this report several years in a row so in the interest of brevity ill clip through this. On page 1 a reminder that we cull pair your data against the very large database. There are 9. 3 million participants. Your group represents about 1 percent when you compare the employee count between active population and the database. On page 2, we look at several benchmarks so we look at Public Sector industry which is government and education, Organization Size over 25 thousand, fortune 500, labor market which is San Francisco since your active population is living nearby and a entire database which is the orange bar. Looking at page 3 and annually healthcare cost you see you paid about 12, 268 thousand an nually and about 86 percent the total cost of the healthcare versus the benchmark and see for Public Sector at 5 7 percent all the way down to hvi at 65 percent. When we look at member share which is the pay roll deductions members pay 10. 1 percent of premiums compared to 31. 4 percent the public peer group. And then when we look at out of pocket cost which is plan design because members pay less at 612 versus average of 1441 for Public Sector. Page 4 the financial induct we look that efficiency of the plan for demo graphics plan richness and geography. Anything 100 percent or higher the more efficient. You are at 118. 3 percent, which is quite high compare today the peers which indicates the plans are running quite efficiently. That trend is true for some time if my memory serves that trnd is true some time. That is correct. The last couple pages dive into it details and numbers that went into the numbers that we just looked at. Cost and head couts in total on page 5 and then by your three tiers of enrollment on page 6. If you want to see detailsism page 7 looking at the comparison from 2016 for yourself versus 2017 and versus the peers. All and all i think a positive message. Questions from the commissioners on the hvi report . Any Public Comment . Hearing and seeing no Public Comment, we thank you for the presentation. The update of the data, it will be posted on our website as part of the agenda for this meeting for fuper reference. Thank you again. With that, we are now moving into our regular Board Meeting. Transformative. Item 10, discussion iletm. President s reportfelt president scott. Yes, as a discussion item we talked about the rfp process and i along with commissioner breslin had the opportunity to attend the integrated benefits Institute Forum held in San Francisco on a Scholarship Program. We had members of our staff lee haighy who also attended on the Scholarship Program as a member of this to this forum. How did we get there . The facts are that the Wellness Program under Stephanie Fishers leadership, was considered for a Enterprise Health management and performance award and we didnt come out at the Top Organization judged by this group, but we came out very strongly. Very good contender. Dont know if it was number 2 or 3, but it is again a testament to what has gone on under stephanies leadership over the past several years we worked at wellness. I found the forum to be informative, there was sessions that were somewhat repetitive. If one employer or vendor giving one perspeckive and go to another slightly different titled forum and it was kind the same message but the integrated benefits institute is in existence for about 20 years and headquartered here in San Francisco and it seeks to bring together from a Employer Perspective the issues of wellness, disability benefits and management and Workers Compensation and they are actively working at that and is a lot of benchmarking their do around these isues. I have done oergzal research and very large employers involved in it along with heth specialist and experts so i find it to be a very useful and informative period of time and commissioner breslin also attended several of the sessions as well and thats where i met the representative told me we got 100 thousand Specialty Drugs per prescription coming your way very soon in the next decade. Beyond that it rfs was a very Good Opportunity and commend it work of stephanie and her team for according the Educational Opportunity so thank you. So, with that i will stop and that is my report. Ill turn to discussion item 11. Item 11, discussion item. Directors report. Active director griggs. Good afternoon. Mitchell griggs acting director. I have a few points on the operation report and director report but i will be brief. The first thing that i do always want to menshz mention is personnel and we have two benefits analysts that are open positions at the time and currently recruiting two interns. I lick to recognize we have a new staff member and her name is megan mc carthy. Megan, are you here . She was earlier. She was earlier. She did come. For the record the board welcomes you to the Health Services system. She is a 1406 administrateb assistance. This is temporary position we brought in into do scanning for the contracts. Contracts how operations and Member Service is digitizing all the member files and said that looks like fun, so we are having all of those scanned as well. She is helping out with that. And as you know, catherine daud rr the last Board Meeting was last march and last day is march 14 and march 13 we had a retirement event. We asked what she would like and she asked to have in the Wellness Center instead of going out and having it anywhere else so the staff got together and we pulled off a great event cht it fsh highly atepded about00 or so people and about 12 people voluntary got up and spoke about her service with the city and Health Service system. A great idea speaking of wellness earlier of the wellness staff was a honor since kathleen didnt want gifts to honor her service with the city and her devotion to bringing up wellness is to name our Wellness Center the Kathleen Dodd Wellness Center so that is watt we are doing and the plakes plaques are on order and there will be a plaque next to the door that says Catherine Dodd Wellness Center. I will segue into the management report and start with wellness because i will ask Stephanie Fisher to come up and give us a brief Quarterly Report on wellness. Well have a presentation. Stephanie fisher, wellbeing manager working on our new term. But it still going to be the Wellness Center. Thank you for enjoying the ici forum and definitely want to thank lee for drafting our application on my behalf. He put a lot of work into that. Today i get to give a update on a web wellbeing program which is the Larger Program that we do tr fr all employees retirees and all our members and also a piece of that is the Wellness Center. We like to thing where we pilot things and our home and shows we walk the talk and brings people into us but we aware it only serves a small portion of our population, so it is only part of todays report. So, early in march we had a Large Department head meeting. This is our third Department Head meeting where we introduce wellbeing and wellbeing assessment and had a call to action for champions and expanded the department this year. We had 41 attendees there and at that meeting we introduce thd new structure so in the past we have been working on assessing departments and letting them know how they are doing and providing programs to them and starting to get this Grass Roots Movement happening. This year we introduced a structure that is asking each to d department to have a plan and part of that is asking a member of leadership champion to support wellbeing at the department. That fts the ask of the Department Head meeting. As of the time of this report, we had 18 department leads and departments so far. I had 3 meetings that resulted in department leads today so that number will be growing quickly. We excited to see the departments are interested in personalizing this and making progress, so we couldnt be happier with that progress. As part the rerecruited champions. In the past you had to opt out and now we made them reopt in instead of keeping on champions who didnt bother to tell us they dont want to be champions anymore. We had grown to over 200 champions and expected to be back closer to 100, 120. As of the report we are 137 and this morning at 151 so keeping the ones that were engaged and they are growing without much effort from us to recruit them so really excited about the infrastructure changes happening and thackt if is becoming mart part the culture. We implemented spot light awards and different resources which allow us to tell the story and analyze the program at the department level, so those pieces are coming in as well. We had our second campion training the year. The first one focused on the transition within the program, the second one focused oen our First Campaign which is around physical activity. The campaign is called, play your way and above moving your way and use the tool that works for you. In the past we had everyone tracking on the same app and website and there idea is there are so many different tools. Some people like the physical activity tracking device squz some use their phone and some just use a friend to keep them accountable so making a challenge that allows people to be active and push them to be better each day. But also doing it in their own way. That the idea bethined campaign and has a 30 day challenge offered enmay. We trained just about 100 champions ovthe course of 12 trainings. That page is now live so if you go to my hss dautd org wellbeing you can sign up and energ encourage you to do that. Read the resource squz learn about tools that could help you. As part of that we are having like i said that is our big program for everyone retirees family members, employee cz participate but the home at the Wellness Center we will have a play your way week april 2428 to launch that really walking the talk having the activities we encourage the departments to do at the Wellness Centers so folks come in for instance recess to get a 15 minute break, physical activities class jz all our health plans dental and vision partnered to put together a fitness fair so from 112 wednesday of the week which is the 26 all our members can come and learn about the resources offered to them through their health plans, through delta dental and vsp as well as our Fitness Center discount partners and all our City Partners so even the fact you can volunteer at animal care control to walk a dog, they will be there offering that to show the diversity and what we mean when we talk about movement. The rest the report takes you through the data on the Wellness Center, usage around Group Exercise and on site activities so ill let you read that on your own. If you have questions im happy to any questions that came out of the reports provided so far. Questions from the brored . I asked a while back about how to measure whether or not any of these are working to make people healthier . You had said it takes i forget how long so wonder when you expect a report like that . Some the indicators we have and can put toort a presentation on that is wellbeing assessment data we had in 20 freen 14 and 15 has shown lower cost in the data. Not just what the research said will happen but this is a true association in our data, so we have seen things along those lines already. Each of these programs again tell a story we are starting to move people into different behaviors as you heard today there are a lot of things that empath our healthcare cost and health are not necessarily in our control, so having a direct correlation between those will always be hard. But we certainly have the data that shows that as we are improving wellbeing in our population we did between 14 and 15 we are seeing better healthcare outcomes and we are seeing lower costs. We chose to not assess in 16 and 17 because we spent ought lot of money and time collecting data and not a lot of time helping people improve their wellbeing so changed our focus on programming and make sure we create a culture that will sustain that. Yes, we need to assess again evaerch wale, but it is a very large investment and we wanted to make sure we had a Strong Program in place before going back to do that again and spending our budget othen programs. If you can plan on it maybe at the next Quarterly Report doing high level summary of where we started and where we are to the extent you have that supports that i think that will be usefoot. Useful. Certainly. Maybe looking at this strategically we think about a 2 year cycle taking that measure rather than annually but that is your judgment. Any other questions from the board on this topic . Again, stephanie thank you for all your efforts. Thank you. Any pubhook comment on that particular item of wellness . Go back to theyes. Dennis kruger active retired Fire Fighters if you come early to the meeting and have a few minute on the north court 55 people doing exercises so from that perspective they would be outside eating lunch, instead they are doing something so i say the Wellness Program is working. Alright. Director. You have other items . Yes. Just to quickly go over the things in the other divisions within the Health Service system. In march calls increased by 20 percent over 2016. Call volume mainly had been announce td 1095 were due early march so people received those calling about those and wndering where they were. Also, we are beginning work on our e benefits, self service part. We started meeting regularly and we are got a project plan and key members are working on bringing us to a point where october 2017 we can do a pilot the Self Services benefit so people can enroll electronically or change their benefits or change dependents. As far as Data Analytics is certained, we have at the time of the report we had 54 percent of our digitalization project complete but we are now we are over 60 percent. We have the opportunity to go down there to the vendor doing that which is called fmti and look at their process and facilities near san jose and reasering experience how good they are and so we are already able to use our system and when i have a call from a member i can go electronically and see their entire file, what used it be paper file. I want to mention a important thing since after open enrollment and it was a busy open enrollment and things for at least Member Services we have a breather in april as far as calls but the Data Analytic Team is still working on issues with open enrollment with the split area issue. When we move to United Healthcare a medicare member the family any non medicare family can stay in blue shield and it wasthey have been extremely successful but the amount of programs and code changing and we are still working on that mostly with the reporting currently. Like i said earlier, we completed the electronic1095 paper reporting and completed early ahead of schedule the electron ics and upload the information to the irs. I also wanted to just briefly mention finance. They are currently going through a Financial System project and i have to bring this up in front of the board and public it is a lot of work changing a Financial System and so we are expecting i believe july 1 implementitation date so they will go into the change over at a very tricky time for all of us especially looking at our rates and they are moving from one system to a people soft system. It is difficult and challenging moving from one version of a people soft system to upgraded version which is what we did in august 2012 from 7. 5 to 9. 0 in the benefit administration side so going from another system to a new system and it is people soft so have sympathy for them and acknowledge it is a lot of work coming up. Communications we continue to working with our new Communications Manager Pamela Johnson and work on getting her really informed on open enrollment material because in a couple weeks we will start tearing those apart and inserting the information we need to put out there for 2018. So, last but not least i want to talk about a meeting that i went to and report out the meetings and presentations we give and i had the opportunity to athend united educators of San Francisco Membership Meeting in match and have to say that earlier i talked about things i like about my job and this is it, engaging with retirees and Retiree Association because there is a big need for hss especially in the Member Service side to talk and find out their questions and this is again why we lead to the multireneen plan at kaiser. We engaged the retirees a lot last quarter last year because thechange in the medicare plans and i thought that was a helpful thing. I think we did 18, not saying we need to continue to do that many, but as many sessions and ujication sessions and opportunity to meet with retirees and those associationicize very important. I have to say too, after i gave a small presentation at Membership Meeting, the first question was about the Second Opinion benefit that is offered out there through best doctors so do think also when we review this next Board Meeting i believe enour communications and our education and training we put out there during open enrollment we need to do that again. We put it out as new benefit last year so will continue that education because it is obviously big interest in that. We also were asked by the board to give updates on Affordable Care act and repeal and know what happened with the last attempt, it never made it to vote so we are still under the Affordable Care act status quo with that, which means we have a hit tax and still have a cadillac tax that is effective in 2020 which is very soon. I believe the position the president at the time when this didabout go through is we will focus on tax code reform, he switched that opinion and now repeal before the afford rbl care act is something he feels he needs to do before he goes through tax reform and that is because it is difficult to pass trax reform with the trillion dollar taxes wrap udin the Affordable Care act. Sorry. Keep turning my head. Sorry. So, it difficult because there is a lot of talk but nothing really for us to report on accept we are going back and forth but i wanted to make sure the board knows we will be regularly updating them every Board Meeting on whatever is happening at the time. Thank you. Any Public Comment on this discussion item of the directors report . [inaudible] i thought there was no more hit tax base odthen presentation on the last meeting or meeting before and you mentioned there is a hit and cadlic tax for 20 twebt with the aca. I thought it was proved through the dmhc at least one the plans no longer qualified for a hit tax. That was blue shield. But the hit tax still exists. It exists but is it impacting our plans . It impacts the insured plans. Okay. Thank you. Alright. Any other Public Comment questions . We are not at that point yet. This is Public Comment on this item, the directors report. We are now ready to go to the next discussion item. Item 14, discussion item. Hss Financial Reporting as of february 28, 2017. Pamela levin. Pamela levelen chief Financial Officer helths serviceest system. We have now completed 8 monthsend of february 8 mupth synchronize to the fiscal year. We have a projection for the fund balance in the trust for june 30, 2017 to be 73. 5 million, which is 1. 1 1. 1 million greater than the amount in february that is due to favorable claims experience both for the self funded city plan and delta dental. We received a pharmacy rebates in the amount of 140 thousand in february but the year end as projection remains unchanged because we anticipated that. As i mentioned the last month two applications have been received for surrogacy and adoption 6789 one applicant is deemed eligible for the benefit and we will issue the payment in the next couple weeks and then the other application is still under review. In terms of the general fund, we expect to end the year on budget. Alright. And can you tell us anything about the status of the upcoming budget cycle, just a cliff note where we are in that process . The budget is stim in the Mayors Office and under their purview. I can tell you we have been successful in convincing them that we should not be cut and i expect that we will have a budget as we proposed it without the cuts when it comes out in june, but they can say everything is fine and you are finalized but there is stilluntil it is published it is still in their purview. Alright. Thank you very much, director levin. Any questions from the board . I dont see the Financial Report in my packet but i justyou have been reporting under the surrogacy but not reporting the performance guarantee amont is. What is geing in and out of it . Performance guarantees we are doing that quite a few mupths back but dont see it anymore. They rin here. The line for performance ganer teens we have not received performen ganen tees for this year as of this fiscal year. We are using the performen guarantees in the prior fiscal year sitting in the fund balance. We moved those 300 thousandactually 150 thousand over to this special fund for fy 1617 because it is 6 months so that is wlie it is 150 thousand and sitting waiting to be used for eligible expenses set astd. Hew much is set aside for sur gaes. It is one amount for surrogacy and adoption and it is it annual amount being a annually year, not this fiscal year, a reg yoorl is 300 thousand. This year because we report on a fiscal year basis and didnt start until january it is only 150 thousand we put in there. There is 300 thousand set aside for the surrogacy or 150 thousand . Im still confused. In the report we report on a fiscal year basis so for the fiscal year that covers july 1, 2016june 30, 2017 we only put 150 thousand because the benefit didntisnt effective until jan 1, 2017. For 17 18 we will put aside 300 thousand. There is 300 thousand. But as i said we havent paid out any at this point. I can tell you that the amount for the application that we have approved is less than 15 thousand, so but aside from that what you are setting aside how much is in the fund . It is all in the fund balance. So are taking everything . No. Im taking only a small portion of the fund balance how do we know what the fund balance is . The fund balance is at the ends of june 30, 2016 was 68. 6 million. In the performance guarantees . No, overall. Im curious about the performance guarantees. It isnt segregated. We are not spending any money from premiums from any of our members to pay for the surrogacy and adoptions. Any performance guarantee money we received at the time it is tracked and credit into the fund balance. Correct. We have been doing that a number of years, is that not true . And we have annual Financial Statements that attest to this, correct . Iect. Any other questions . Maybe just a suggestion started fy 1617 if you drop the performance guarantee from here on and how much of that amount was taken out to put into the surrogacy benefits. I do that but let me point out one thing, to the extent that performance guarantees are not used for the surrogacy and adoption, they are part of the fund balance is being unappropriated if you will fund balance. Within that fund balance we always talked about how much money is available for any non obligated understood, but the surrogacy when we approved that it is taken out from the performance guarantee, so we just need to track from here on starting fy 1617 how much we got for performance guarantee and how much of the guarantee was used for surrogacy and going to fund balance. Just to track purpose. I do that. Deputy if ia make nolet to do that. I dont want impression left we have level of income coming into the operation the system not properly accounted for and audited, we know they are. Thank you very much for what you report today. Discussion item 15. Item 15, discussion item report on network and health plan issues if any. If there are any will any plan representative come forward. Kate kessler kaiser. Wanted to let you know about a account management change. Cindy [inaudible] dont tell me she is leaving. She is not leaving she is recognized for her work and been promoted in our organization so now the director of our strategic acoupt private Sector Department will not be mubing off ouf work wg you immediately but we do have a wonderful new account manager, patricia pervs who is here if she can stand. Well come. We are delighted to sl you will us and have big shoes to fill. Patricia is with us 20 years so in good hand and cindy and patricia will work side by side several months. I like to add that i want to thank cindy and mary ann for their work. They worked with me probably the most during my time and want to say thank you. Alright. Thank you. Any other network or health plan issues from plan representatives that we need to i have a question of all plans. To let me know what your Nutrition Counseling benefit is now. What you provide for that and what you plan to add on since that was requested at 2 or 3 metings ego that Nutrition Counseling is included in the plans going forward. So, i havent heard any kind of comment how that will work and to emoo that should be cost neutral. The savings im sure will outweigh the cost. We talked about dibeatacy dibeatys is one of the highest cost. We still dont have 23450utrition counseling. To this point, well take commissioner brezlens request of each of the health plans and ask director griggs to please get consolidated report to the next meeting, a consolidated report from the plans not a individual report from each plan but consolidated report around this aspect of the operation and where we stand , what they do or dont do or planning to do going forward. Thank you for the inquiry. I want to mention another thing, United Healthcare, there required doctors referral for physical therapy in the Medicare Advantage plan and that was presented that we did not need a doctors referral but you do need a doctors referral i was told by a physical therapist. Is there a United Healthcare member here. There is closed session and need to be out of 5. Very conscious of the time. United healthcare. There should not be a referral, so if you have a specific member we can look into that. I had the form in writing where you required that from the physical therapist. I got there and they said they require it. For you specifically or a member . Y can look into it. Anybody in medicare. I request you follow up on that point. Any other questions of plan representatives . Moving to item 16. Item 16, discussion item. Opportunity to place items on future agendas. Hearing and seeing none, item 17. Item 17, discussion item. Opportunity for the public to comment on knhae meaters within the board jurisdiction. Do we have Public Comment under any of the matter snz please come to the microphone. Good afternoon. Ann dawnlen the communication director at the San Francisco superior court. Thank you for the opportunity today to speak with you to make you aware of extremely poor Customer Service from ebs the city and county of San Francisco benefit vendor. I lick to acknowledge and thank mr. Griggs and mrs. Oconnor for responding this week to my particular issues with ebs. I note with interest you have before you many Customer Service metricrix jz measurements for hss mpt im here to strongly urge you to do the same for ebs. This is a lucrative contract and as such incumbent as Board Members to seek and obtain Customer Feedback from us, your customers and consumers of the many fine benefits you offer to ccsf and eligible employees like us from the court. My tortured experience with ebs demonstrated they have many strides to make to deserve your business. The simplest of tasks such as accurately arranging for pay roll deduction for inshurns products to making Customer Service representatives accessible, responsive and efficient at problem solving elude the vendor that is why im here to request you undertake and evaluation the Companies Performance to determine the level of customer satisfaction. Has hss asked the customers to rate their satisfaction with the Customer Services provided by ebs . Does their contract require they meet certain Customer Service benchmark . More than 9 years i worked for the corep i dont recall being asked for the quality of service provided. If you ever have engaged your customers to find out if you everif you never have engage your xhust customers to find out whether ebs should have our business i suggest it is time to do so. Im a robest consumer of the money products you as Board Members decide to offer to us. I am but one person with a long list of documented service problemwise ebs, but you dont have to pake my word, a Google Search demonstrates that my Consumer Experience is not unique. Here in my hand are the 9 ebs reviews posted on yelp. Every one is a one star rating t the lowest rating on yelp. It is time to deman your benefit of the vendor and employ you to assure getting what the taxpayer squz employees are paying for. Thank you for your time today and look forward to accountability from you on this important consumer issue. Thank you for your statement sphyou care to leave with the scaert you can do so. If you care to. Any other Public Comment on any matter of the board jurisdiction . If not we are moouv toog action item, which is vote whether to hold a closed session or member appeal. Item 18, action ite item vote whether to hold clodezed session. Do i is have a motion . It is moved and seconded there be a closed session. Is there Public Comment . Hearing and seeing no comment all in favor say ad session. [members in closed session] i will entertain a motion for adjournment of this meeting, the regular meeting of the commission. I make the motion tew to adjourn. It is properly moved, is there a second . We have the action to vote whether to disclose. So, we have item 20 action item vote to elect whether to disclose any or all discussion in closed session. I move we do not disclose. It is properly mubed and seconded we do notd disclose the result oz our deliberations in closed session. Any discussion by members of it board . Hearing none we are ready student vote. All in favor say aye. All those opposed . It carries. There is the report on action in closed session. Move not to report. Is there a second . Second. Properly moved and seconded we not disclose the actions taken in closed session. Any discussion by the board . Hearing no discussion by members we are ready it voted. All in favor say aye. All those opposed . So ordered. Now ready toentertain a motion to adjourn. Make a motion to adjourn. So moved and will give approval by rising and leaving the room. [gavel]. [meeting adjourned] good afternoon and welcome to the Planning Commission this is the regular meeting for thursday, april 13, thursday, april 13, any kind. Proceedings. And when speaking before the commission, if you care to, do state your name for the record. Id like to call roll at this time. Commissioner president hillis commissioner Vice President Richards Community college commissioner koppel and commissioner moore we expect commissioner johnson and commissioner melgar to arrive