Transcripts For SFGTV Health Service Board 9816 20160915

President scott. Here. Vice president lim. Here. Supervisor farrell. Here. Commissioner ferrigno. Here. Commissioner follansbee here. Commissioner sass here. We now have a quorum. We will now take item number one. Item number one is the approval of theminutes of the regular meeting of august 11, 2016. Are there any Public Comment . All those in favor say, aye. Opposed, nay. The minutes are adopted [gavel] item 2. Item 2 is gen. Public comment on items that are not on todays agenda. Are there any Public Comments on items that are not on todays agenda . I only have a few minutes but i did want to mention that we will Start Talking to the board about the benefits that the members will receive and we have a quite a few members who did not have access to these benefits before or they used it and had not wanted it but its been run through hsf and it has been monitored and it has been vetted andwe thank you for that. Thank you and thank you for bringing your thanks. We need that. Yes sir . Good afternoon commissioner, richard lawson, long time county employee and i want to talk about the negotiation with kaiser. If im not mistaken we are the Second Largest Group with kaiser and we should have our own phone number one we call into Member Services group ince we have such a large group and also with pfizer, my doctor luckily did move but i havent seen anything with a traffic manager plan where how do you get there whenthe giants are playing or if there is a game. And one thing we salt was they had buses that were traveling between the connections. Pfizer can now bust within the system. And, they have an email system. Now they are starting to use it for nonmedical issues such as race or to fill out a form. Because, it is a process. When i get an email like that my pulse goes up because i worry that something might be wrong and now we are able to use that email. Thank you. Any other Public Comment on items not on the agenda . Hearing and seeing none we will now go to the president s report. I just want to call to the boards attention that the series for 20162017 for the International Foundation of Employee Benefits has been published. And, one of the things that we have continued to talk about is whether and when we can continue to access certain of these Certification Programs and the related cost. It turns out that this year in our own backyard in san jose this coming year there will be a course in october of next year one healthcare cost management. And, it may be worthwhile if you havent received the mailing or if you havent been going on their website that you give some thought to maybe that might be an opportunity to get further exposure around one of the well Done Foundation programs and it is nearby. Normally, they are held at their annual meeting and that is in Orlando Florida in november. I always have a hard time in my profession to explain why am going to florida for a meeting in the middle of winter. But, while they are nearby, it might be worth your while to look at it. The other thing is the recent announcement this month for the planned increases next year. They are mitigated by the fact that there will be a lot of planned choices. This is kind of a signal as to how this may work out as it impacts other employers. Particularly the way these are being drawn these might not be offered in the exchange and the others may not be present in the exchange but what im hoping is that while were reading this this may have some Ripple Effect back to us in the state in the northern part of california. This might be something we can talk about during the upcoming course in november while we are looking at a variety of topics and trends. And that is my report for today and ill have more comments as we go forward. Mme. Secretary . Item 3 is the directors report. Director dodd. Thank you mme. Sec. After 27 years rosemary has left. She brought some real talent and professionalism to her position. She is anxious to move to and her mother, she is anxious to move it to her new home in sonoma and her courses and we probably all envy her to some point. The new Operations Manager position was posted may 5 and candidates have been selected and this will be on october 15. She was at pfizer for many years and that she[inaudible] and jones took a position at the Human Services agency and that left a position vacant that we will be filling. Two of our former will be coming back as a prop f and we still have those two positions and it is of note that there were applicants for the 1210 position but there were only so many qualified to be interviewed. So hopefully, we will have things up and running as we promised. United healthcare did a training for the benefits analyst under the new city plan and they are the invitations that are in your packet. We will mail them today or tomorrow. You calling you are asleep. Goes live tomorrow. I am sure that we will be busy. I will tell you that i made a mistake of putting my own direct line in. If you have any questions about the new city plan i was very busy that first day i had to answer a lot of questions, good questions and by and large people were concerned if they could still see their doctors. There wasnt any angst they just had to have their questions answered. So, i got to answer questions for the day. I wanted to touch on mitchells points which is our Enterprise Management system and that is done so that as new faxes come in they go directly into the computer and directly into the file. People will bring in things and then they willfactor but they will go directly to their file we will have at least 7 million changes and you will see that. During rosemarys absence i think you know it that we all worked hard at when rosemary was here and we worked really hard to her credit to make sure that everything was ready to go for open enrollment. So the complex process of pulling the different mailing list, making sure they are accurate, making sure that we are printing the correct bar code lists and making sure that they are where they need to be and with the retiree guys these are being hand stopped. But, they are all they are and they are being hand stuffed and they should go out about the end of the month. The actual booklets which will direct you to the website. A excuse me,when does open enrollment actually close . It begins october 12 and and october 31. There is other information from operations. We have met weekly with kaiser and United Healthcare with the retiree transmission approval to discuss a lot of the transition material that is going out and its been a very colloquial relationship on how we can get the financing. Its just not thee1,or the e2 it is not just the 700 and £. 50 rates where we rounded up a penny or down a penny and we have to check to make sure that they are correct. That kept finance and analytics is the. You may recall when we got broken into last year we lost one of our call boards and we arranged to have that fixed so that everybody could watch it realtime. Have a coauthor on line and how many are getting answered etc. We have a majority of things to discuss. The most significant thing is getting the invitations out to the retirees for the forms that are coming out and as i said, they will be going out tomorrow. We were able to fund 135,000 of the administrative budget. Hopefully, the request will be approved. We closed the fiscal year and they are now in the midst of working with external auditors. They are now in the midst of working with external art of auditors kkmg, the auditors are on site looking atofficial documents. We are working with an Investment Group to put together a Health Service policy for the trust fund. This came up last year. Its just taken a long time to get all this up and running again. I know that pres. Scott and commissioner sass are supporting this in terms of moving forward. I know what that we are looking into the Different Department heads to look at where they can approve different areas for the different assessments. The movve more feel better week had a huge response in terms of participation. On route 66, i hope you are all participating. We had an initial meeting with the Treasurers Office to put together a Financial Wellbeing plan for the employees. Not just the nuts and bolts of balancing a Checking Account but what are the behaviors and the attitudes that are handed down what are the behaviors and the attitudes that are handed down generation to generation that get us into financial trouble. Or, we begin to repeat things that have happened before in our families. So, that will be a fascinating work. They do lot of coaching an it will be fascinating to see how the different agencies will improve within their agencies. We are always looking at how we can improve the content. It seems like it should be the same but always changes a little. We had weekly open enrollment meetings i have attended the statewide worker underuse twice now. This is where we are [inaudible] Fascinating Group and i have certainly taken what ive learned at those meetings and brought them to our contracts. War that was dr. Ware who presented last week and we have to create a plan on how we will address the survey. I put in the directors report the url. If you have time to watch these three presentations, they are very well done. So the take away is that Palliative Care is not about just endoflife care it is about care focused on improving life for people with serious illness. So, you can get Palliative Care for many, many years. You can also get Palliative Care for the end of life. Blue shield should be sending out a mailing in november. And in kaiser, they are going to present three forms all on september 15. And that is on life Care Planning or who speaks to you essentially, and if you needed to make those plans you need to make them for. So they will be on site on september 15 and they will come back on the following meeting at the 29th and they will have a counselor there so people can actually start their forms, we are starting to do advanced skill planning. How many retirees were there with medicare only . Medicare only will stay within the sub funding of medicare cob plan and that is 18 out of how many . Close to 30,000. Close to 30,000. I just want to put in context. October, we can see that we are having 13 benefit fares and 10 flu shot clinics. Imagine having people off site while we a people coming in and the phone is ringing. That is going to be a very, very, very busy october. With that we printed extra copies of everything and the Financial Officers and the Department Heads will be sending them depending on how big the department is. We will have extra guys if you want them and if you want a hard copy guide just send an email to this address. Were doing the same thing as we did last year that people want a guide, we can provide that with them. And, that is it. I asked this earlier and mitchell is not here as long as me i awill still have to close processing on the two wednesdays before payroll because that is getting people their paychecks is more important than getting people process. Is there any exchanges the conditions in my system to help accommodate that end, i agree for your request and i will point out to todd reeks of the Controllers Office that we are in control everything because it is hard to not lose sight everything. Thank you. Is there any public, . I have a clarification. To be green, on the day of september 29, it will be a notary not an actuary. [laughing] thank you very much. Any Public Comment. On the directors report or the president s report . Thank you pres. Scott claire or cvs. I am not clear what is going on through your ucc blue shield all that will allm send to all of the information. The three courses on the 15th and the opportunity that wouldnt on the 15th there are 15 planned retiree programs for everyone. Including you see . 15 retirement plans for everyone. We are talking about the two that can stay in the coa plan and two in the cob plan and we have information on what the exceptions are. Because, i do not know if it is a matter of where they live or Something Else that happened but i know that we have some people didnt go into medicare if they should have a large need talk aboutthe 18 the word once you talk about. I donthave the specifics about the individuals but if i wanted to talk about it i couldnt because those 30,000 people. Okay so we dont anticipate there will be any others like this . Okay, i will go back and see what i wanted to say from my notes on the presence report because i did have a common. Thank you. Getting back from it [inaudible] it might be useful that invitation that they may want to bring a friend or the two people here which are posed and so, we say that when you come back on the 29th you should bring someone with you. Great, thank you for you that suggestion. That is duly noted. All right, thank you. Additional Public Comments and you are . Would it be appropriate to ask if when our newsletter comes out that i am not sure that there is sufficient indication of the planning and i think that the life Care Planning is essential. Information went out on tuesday. And it was. And we got just a couple of questions on that. The more you can publicize it the better. We will double up. Because we are putting performance categories in there. First were doing performance education and then we want a certain number of people over 55 to have these in place and eventually, everyone over 18 will have one. It should. The last thing that i wanted to mention is that we use to have the public isep some of those programs and they are one of thewe use to do them in monterey and very often the one with the Public Employment plans are within driving distance hereasep plans most beneficial conferences from the time i was on the board and we didnt do them for a long time because of money issues and the money comes out of the trust fund and not part of budget for commissioners and i think it is highly aand i think that for any staff they were going to be training i thinkworthwhile and i think is commissioners any opportunity you have to attend these trainings for anyemployees for training that that would be beneficial to you and i thank you. Moving onto item 5. We handed out track changes to see what changes we had made since the last meeting. So this is the adoption and surrogacy assistance program. We clarified that retirees and eligible retirees were certainly eligible for this. We went through who the dinner composition could be and i will leave it at that instead of going through one of the exceptions but i urge your approval. Any questions for dr. Dodd or for members of the board. Is there any reason that their people cannot get these part b benefits. It was my understanding of pay about 140 and get part b benefits. Is there reason people cant get this for some reason that i do not understand . Is this on this topic . Are we adopting this motion now . Okay then not i dont want to put you out of order. I do have a comment on it. Im sorry. In the last section of this on the track changes section on 7 the reimbursement policy says that the reimbursements exceed funding and the reimbursements will be funded in the order of the applications. I would rather see the not to exceed number for the first year of this program. Given the fact that letter a, we expanded the population and when you dont even have baseline information wanna our City Employees and employees elsewhere. In the reality is, i really dont know how much funds are available or whether that is a reasonable fresh old to set as a. If we were to get 1 million worth of requests. I would think that that waited be a reasonable amount of trust funds to vote to this purpose. I guess i would propose that we would consider setting a cap some level we cannot prove that of these for this year were into we have some experience. Is there a consent or acquiescence or approval from the board and do we have an amount of money in mind and i guess we ask that question and are we doing any free analysis of who may avail themselves. I think that as the commissioners said we have no idea who will enroll and it may even be the second year after people find out about it the first year. So, you have to look at a couple years of data to look at what an appropriate cap would be. I would like to obtain a motion. I would like to see that we reimburse 30,000 applicants for 2015 at a total of 15,000 per applicant. Could that be subject to further review of the board . If we do get 22, is there a way to come back and revisit this . A guess that is my question. I would refer to eric on that. Once we have a Plan Document that defines the cap. Once we have a planned provision for Commission Review and that will all give the permission to make up sections. I only ask that question because we are in unknown territory and if we are pulling that number out of the air, we might turn 20 out of 21 people and what i am asking is is there some way we can craft this so that if this is needed we can do this during the course of a planned year. If it will create too much of a problem, we can take this motion as it is and move on. Im just raising this is a point. I mean, the plan itself, jeff, basically, it is leaving up to the discretion of what the Health Services board is considering funding under the plan. I do not know what the current funding is is there current funding at this point . We are using the funding from performance guarantees okay. And, i have Health Services designated a certain amount . We have not designated a certain amount. This motion would designate a certain amount. I think this board can do it if they want to or we can do it at the next Board Meeting if you are not prepared to set a today. If the plan is not drafted it does not define what the plan is. If we had 21 and it is possible to make an exception if we dont want to but what if we have 70. I think that we really have to be careful about leaving some discretionary cap under our control. We have no idea what the volume would be. If 300,000 does not seem adequate then 5w600,000 would leave 40 and i am not certain that i am personally comfortable with dedicating 600,000 of trust fund access and that is irma do sherry process to maintain that for our members to take advantage of that. Okayany more comments . That would be during the year, right . That would be expenses . Thank you. I remember the cfo gave us some kind of a timeframe and if you explain where the money is coming from then it should be a much. More reasonable number. And, i dont expect that to be a problem. Good afternoon deputy elevin. Ann elevin,financial performance ofc. We have sufficient funds to fund 300,000. If you want to increase that we have sufficient funds up to one half of 1 million. In my own opinion i think we could start with a certain number of packets and then report to you on a monthly basis how many we have, what is the amount, how many have applied, how many have met the qualifications, how much has been disbursed, and, decisions can be made based on that information. All right, thank you for that input. Any other questions from the board . That is the when we looked at the last years of the performance guarantees, some years were more and some years were less. We had a lot when we had some problems whereas blue shield. On we had blue shield and with care and all that. It is hard to say what will come in. It is hard when they are active it is really hard to predict how much will come in. So, it is not it is just an estimate. I mean, that is the best way of answering your question. Right now, we hope for 100,000 . Yes. If a City Employee adopts this andseptember 1, 2016, they will not be applied until january 2017. Any other questions . If not we will go to Public Comment. Did you say 300,000 . 3000 is where we are. It has been seconded. Good afternoon commissioners my name is andres power, and i support commissioner scott wiener but i am here on my own behalf. Four years ago my child was born by a surrogate. My sister donated an egg and the the surrogate was a close friend of the family. A lot of people came together for us in order to do this. This process cost us approximately 400,000 and i will bepaying off this for many many years. Im fortunate that we were able to do this but for unfortunately for many, that is just not a possibility. Imagine justhaving to spend 100,000 before you have to consider the cost of raising a child in the city. In support of the Lgbt Community we want more children in our community and we want more families raising children in our community. As this policy proposes, this would be a great first step by it is not an end solution. 15,000 is a very small percentage of the cost for adoption. It supports the families that work for our city and it urges the city to be on the right side of this and we support this with you. Thank you. Is there any other Public Comment . Seeing and hearing no other Public Comment we are now ready to vote on the motion whicch will amend the provision that was contained in section 7 not to exceed limits of 15,000 under the benefit purposes. I think i got that right, or contrary. That is the crux of the motion. Are you ready to vote . All those in favor say, aye. Opposed, nay. The motion carries [gavel] we are now moving onto item 6. Item 6 is approval of section 125; cafeteria plan provisions by dr. Dodd. As you know we have to approve the cafeteria plan revisions and we, as you know, have to bring this before you and we have to know what the city means according to the Affordable Care act and we have the benefit table. I am sure that nobody ran through the entire section 125 document. Au contraire. Im pretty sure that before i started here they had in on their section 125 document for years. So we are constantly keeping up with the law with the assistance with the City Attorney to keep these things accurate. Is there any comment from the City Attorney . Im glad we have a cafeteria plan in compliance with the city services. This will be posted on the website for availability for all of the members and so forth. Are there any comments from members of the board . Are there any questions . Is there a motion . Motion is there a second . Seconded. Properly moved and the cafeteria plan for 2017. We are now ready for Public Comment. Seeing no Public Comment we are now ready to vote. All those in favor say, aye. Opposed, nay. The motion carries [gavel] we are now down to item 7. Item 7 is the update on voluntary benefits and who is the presenter on the benefits . This is the Employee Benefit specialist and was waiting for them to come up. Thank you. These are benefits that people had to grow and scrounge them out on their own. Lisa, did you want to read . Lisa garrett, ebs. Thank you so much lisa and you are welcome. Why dont you make a comment on what the different benefits are. The different benefits will be a supplemental term life offered through at not which will be issued at 100,000 for employees and 50,000 for spouse. That will be in this enrollment. The shortterm disability i think its important to know that the guaranteed issue is that you will need to have a medical exam. Yes, i think that needs to be stressed in your reading materials. If you pass by and you want it later you have to come back through what and do a physical exam process. They can deny your benefit. Yes, you have to go through this process and you can be decline. Yes. The shortterm disability for kansas city life offers a guarantee disability issue up to 3000 per month. And so, if they are not signed up this year they can find next year. This is set up to work with state disability benefits so that they can collect additional money from those who receive more than 106,000 a year and that 55 is no longer 55 . It is actually reduced so that will help them. There will be an accident benefit offered through financial and that will put money in peoples pockets so that when they are in accidents there are benefits that are passed out. There is a Critical Illness benefits that will pay basically a lump sum amount from a Critical Illness like a heart attack, stroke, certain cancers or renal disease. So, that pays one time and let me see there is life, loss, Identity Theft and protection, which basically monitors and notifies you of any kind of identity breach and legal shield plan allows you to work with an attorney and certain Legal Services at a reduced rate and pet insurance is for cats and dogs. And if i have another type of pet, too bad. Yes, [laughing] only cats and dogs. No fish, no birds, just cats and dogs. No turtles no fish,just cats and dogs. I also have a little bit of information on the Enrollment Services that we offer. So, i am going to read this part that we are on. Would you do this . Can you pull your microphone down. Work terra is aproprietary system that eliminates the complexities with the enrollment benefits and compliance concerns. Enrollees and employees are to complete the benefit election process. Most ccsf employees that want to enroll in the benefits will use work terra. Some of the tools within work terra are our videos and any tools and work terra will be available 24 7 and if they are not available within that timeframe and then we have a numberthat they can call. They can call asking questions and if they actually want to enroll we can enroll them. And, if they just want questions about rates, whatever, we can roll them through the enrollment process and the call center will be open monday through friday. We have a number of hourly employees as well as contracted employees and they will work with us through open enrollment and through the Community Plan for new hires and promotions. All right, are there any questions from members of the board . I want you to carry a personal message from the board back to your colleagues for what they are about to do and have been doing over the years of my tenure on this board and there are guys doing an extraordinary amount of work over a small period of time with a lot of diligence, accuracy, and support to the members. And, you will be profoundly thank for that. And so, please convey that sentiment to your colleagues. And thank you for coming to speak to us about this. Is there any Public Comment on this item . Seeing none, we will move on to the next item. The next item is itemeight. And that is an update on the process to determine the sustainability of city plan for active than early retirees. I would like to explain how this got on our agenda. We said that we would reply to this question. I thought it be important that they are not be a gap from the formal type of suggestions to where we are at today. It is more of a process update. What is going to be happening and he will be able to inform us. That way, we can form a response to the question. This is not something that is being put in jeopardy or changed or what have you. It was a question that was raised and we are systematically going about ascertaining and actuarially valid response. To the question. So i prevailed dr. Dodd to put this on the schedule today so we can least have a idea of what the result will be. With that, go ahead and present this. Good afternoon aon hewitt. Item 8 on our agenda i am going to discuss what we are previously done. We are trying to maintain sustainability under the city plan ppo and the early retirees to refresh the memory of the board and the public who may be interested. This population is pulled together so all of the loss experience and the subsequent Rating Action on the former rate period and how this is done collectively. But we have done is weve decided that we want this program and this program has been noted as the city plan. This is been the plan of the city and has been reviewed in several meetings prior to this. What we decided in may 2015 is to take some of the available stabilization dollars and reduce thhe contributions to the city plan for active and in early retirees. This had been to the lane and this would be very expensive because of renewing the rate. One of the Board Members, commissioner lim, asked me to help with this and i honored his request and we did the calculations so that was the driving force for when they elected for 20162017 we need better, risk slides for pools. It tends to deteriorate so you better battalion. We at 72 and 1990 5e 1 and we had 40 1e 2s. It was expensive to do this. I really am excited to say, even if we dont know the answer will find out the answer during a normal rating cycle. As of the 15th there is over 100 families. Week significant exercises to keep blue shield separate from kaiser because it has adding 41 families to 100,000 families. That is pretty good. That is better than was done with 18,000 population. If we are going to bring this forward with a pool that is going to go forward on is now. We have and we need a formulary and we needa product sizfor ethose of you that refresh your memory,for those of you who it cost 400,000 for the family that is no way that you could bring a family on to the board. Theres no way you could do that. But for the family i think that is important. Pistols pistols 17 04 26pistolsdata would be the normal rate and we would need to just wait six monthsand go with the normal rate. With that being said, we decided on june 21 two again, exercisable we can continue what we startedin 2015 we did it for 2016 and 2016 we did it for 2017. Normally speaking eight winter a couple of times because we bring the action in and in that case, we need to decide what happens in open enrollment and we get these people in and hopefully more people would join. Hopefully, enrollment can address things such as samesex marriages and we dont have the information that we need for 2017 to determine what we need for 2018. I think that has been a very good exercise and what does that mean . Have we spent all of our money . If the laws experiences good we are adding money on to that. That is grown particularly that we removed all the retiree with the Medicare Advantage and that will have medicare be back therefor various reasons. We need to know that at that point in time. So, what are the steps . I said im excited about the direction and weve already done it. By the by the kinds of esf we want to keep this plan in place and i have no information that we are doing anything other than that. That is my charge and you guys have been doing this for two full years. If during the rating cycle we review the financial position of the program and we review the demographics of 2017 and determine what the radius is and bring to the board any recommended steps that will increase the board and reduce the risk of profile to increase longterm disability. Before, it came down to a point where we had to do something and weve done it to make sure that you have these things and right now were taking care of our full with our assets. Thank you. Are there any questions from members of the board regarding any of this . Just think you for giving us the percentages. And, the reason for the request that this was for me is if we take the action that we may take this afternoon, there will be a void, for providing an interim relation for open enrollment. We are almost to meanings away without this prevailing. I do not want this question hanging in the air with no reference or response to it. And so, thank you for bringing the information forward. I will ask for any Public Comment . Thank you commissioner scott. Claire lansky ccf, as you know i have been a long advocate of city plan one it belongs to me as a board. That is over all the other plans that we offered. That was the original charter mandate and that was to that is over all the other plans that we offered. That was the original charter mandate and that was to provide that programto offer. If we cannot sustain thesystem plan one we that word isthen we will turn it back into its original plan. But over time you will find this and the continued plan will save us lots of money. I am continuing with the hetch hetchy group. I believe a lot of your families are up in that area because they have no alternative to an affordable plan. And while there are supplements that go through with their contracts with regard to premiums, they still have to pay the outofpocket percentages so that is very, very expensive. So whatever we can do to sustain this plan and provide good, quality, and affordable healthcare for members that have no other options, i would really actually encourage you to do that and i think that actuaries further creativeness and also for commissioner lim to do whatever we can do it to maintain this financially and thank you very, very much at least from the people that i support these days and also my relatives up in hetch hetchy and what is the that this plan continues to be available. Thank you. Any other Public Comment . Seeing no other Public Comment we will move on to discussion item 9. Item 9; discussion item. Discussion of the presentation of blue shield of california audit aon hewitt good afternoon, aon hewitt. What i would like to do this afternoon is thank you for lettingeveryone bring this on and it was as painless as it could be. When we go in to do an implementation audit, we compare the processes, policies, and procedures and when they were on their former system and when they transfer over to the facet systems. And so, what weve seen over time, and i have been through many a claims transition is very painful. The audit was not painful, let me tell you. But, the transition was painful. In a sense, you build all of these workarounds. You cover 30 days of Skilled Nursing but for whatever reason the system was hard program to say 18 so you do a build around. So as we went through and looked at the system, we looked to make sure that all of the workarounds has been implemented in the legacy system and they were able to be continued in process inappropriate way in the facet system. I do want to make one clarification and that is that blue shield has transferred to the facet system over a longer period than what we have been exposed to. We were one of the last groups to come on, facets, so we came one in 2016 and this gave them a proximally six months of processing time. And so, what were really looking at is how did facets impact Customer Service, how did it impact the claims processing and how did it impact the service to process claims and recognize and hss member within the blue shield system. What we had found is 90 of the claims submitted by hss members come in electronically. Of those, 73 is what is called auto adjudicated. What this means is that no one touches it. It comes in and the ic9 or the ic 10 code they matchand the person that matches it. Will get paid. One of the things that we do when the claims get paid and how the customers get answered when they call in is that we set targets. During this time period during the six months of implementation, blue shield was not able to maintain his claims, financial accuracy, or the processing time. Some people know that in california you have standards that you can meet which means a claim must be paid in seven days. So, you might have a claimants be paid within 14 days and must be completed by 30. So, they were not able to meet some of those target points but however some of those impacts Customer Service was not able to see without providing the claims that were being made. And the claims were all within their target range. We were able to maintain the Customer Service side with the claims processing and you will see that. A couple of things with the processing and we will go quickly through the details which probably could put some of you asleep its not overly exciting about any claims get paid in a day. But really, what we saw is that in transitioning, we hit during the holidays. So, we definitely have a low period during the holidays and it took a little bit of time to ramp up. Now if you would go over to i just want to talk about claims processing first and that is on page 5. Page 5. And, if you would pause, is this presentation one that would be projected . I know it is posted on our website but i didnt know if it was being projected or not . That is a question of the secretary. Someone would have to bring up a computer and put that in. Lets not stop the presentation for that. I will say for members that these are posted on my website and you members to [inaudible] most of the claims are processed in o die and one thing that we look for is do you have experience processors. One of the requirements would be that they have been there for over 10 years. He was in the processors average is 12. 84 years. From that perspective, it was a really because you dont positive finding have many mistakes made by people that know your accounts and so at one of the other things that we look at is where our people working and are they working offsite on site. At the time of these audits there were no claimed processors that were working remotely from blue shield of california. That have worked on this account. And just to be clear, when you talk about offsite do you mean offshore . No not offshore were talking about working at home or working remotely. Here in the us . Here in the us. We do have an offshore account as well and there are some that come up basically the on paper and on this paper some are what we call itable to be imaged and read and then they will go through the processing. But about 5 of are required to be transcribed into the system. Called to the processing systemand that is a vendor out of utah. And,again, it is a very small number of claims that end up going offshore and those are the ones that need to be manually keyed in. Any other questions . There is no provision about a restriction for offshore. Im going back to requiring business experience where there was exquisite prohibition for offshore claims processing. It is something we looked at in the rfp process. All right, thank you. We did check for that because we are used to that being often found in public accounts. All right. One of the other things we want to look at is how is the inventory tract. When a claim comes in, often times what you see is that the claim comes in and it is assigned a claim number which is called a julian date and when it comes back in instead of it maintaining its initial julian date were its additional claim number we want to make sure that we assigned a new one. And what it says is that based on the statistics of the audit team about 90 of the claims received electronically. And, of those a fair amount also comes across to some so, those of you have experience with the blues plan you know that they have a service area location where those providers in california that of her blue shield would be blue shield domestic. But then, who lives in oregon and that is where i live and they also go through submission and that submission will go through the process of california. Which this allows people to get the prevailing rates of california for the claims processing. So, a fair amount of the electronically submitted claims are also part of the blue card system. And so, not all of them is sure hss claims that we have adjudicated the system. Normally where i shot through that are here away. They may easily the achieve them but they will be through the audit. This could be initiated through the claims service. This can be done through the callin service where you could say i dont think this was paid properly and there also be tracking workers within the blue system. One of the suggestions from the performance guarantees is that blue shield would consider to adopt a target of 90 to 95 to make sure of that,. And,those are on page 10 and page 11. Moving on to page 11. Its very common that the providersubmit the bill and its over paged atit. But we sent it is the majority of collections of aromavery few if any outfit that ieveryone will always beassessed on their just and bdl be for them it would basically be there claim statement and that you would be able to track them in this way. That makes for a large recovery bracket for recovering bills. If you will notice, financial accuracy is 99 . For those of you following along it is 97. And for the system they just enter 100 . Their financial accuracy was moving back up so that by april they had exceeded the target however the payment accuracy is still slight. Well, it is above target as well. But, like i said, with january and february they had a tough time[inaudible] again, it is not reflected to the member but to the physician or to hss to the physician or to hss to the physician or to hss staff. Then, i look at claims processing time. And, like i said, they can perform certain claims within certain periods and what they are to do is to process 90 of claims within 14 days and 90 within 30 days. And as you see here, that is like when the transition occurred and we can make that 90 on 14 days your way off. So on the days your way off. So on the days your way off. So on the days your way off. So on the days your way off. So on the the that they didnt know they had that theyve updated it there that they really had to update the facets to accommodate. As i said, we did check Customer Service because that is what is visible to your members. They are open 727. And, most of the Service Centers again, is offered up through lodi. And they are also able to access it 24 hours a day so we looked both at the one line and the actual facetoface contact. The facetoface comment will lie to get your id card and get help from a nurse and whatever. Was found out now is there allowed have not d of those accredits results in one business day. They were able to come to this results in the transition period. Most people tried to do 95 in five days so having 90 in one day is a very aggressive thing. This is ,again,not clients pacificare saying that this is something that you might not be able to do on an industrystandard and again you are to look at how fast your call gets answered. And, they track it. We do the same thing that blue shield does. Their average lead for a call was six says that and the highest was 21 seconds and the blue shield standard is the high of 21 seconds and again what you will see is youre trying to answer everything within hsf for 30 seconds. They dont want more than a 2 drop rate and they were able to maintain these. Any questions . Were you able to maintain the accuracy . We were not able to change accuracy but we were able to do this. All right any questions for the board. It seems to me it like with the statistics they got trouble for a month or two and got back on track. I would think in a transition like this it is probably not unusual. It is hard for me to pull out from this what kind of problems that created for members or for hs a for our operations. I do not get a sense of that or a question as to how people are affected by this. I think it would be helpful especially for me to understand what the implications of the status were and what was the experiencefor the office and what was the experience for the members during this transition . First of all, i will be sure to go back and write it for you rather than just to speak of it. But, i want to be sure to say that the ones that we watched for has to do with the eligibility of people that had problems within the system are not. And then, we had claims to support it. So, let me go back and get an answer for you and particularly focus on those two areas for you because that is the area where the Health Service team staff would hear the most complaints about. Did you have a comments . I just wanted to say that there was a recommendation that she made and i would like to keep that up. Yes, i saw the recommendation and what page was that on . Page 3. And hss will request a status report on the final accuracy in november to make sure that california is meeting the hss business objectives. Okay. We have heard the recommendation but i believe we had a question. Not about that. Not about the recommendation, i understand. Go right ahead. As a former position like this i was little unclear on what blue shield would do about that. So what percentage of their claims are overpaid and they tried to get repayment within the first 45 days rather automatically trying to adapt. This is something im kind of curious about because this leads to a certain amount of provider discomfort because they are asking for the money back. I have to get an answer for that. I probably have it i just did not put it in this report. I will ask the auditor to get me the answer. And, when overpayment is made, the member is not allow this is a bill for the contract. Any other questions . To have a recommendation . What a member of the board like to give me a recommendation on the accuracy . A discussion item. A discussion item. I like to request a followup. There is a request by commissioner lim and we are instructing staff to follow up with aon hewitt on the recommendations you made. Thank you mme. Sec. And, our council is at hand. Listening to this i have been through my own experience with this. Usually am listening to other peoples processes but i have been going through a process with blue shield for over three months. Mitchell luckily got this resolved for us. My wife fell down the stairs and we went to urgent care as recommended. Nose peninsula was the hospital that the urgent care was centered and all of a sudden we start receiving bills from them that blue shield refuses to pay and they comment on this and they comment on that and it is like, we followed all the procedures. Finally through mitchell, we got the bill down to all you o is copays which we paid. We just received another bill for 150 for an inoculation for tetanus that blue shield refused to pay after they said that everything was taken care of. I thought in all of our brochures that it said that inoculations were covered under our plan. But now, i have to go back and fight with blue shield with our care people and bring this to blue shields attention. But im just thinking with the amount of time that it took me and what i know of the Healthcare System to resolve this problem that i did go back to the Health Service system for assistance to where what i i thought could do yself i couldnt do. And i just wanted to thank mitchell and i wanted the board to be aware of it. Thank you for your comment. Is there any other Public Comment . Just this week i received a call from a member is being billed 3100 were blue shield already paid 3600 and theyre being called by other providers for a similar situation and i do not recall the urgent care or if it is an emergency. But, some of these claims are not resolved yet, sadly. And so, i referred this member to mitchell who has been working i know, over time on this. But, we still have members that are experiencing these difficulties and i hope that we can find these all very soon and get them resolved. But, we will continue to refer them on and i think you need to continue to monitor and honor blue shield with regard to this and maybe once we have this change we wont have to do this anymore. Thank you very much. All right, thank you for your Public Comment. Is there any other Public Comment . Hearing and seeing none, we will now move on to discussion item 10. Item 10; discussion item; Palliative Care presentation [Kaiser Permanente and blue shield of california] we are pulling up the presentation and you sent it earlier. That would be great. We will follow along but again, we should make the public aware that this is on the website. Okay great. Please proceed and introduce yourself and think you and im sorry that i interrupted. Cindy green, associate account member for Kaiser Permanente. First of all i would like to say that our representatives on pallets of care are at a presentation out of state so i will do the best that i can to answer questions on Palliative Care but any questions that i cannot answer i will make a note of and follow up with the appropriate responses on the information. I am here to walk you through some basic information between what is Palliative Care and what is hospice and Palliative Care and talk about the two types at Kaiser Permanente which are specialty and Palliative Care and how this fits under our broader umbrella called Supportive Care services and also let the audience know how to access. I wanted to go ahead and start. If you are following along this is page 2 on the presentation this is from a journal of the american journal of medication. Palliative care is not browbeating patients into accepting hospice. Palliative care is a relationship centered profession. Palliative care is where patients will find relations to the situations and to make each day as good as it can be. Page 3; the field of medicine helps these patients to have more good days more good days with those qualities of life that are affecting them. This Palliative Care can be received during any stage of an illness and it can also be received with curative treatment. And it can also be an enveloped where Palliative Care treatments. At Kaiser Permanente we mainly provided at a hospital or a clinic and we are piloting programs in a nursing, clinic, or home setting. I will refer to it as pc if you do not mind. Pc, is a valued neutral transdisciplinary specialty. And what that really means is your specialists from two or more disciplines all working together across professional boundaries with other specialist on a team to address the needs of a patient. And, at the very core it is usually a primary care physician or a physician that can be a counselor or another specialist and depending on the needs of the patient it can be a nutritionist or a specialist. The Main Objective is to help the patient articulate their desires and their goals in life and to make sure that they understand the disease process that is available to them. They are also available to treat the symptoms at any stage of life in the process. It not only supports the patients but the family and helps them to live the best they can with their illness. It iss best described as an extra layer of support for the patients and their families. It is in addition to the usual care that the patient is receiving. And slide for if you are following along is defining the difference tween hospice and Palliative Care. Hospice is for patients that will not be living longer than six months and they do not want to prolong their life or have curative treatment. Palliative care can be at any stage in the illness process and whether it is curative or not curative phase of illness. Palliative care usually at the very core has your physician, your pharmacist, and your counselor. Palliative care can include a larger group depending on the need of the patient. Hospice supports the patients and the families through the natural dying process neither attempting to shorten or prolong life. Palliative care helpss patients and their families to really contemplate and be able to talk about what their goals are and whether they want to prolong their of life and it helps them to manage. This forms of distress and not only physical all but cycle and social and psychological. Slide five as i described earlier when i walk through the objectives, there are two types of Palliative Care. There especially Palliative Care and primary Palliative Care. This fight discusses what is a specialty. Again, this is transdisciplinary say you have a whole team working together a team of doctors and nurses and alsoa chaplain to provide an extra layer of support and each member of that team has a really unique role and that role is to help relieve suffering and increase the value of the individuals life. The individuals may yet have not a traditional family unit as we know it but it would be a what we call self identified family. So part of the palliative plan is we will determine what in the treatment plan is appropriate and also we will help to develop a plan and a trajectory and also develop the purpose of the plan and the care and followup. Next, is the primary Palliative Care model. This is really skills that their primary care physician currently has. The specialist models are skills that are necessary for more complex and coordinated models. The Palliative Care and problems initiate a care console and the care consult are initiated for the more complex. If an individual is receiving Palliative Care they are from the primary care physician and they can manage anxiety and care and that can be through their primary care physician and it can switch from primary to complex and from a primary care physician to a specialist at any time. Finally, it encompasses advance Care Planning that we touched on earlier such as advanced care Health Directives and completion of a healthcare treatment for manic kaiser we call these services a life Care Planning and that still under the envelope of Palliative Care. Slide seven will help us to explain a little bit more about how everything sits under what we call Supportive Care services. You can see that outside the life Care Planning, that is for everyone. For instance, the seminars that we have coming, you do not have to have a life threatening illness. It can be for anyone. It can be for all adults from age 55 regardless of their health status. It can even be younger than 55 it can really be for everyone to really think about life and those things that you need to think about. This can be provided by the primary care team. Then, the specially Palliative Care provider will work with all adults with them. This slide discusses who would have primary care Palliative Care and specialty. For example someone with high Disease Burden would receive specialty level Palliative Care. More importantly there are a how a member can access Palliative Care. This can be accessed through the primary care physician or through a hospital specialist such as an oncologist or it finally, it can be at the members request. They can request this at any time. At this time, ill answer any questions any questions . Kaiser does not have a Fever Services which means that there is not an additional cost for these services to members of on an Outpatient Services is there a copay or something. How would that work . If you had a prescription it would be under your normal prescription plan copay and there is no additional cost to the member to have a Palliative Care team. I had a friend who was very ill and he had 30,000 of matter call needs and he was unable to make those decisions and this was put on his wife. And then with the guilt of the wife she had to decide whether or not she was going to not get him the care that he needed or put a second mortgage on their house. So, that is why asked howdo we prepare to make this successful. It is really about educating people on the importance of having that discussion and why it is important and who would be a good candidate. If you have a partner you assume that would be the person next to you but that might not be the best person on your behalf. Is really an Educational Forum nd i encourage you to view it, because it is really something we should talk about. I myself learned a lot through this forum and i think you can any age. When patients had to deal with this before kaiser essentially our request came through the patient of the family through approval. May be through a nurse or a physician or a social worker, they may suggest to them but if the patient does agree or doesnt agree in my experience it doesnt always go forward. If the hospital says you need Palliative Care, does the patient get a consultwhether they want it or not . Yes, it is offered through part of their care team. They do not have to agree to the page of care but it is offered to them and they will discuss what would benefit the best for them and their family. I knew a retiree that was refusing hospice and did not like the words Palliative Care and they referred to this as life management. I think Palliative Care is often called because people do not know the difference between hospice and Palliative Care so any other questions from members of the board . Is there any Public Comment on this presentation . All right, thank you very much for this. And again, i want to remind people who are viewing this that this particular presentation is on the Health Services system website and i would strongly encourage folks to take a moment to look it up. Thank you again for your presentation. We will now have the representative from blue shield on this topic. Good afternoon, with blue shield i want to thank you especially dir. Doddfor your support on this. I work with the center of Palliative Care in new york. It is that organization that focuses on evaluating the workforce and they are really grateful that you are one of the first employers to actually want to address advance Care Planning for your employees. You are a true ally to the field. And, starting our presentation i want to say that kaisers presentation thank you for going first. You really actually outlined very beautifully what Palliative Care is especially what advance Care Planning, and primary Palliative Care and specialty Palliative Care is and that allows me to really get to what blue shield has developed and what our approach is. Is a little more nuanced in being a nonintegrative Delivery System. We have to focus not on only delivering our Delivery System but how we address reimbursement and are benefit policies. And, we can go to the slides now these slides as well are on the website. They are not being shown here today so again, i would encourage members who have an interest i hope the majority, of folks will go to the website and take a minute and take a look at these. Thank you for that. The 2011 national pollfor Palliative Care found that 70 of the population has stated that they wish to die at home. One national average, 70 of the population actually die in the hospital. And, this is actually in our opinion, really the crux of unwanted medical treatment. There are people being subjected to things that they actually do not want because they do not have an alternative. And, i think that your point about waiting until somebody is in the hospital and has a stroke to actually have a condition manifest and the management of that condition is really getting to this point of unwanted medical treatment. We know that patients especially patients with a serious illness want to have control of their pain and symptoms. They want to lessen or avoid inappropriate or prolongation of the dying process actually it is x essentially very scary and its also quite painful. They want to continue to have or achieve a sense of control at the center of their healthcare and not be a burden to their family. When we lend focus in our local area and on the National Level when there are surveys that go out about Palliative Care, this is what patients want. Patients want to not be a burden on their families and they want to not be in pain when they have a serious illness. Really, our focus that blue shield is to transform our organization and transformer Delivery System in order to actually achieve these goals for patients and families. So like i said, our approach is a bit more nuanced in that there is really know what one answer or right way to solve the problem of providing Palliative Care across the continuum. Palliative care can be provided in the inpatient setting, outpatient setting, nursing setting at home. And, if only it was something that we paid for as a Palliative Care benefit. It actually cross cut all of our benefits. So internally, there are a lot of organizational structures that have to change. We have to change many of our internal Business Units to be ready if a patient calls then asking for Palliative Care or if a provider wants to provide it. We have a six pronged approach in order to do that. I am going to focus mainly on our provider Delivery System and are alternative reimbursement structures andi do want to call out our casemanagement and our benefitpieces as well as our management approach. So was most beneficial about blue shields approach is were leveraging partnerships to educate and develop partnerships to educate throughout our Palliative Care, system. And we are starting with our Accountable Care organizations with our physicians and we are moving to brown and tolan. So this directly affects the ccsf partnership. What we are doing is really a threepronged approach and the first is primary Palliative Care in providing Clinical Training for all of our providers in Palliative Care principles. We are supporting also the membership to advance Palliative Care that also has a number of training modules that include cme and ceus. Not only for physicians but also physician extenders and nurses and social workers to provide organizational change. We are providing that to our partners through our implementation funds. We also note that Palliative Care takes time to show a return or to share revenue. And so, we are supporting efforts in implementation to extend Palliative Care from the inpatient setting into the clinic or into the homebased setting. For example, with ucsf, we know that ucsf has a clinic based system that is designed to only include cancer patients. That is something we are actively working with your ucsf to expand their clinicbased Palliative Care for her one failure and Heart Failure and copd and Heart Failure and things like that and we are providing startup funds so that they are able to transfer their structure prior to getting that additional revenue. We are also working so this year we started a Pilot Program with ucsf and hospice by the bay with their Strategic Partner in providing interdisciplinary homebased Palliative Care. Which is your specialty Palliative Care. That focuses on individuals that have 12 months or less to live in that focuses on individuals that have cancer or Heart Failure or lung failure. And, we will be expanding this in march to the ccsf population as well as the outpatient population where we will be prospectively identifying patients with a serious illness there were not waiting for an inpatient screening or a provider referral to get people in to talk about what Palliative Care is or symptom management is to those individuals and their families. What we are seeing with our home base Palliative Care program is that you might have positions within the aco that can provide Palliative Care as a physician but they do not provide the homebased care support which is very important with this population with acute affirmations happening over the weekend or after midnight. We are introducing our Accountable Care organizations to our Care Partners that have quality care programs within the homes, health, or hospital settings. And, those teams are being created between the two Delivery Systems. So, you have providers from both the hospice setting and the medical system like ucsf coming together. And, we are actually pulling that out of the feeforservice structure altogether and providing a case rate. That then allows those teams to have flexibility and coverage for nonbillable encounters which is also quite necessary which much of this management is over the phone. In addition to our work in developing our network and in helping to expand the workforce through Palliative Care reimbursement, we are working on policies and advocate fees on the state and federal levels and making sure that we are removing barriers for care in accessing Palliative Care and supporting individuals with serious illness. For instance, we have signed one with our champions in the expansions for care at a home level and we support the Palliative Care education and training act which is currently up for legislation this month. We have also worked to change our internal structures. So as i said, we need to educate our Customer Service staff as well as our current review staff for what Palliative Care is so if a patient comes then asked if they can get Palliative Care, we have a team that can respond, they can respond timely and they can help our patients to navigate the benefit in the best way possible and maximize their benefits. And, we also have 100 of our case managers that will be trained in Palliative Care principles by the end of this month i am excited to say. And, that training is not only what is Palliative Care but how to how to deliver serious news or bad news or how to have serious conversations over the phone with members but also it is training them to find the best resources in the community if we do not cover those types of services. So, not only knitting together the medical system but also the social supports that are important for these patients and their families. We are also working on developing tools and member and patient and employee education and working in our local community in order to support events or trainings within the community that focused on advance Care Planning as well as caregiver support and grief and bereavement. On slide seven, you will see the Eligibility Criteria for homebased Palliative Care programs. We have actually made it so that we are working to build the capacity for homebased Palliative Care in all of our e ceos over the next three years. This is an aggressive timeline but im actually quite sure that we can nail that. So, we have been working with all of our acos to assess what they have and what they need in order to support them and that is one that inpatient, outpatient and Home Settings for delivering Palliative Care. What you will see yet that for homebased Palliative Care that is a specialty Palliative Care model and that is for individuals with much higher of an acuity. Cancer, and lung cancer and copd you will see and that will [inaudible] within the last year and that gets within your status criteria for homebased Palliative Care. For those who do not qualify for homebased Palliative Care were working on changing the reimbursement for the structure so that outpatient height of care can be provided for all of our members. There are some results from previous homebased Palliative Care designs in with the on slide eight which shows that with homebased Palliative Care intervention individuals are less likely to go to the emergency room and less likely to have hospital visit and less likely to haveold nursing facility days. This really is an achievement of the triple aim where you are increasing Patient Satisfaction as director dodd was saying it you can call it willmar for all i care about people want Palliative Care when they know it is pain and symptom management they may not want it when its called Palliative Care. But 90 of thepopulation that has had Palliative Care loves it and is happy that they had and they are also increasing the quality of life and quality of care. I have already went through a little bit about what our Case Management team is providing. We are providing a Case Management team for a special live a Case Management team with nurses and physicians and providers that specialized will work withwe will be monitoring patient and family cost of care as well as on wanted medical services which leads to documentation of directives to know what people want and the success of that. Thank you for your presentation. Are there questions and comments from the board . I see a commissioner from my right who is trying to say something. Thank you. I see use the word nuance as a nonintegrated Healthcare System. My question is this. I will give you two antidotes because both of my parents are deceased. But, what are the two biggest obstacles that you see with this program. You have nicely outlined all of your attributes but im curious to know. My father died of cancer and when i talk to his primary e was not in the service area of the nonintegrated Healthcare System and he was proposing Palliative Care and he talked to my parents and after their visit they told me what they talked about and then i called them up and i said what happened and he said they werent ready. After he went home he was kept at 46 more weeks to regain his strength while. Was dying and i asked my father what he wanted and he said hospice and thats what we did because he did not want Palliative Care. The provider had certainly dealt with people in need of Palliative Care all the time. In the case of my mother, she did not die of cancer, when i went to be with her for the last 36 hours of her life, she was in an assisted situation and the nurses when i showed up said go see your mom but when you come back we have a question and the hospice Palliative Care doc had written for sedation prn. And, presumably my mother was supposed to wake up from her lethargic, comatose state to be able to present with this and i think prn that means every two hours around the clock and i felt as a son, and as a physician, in both cases, sort of being the Palliative Care and initiator provider in a sense giving an order in the system for which i had no legal right to write an order or temporary water. So in both cases, i saw communication problems. Im just curious if that is one of the obstacles that you see and if there are other obstacles that you might want to briefly mention that you have to address in order to make this successful in the Blue Shield Network . Sure. I think you highlighted two of them very well. In your first anecdote i think it is getting providers to refer to Palliative Care and in our Palliative Care organization that is not jazz provide a Palliative Care how to provide this properly to the patient. But we will launch on october 1 actually with Hill Physicians that all of the primary care providers will be provided with a panel of patients and we have respectivelyidentified as Palliative Care eligible and we will teach them to things. One is we will teach them there palliative performance score which is their functional status scale and the second is the use of the surprise question. Would you be surprised if the patient died within the next year . Primary care providers can actually answer that question with a lot more accuracy than if you ask them about prognosis. They are very hesitant to give prognosis but they are less hesitant to say, oh, i wouldnt be surprised. In that way, it allows them to have ownership over their patients and also understand what might be right for that patient. And so, we are working with our primary care physicians to incentivize the primary care providers to Palliative Care training. They want to be part of this but a lot of times they do not want to lose their patient. So the primary care provider even though they were further patient to a Palliative Care team, still remains on that Palliative Care team. That is the first issue. The second issue that i have seen especially in the nonintegrated environment is that all of the medical benefits that people might be receivingwith no centralized care plan for a patient. That actually gets to an overlap of services. It gets to the need for care coordination and what we have created is a shared care plan and whoever gets that patient will be the last entity. So whatever comes into the home and the health and the care of that patient with blue shield well track their care and their services so that the patient is getting confused and the family is not getting confused and that takes a lot of integration on blue shield side and then we have been working quite tirelessly on being able to track these patients through our system quite accurately. Does this include their patient information . We have this at the Palliative Care providers disposal but it is limited. I dont want to derail your presentation but it gets back to this joint effort that has been declared in terms of Health Information being shared seamlessly between providers and someone in someone and i do not want to use this for this today to talk about this but we have opting out and all of the rest of the discussion that we have gone through and it would seem that this would be a justification for this type of intervention and i have not heard that said anywhere in this process. So, i will leave that right where it is. Any more questions . Commissioners sass. I think it can work it depends on the family ran and how isolated the patients are and if you have a patient where the parent is the patient and their sick and the kids are in florida and the patient becomes depressed angry and stricken and that they have never been very good about caring for their partner anyhow andthey get very emotional and its hard to care for the person in that situation but people ideally when they say they want to die at home, want to be surrounded by their family and then close their children and their grandchildren and that is what i consider to be a big part of Palliative Care. And, you can augment that and supplement that with either hospice care or a Palliative Care team but at the end of the day, its really the family that needs to make that happen. I appreciate the efforts but in a nonintegrated setting i think that the tendency to put someone in a Skilled Nursing facility and i will tell you that in my experience, the physicians do not visit that Skilled Nursing facility and visit those patients anymore. They are not visiting that patient and the team at the Skilled Nursing facility is not organized and the doctors arent talking to the nurses or the dietitian and they are not giving them the kind of support that person needs at all. It just seems to me that that process of the endoflife care is really kind of it is a disgrace really at the end of the day. So everything you are describing and talking about to me, as appealing as it is is almost the exception. And, the Family Support cant even really be applied. Let me give you an example of a patient that was in a Palliative Care program this year. I think you are very right, Palliative Care, or endoflife care, is the space where you need high, high personalization. Based on things that might most often fall out of the medical benefits, right . So, one of our patients, actually was dying of liver failure in a rural area and his wife has developmental delays so there was no way that she would be able to take care of him as he declined. They had no children. His family lived outside of the state so he had no support. He ends up landing in a hospital 500 miles away from his home mostly because he is from a rural area and that was the closest hospital. He had a Palliative Care physician who is one of our contracted Palliative Care providers who is on an alternative reimbursement arrangement. So, a case rate per member per month. That provides an Interdisciplinary Team. The social worker contacted our case manager at blue shield where she expressed as part of the , assessment as part of a comprehensiveassessment of the patient he really wanted to die outside of the hospital so there is a concern there, right . So,after about three days this patient ends up in the hospital and we had done a benefit, an alternative benefit where we negotiated an inpatient hospice rate at the Skilled Nursing facility where that Palliative Care team visited that patient so that he had wraparound supportand the wife was taking care of and there were plans made for the wife so that she could get into the story bereavement support and social support with that kind of care team and, if the patient actually ended up dying in that inpatient facility but blue shield actually paid for his nonemergency transport home to the place that became his home for the last four weeks of his life. And that is what you would want to happen. And it needs to be highly personalized so if you are the nonintegrated environment, you need to train the people that are doing concurrent reviews or providing a benefits lot as to what the needs of patients are that have a serious illness and what that tradeoff is. Ultimately, if he does not want to die in the hospital, it saves the Health System money and it is what he wants and it is supportive of his family structure. That really is there. Ultimately, that is what we knew the patient needed and that the patient felt supported because we had an Interdisciplinary Team that was actually working with that patient. Is this approach and intervention, i guess i would gracefully describe it as a relatively new process for you at blue shield . I started at blue shield at the beginning of the year and so, it is a relatively new approach. We started our first home based pilot of Palliative Care in march and i was brought on just before that to really outline the strategy and structure of how we would move forward. Thank you for that. Any other questions from the commissioners . Any Public Comment for either of these presentations, kaiser or blue shield . I do not see any. I want to thank both organizations for bringing representatives today to help us but, more familiar with these details of these organizations and we will look forward to Additional Information as the programs continue to develop and thank you both of you for coming here today. All right,mme. Secretary. Item 11; is an action item to vote on whether to cancel the october 13 is an action item to vote on whether to cancel the october 13, 2016 regular Health Services Board Meeting due to open enrollment. Dir. Dodd. You are welcome to come in. Like this is going to be an opening while enrollment. All right. Any questions do i have a motion . I motion second. Any questions about the motion from Board Members . Seeing none. Any Public Comment . I would ask again, is it lisa . Please convey our hopes and expectations with good work of your colleagues. All those in favor say, aye. Opposed, nay the motion carries. The october meeting will be canceled [gavel] item 12; is an action item as to whether to cancel the november 10, 2016 Board Meeting and instead hold aboard Educational Forum meeting. President scott. That we were looking at the excise and catalytic tax and those variety of issues and we might have those issues in front of us but i think the agenda has been accumulating over the last few weeks. And so, director dodd and myself will ask other commissioners to weigh in and focus on the presentation so that systematically we are not only looking for a nearterm issues that will affect the role and programs and work of this board but also the longterm trend, and that is the request of the board that we cancel the regular meeting and moved to an Educational Forum held at that same date and time. And so, im willing to answer any other questions from the Board Members and also to entertain the motion. So moved. Is there a second . Second. It has been properly moved and second that we cancel the november 10, 2016 Board Meeting and hold a board Educational Forum at the same time at this location. At this time, Board Members, do you have any questions . Thank you pres. Scott and and all of the Board Members. This time a year we have the updates on the finances. I would like to request that you consider providing some information with regard to our usual business in addition to the Educational Forum because i think is important for us to have those reports. I sort of miss the chief Financial Officer in giving a report today and so i would like to make that recommendation, thank you. All right, thank you for the comment. Is there any other Public Comment all right, hearing none we are now ready to vote and all those in favor say, aye. Opposed, nay [gavel] the motion carries. Item 13 is a discussion item a report on network and health plan issues [if any] this would be the time that if any member has a plan our representatives come forward with any issues and i would expect it to hear about the closure of offices but that would have passed being is that september is almost behind us but anything from the healthcare representatives . All right, moving two we have got one. Lisa garin ems. I would like to inform the board that as of this tuesday ebs was hired. Who was hired . Ebs . Ebs. And they were hired by who . Career builders. Career builders,okay. Any others . While youre billing for these things we keep getting letters from the billing people think we are going to send you to collections. And have your credit affected by nofault your own and nothing apparently due can do because i have tried. This is always on the other side of all of these billing issues. And so, as part of what i went through this time, having to come back to the city because i was threatened to go to collections for bills that i had no control over one way or another. So, that is just the caveat of what all this process entails to the person that is happening who is involved. So, i just wanted to bring that up. All right, thank you for that Public Comment. No other Public Comment . Lets move on to the next discussion item. Item 14 is a discussion item; opportunity put items on future agendas. Any Public Comment on future agenda items futurehearing and seeing none next item. Item 15 of opportunity Public Comment on any matters within the boards jurisdiction. Seeing and hearing none we see in adjourned until