Finance. Im fairly confident over that amount thank you, director. Get any questions from the board regarding any aspect of the report . Is there any Public Comment . Hearing none, we will accept the report as given. We will move to discussion item number five. Item 5, discussion item ages just Financial Reporting as of ages just Financial Reporting as of may 31, 2015. Pamela levin. I would like to take this public opportunity to knowledge the tremendous work effort of catherine and her team. In preparation of the budget and its submissions and all the interactions that go on to get that monster done. I thank you for that. I commend you for your hard work. Im pretty a pretty positive outcome after we went through it all. So thanks. Thank you. Payment of 11 Deputy Director chief financial officer. I do want to take a minute to introduce our new im sorry. Contracts manager. She started in june and has coalesced so well with the team that seems like shes been here for long. Her name is . Amara marilyn. Would you please them. Well, welcome to hhs. Thank you. Today im reporting on the revenues and expenses of the Employee Benefit trust fund. Also known as the trust fund and the general Fund Administrative budget. Through may 31 as well as fiscal year ending objections through june 30. Where we are right now, just kind of in broad generalities, is that the fiscal year closed on 30 june. There are still transactions that are being processed and we always are behind a month in terms of its report. However, the projections that we have here are the general fund our actual actually based on last week and it was absent just a couple of transactions. The trust fund is the audit is started, and we think we are going to bounce around where are at and what are present in the report. The audit wont be concluded until october, and i believe that it will be presented to you in december. The balance of the trust fund on june 30, 2014 was 92. 8 and right now we are projecting and right now we are projecting at 70. 5 million. It will be similar between that and 80 million. I believe at the end. The projected decrease of fort 14. 3 million includes the reserves for unpaid claims and as a result of the following changes city plans has a 3. 4 million decrease in fund balance. This is attributable to 2. 2 million increase in fund balance and offset of 5. 6 million decrease in fund balance. We have had favorable claim experiences. Weve had pharmacy rebates. But, what we did was we used some of the fund balance, 1. 2 million, subsidizing the 2014 rate so that was the first half of fiscal year 1415, and then we also used 3. 7 million were the 2015 rates, which is the second half of 1415. Then, we had also used. 0 7 million without funding premiums in 2014 bringing in the 939383 contribution model. You will note, if you remember, we get by down the 16 rates also for city plans. The flex plan to my right now we are seeing a decrease of 17. 2 million in fund balance. I hope we have 2. 5 million in pharmacy rebates, that is offset by a 19. 7 million decrease in fund balance. Associated with 12. 7 million unfavorable claims experience, we are monitoring that on a very regular basis. Having discussions with the acos, and trying to improve or reduce claims or claims expense in the amount were paying out for claims. There is also a 4. 9 Million Associated with subsidizing the 2015 rates from the claims stabilization reserve. Then, 1. 1 due to the use of erp funds. Other seems to be is in the past because a lot of it occurred in the first half of 1415. Fiscal year versus calendar year, and plan your. Then, there was 1 million associate with funding premiums in the 2014 plan year for unions, except 939383 contribution model knows from the last part of the 2 the shield profit pledge. Other balances that are attributed contributing to the 14. 3 million decrease, overall decrease, in fund balance, is we havetheres always send him. This is the dental insurance plan. Even increase in fund balance with favorable claims. Kaiser and blue shield insurer hmo plans. We have an increase associated with that premium revenues including the use of er which reduce members premiums. We have an increase in interest, . 7 million due to the cash balance that weve been carrying, including the erp funds that we know ended in the end of 2014. Forfeitures, weve had a decrease in fund balance associate with transfers to the general fund. To the general fund. To the 1415 budget. That, for performance guarantees, we have a . 4 million increase in fund balance. We are working withto make sure we are cover all required deserts. We do this during the process of the audit of the financial statement. Overall, we are in a healthy state for the trust. Not overly healthy, but not unduly healthy. So, just where im fairly comfortable with it. In the general Fund Administrative budget, we projected a balance of 1. 3 million by year end. Thisa lot of that is due to delays in hiring. We have asked for carryforwards or we will. Its in the process. 200,000 in professional services. 70,000 in work orders. So, the general fundsounce of 1. 8ounce of 1. 80 million will be turned to the general fund it as i mentioned, there still some offsetting entries that are being put into the system, and i monitoring those very carefully. Are there any questions . Questions by members of the board on any aspect of the Financial Report . Maybe one question on the 12. 7 million unfavorable variance with blue shield, to have a sense of whether that is from i merely an issue related to price of services was at issue more related to Volume Services . Neil. Outlast the actuary to come in. I think its kind of a combination of goals. I think more so than we are not been successful in keeping people out of the emergency room. Theres not a good sense of making sure that the services are given in the appropriate venues. For instance, there is somei mean, my senses there still some surgeries done in patient that should be outpatient. Theres a lot of discussions about length of stay has increased. Theres a lot of bouncing about. One of the things we did have was the 12 increase due to sutter. During the negotiations, when they stop talking blue shield and sutter stop talking we ended up having to pay the sutter hospital rates which were 12 more than we wouldve paid otherwise. We are not seeing the type told that acos had inwhen the acos first started. Neil, j do you have any comments . Please introduce yourself. Neil kosher. Aion ashtray for Health Systems check that the question was volume versus price. Yes. Their answer is there is an increased volume and prices have gone up. To add to what your cfo spoke to, i would say cost specifically specialty drugs, escalated in this time period with several fc drugs coming on board. His increased cost specific to just that. By an estimated 4 million of that 12. Its representative of that is the other issues and the fact that the aco though we are optimistic on a performance the level we shouldve started with. So those are several of the drivers. So, it was a common there was a 12 price increase by sutter as well . The 12 price increase there was one month in discussion about how they were going to go for because they had separated ways for the negotiation. They were trying to reset their contract. The blue shieldsutter hospital conjugate we did see that experience that was a onemonth do. Any other questions . No. Any other questions from the board . During that time am a do, weve seen a couple real serious cases that contribute to the increase in the medical claims. I did not hear. What . Some very serious cases in whichclaims. Claims. Okay. All right. I will just say this. We been getting quarterly of reports on fellowship and because of the worst dismal report were now can be meeting with her monthly. Ill just give you an example. When we looked at the average length of stay, which is above what was when we started, i asked about discharge planning and utilization management and brown and towing and sutter discharge planners only work 955 days a week. I made the suggestion that healthcare and recovering and being discharged was a sevenday week probably tenhour day. Hopefully, they will take some instruction when is your next meeting with them . The phone meeting on him i think its september 5. It just got set. Be sure that im notified . Absolutely. Thank you. Thanks for a much. Any Public Comment court on the Financial Report . Hearing none, well move to item number six. Item 6, action item, approval of testimony on cms regulations regarding reimbursement codes for dance Care Planning. Dir. God. Catherine, as you begin to do this, and again, as were these points of continuing education, there are any number of policy issues that are. Com by way or out in the broader arena of discussion. Catherine has tried towhether it be at the state level or federal level, at least register it perspective from our point of view. Some of these, is a large employer, we need to be active in. So, its a matter of why are we worried about reimbursement stuff from cms. What the devil does that have to do with the city and county of San Francisco . Well, these policy questions begin to translate into real dollars and it comes to how cost are driven, other managed and how theyre determined. So, its quite appropriate that we comments were given the opportunity. More poorly, as we have been doing more recently, seek out the opportunities. So, with that, please. Thank you commissioner scott. You all recall during healthcare reform there was a proposal to include medical reimbursement for position counseling and ecologic care. It was used as a campaign hot potato. Death panels. Just be clear what were talking up. With that behind us, cms very appropriately put forth to reimbursement codes. Theyre called cpt codes. Allowing for the billing of time spent with patients discussing the critical matters at the end of life, which are often called advance Care Planning and advanced directives. I will also have attempted to put in our performance guarantees with our vendors what percentage of your of our members in their Electronic Health records and because theres no building to date for this issue, its notno one counted. You have to go back and go record by record and do searches for the words to find it. So, giving this a billing code will allow us to measure our vendors in terms of how well they are doing and having this Important Information in medical records. So, i will just say that we commented, as i pointed out or we get a very beautiful job on the issue that families face. It helps families prove quality of care. It also saves money because the majority of medicare dollars are spent at the end of life. Blue cross wisconsin is often cited. Even 90 of all the people who lived in across wisconsin regardless if theyre over 18yearolds there been a dance directive. Its part of their egos. Their medicare spending is 25 less than medicare spending. In other places. So, the suggested rule said that we should do this counseling at an annual physical and when someone is sick. We are suggesting that we not limit it to that. If someone isi offer you the example of kaiser that includes exercises of vital signs. You go in and get your Blood Pressure and temperature and your weight then they say, how often do you exercise and for how long. I always kind of go,but maybe will begin to add, you dont have an advance directive on file would you like to make an appointment to discuss that with your primary care provider should thats the hope. Regardlessyour dance directives change depending on where you are in your life. Sometimes, you make one and you want to change it. We also recommended that they include actual training for the people who do this. That they not be allowed to be reimbursed for group settings. Its individual counseling talking about peoples individual circumstances. We encourage them to include Nurse Practitioners physicians, nurses and social workers in the reimbursement codes provided they have trained. We think that advance care directives should occur early and often so, we have before you the testimony and i think its very thorough and i hope you recommend to send it forth to cms. Either questions of the director on this topic . Yes commissioner breslin how do you have is is that in with Palliative Care would this be pallet of care . This would it would be Palliative Care. This is been about counseling care but, if i were very sick, and i did in advance directive, i might say i dont want curative care. I just want harriet Palliative Care. Where i were very sick and i could say that in advance. You know, under these conditions, we included the reference to the physicians order for last sustaining treatment. Under these conditions, if you cannot put me on a respirator or on oxygen to be memake it easier for me to breathe come up thats okay but if im ever going to come off it, dont put me on it to begin with. Its talking about how you want to be treated in advance. I understand appeared to have Palliative Care or do with coverage for pallet of care . Pallet of care isnt a code or is enlisted in her evidence of coverage, but i believe all of our vendors practice Palliative Care. Like special certificates for persons practice . Yes. You can be certified. Medical boards offer certification. Then they would get paid . Winner medical specialist you get paid a little extra through medicare. Which is why they went first for the certification. Oncology positions, internist to domaybe you can speak to this dr. Paul. Yes. Im not clear that theres additional billable reimbursement because one has some specially training in Palliative Care. It probablyin my fall open for different organizations among fall under different payment schemes. You know, i do think this is really nice document from my perspective. In our measurable outcomes, and i think all the things that concern me, its great to encourage cpd codes and all that cv into documents that the discussion happened, but the outcome if someone does have attorney up our healthcare has indicated advance directive and is a form in california called post. The position order for lifesustaining treatment. This is a legal document that allows any individual who is admitted anywhere to have his or her wishes honored even if the Healthcare System they were taken to urgently isnt part of their system. Because it is a physicians order, even from a physician whos not on staff at that organization. It let me remind 98 was put on life support despite her two daughters vigorously opposing this. Because the physician was not on staff. It was a different hospital and it took them several days to get their 98 motor off life support. This solves that. As we begin these discussions with more direct terms, those kind of documents did some concrete evidence that this is actually happening. As much as not about costsaving. Its about caring out people wishes were dignified and. Either other questions or comments from the board . Is there any Public Comment . Good evening. Im going to comment on how they been doing [inaudible]. Thank you for those comments. Are there other Public Comment . Thank you. Claire rcf says he says im writing the article for our newsletter, but i could be clear on this. I know that were probably going to encourage all our members to have these kinds of documents on file, but it sounds from this discussion that these are things that need to be updated regularly. You could put something on file and end up with one set of directions, but as you pointed out, dr. Dodd, if your life situation changes, you may want to change your directive. A lot of people forget to do that. We have a problem with retirement system would advocate to update their beneficiary. We have a lot of problems like that. So, i am wondering if itsand some people dont want to have that document on file. They prefer to have their representative hang onto that so that it circumstances present themselves they can come forward and say heres the directive and what we do or dont. I like a little more clarification on white be the most prudent way to do this and how we would also make sure that members understand that if they do put this kind of document on file needs to be regularly reviewed and updated better latest wishes are what i most accurately reflected. Times, when they go in when their health changes, theyre not a position necessarily to do that changing either. So, whatever additional insight you can provide would be very very helpful because i like to put that in our articles. I . Director doug,. Com point on page 5, claire, it talks about frequency and under what conditions. You can probably take out language and put it right into your newsletter. Also, just like we do with Everything Else during open enrollment season annually, the mighty that trigger. We talk about updating beneficiaries and doing all these other things. Maybe that something might want to call out is another health item to be checked as a person is doing these other things. It just a notion. Is in all of our guides. Very good. Are there any other Public Comments on this item . If not, im willing to entertain any motion. I move we approve the testimony on cms regulations regarding reimbursement codes prevents care plan. Its been properly moved that we accept and approve this item. Is there a second . Second its been properly moved and seconded that we accept this item. Is there any discussion by the board . A Public Comment . Hearing none, seeing none, no Public Comment were now ready to vote. All those in favor say, aye. Opposed, nay. [gavel] so ordered. Item 7 item 7, action item, apartment of Committee Chairs and members for fiscal year 20152016. Pres. Scott happily. Happily. Happily. We now have a full board and are able to announ