Instead of having your Diabetic Management Program happen through Insurance Company x, it is now happening through Venture Capital backed technology organizational wide. For hospitals and providers area and, i mean, an example of a disruptors telemedicine. Finding the opportunity, if you are a telemedicine organization to say we know individuals are not getting as much primary care, or at least lets say in that moment of need, it is 2 00 a. M. , child wakes up crying, you know, holding the ear. The telemedicine organization would say we are going to disrupt by not just assuming that persons should go person should go to the emergency room at 2 30 a. M. They can use their smart phone to patch into a physician who, with some information, can look through the phone, possibly prescribe an antibiotic to help the child because of a probable ear infection. Those are a couple of examples. I think it is disrupting in both ways. I understand the impact. I guess the word is weird to me. But anyway. The only other point i would make is the integration and collaboration to changing Healthcare Delivery. It is a more value based my challenges to understanding, and we hear all this information about where the United States falls in terms of Healthcare Delivery and how poorly we do in terms of many other countries. That doesnt really say how we are doing in the Health Service system and using those same parameters. Are we number one in the world compared to norway, sweden and those countries that do well . I think we seem to be mixing the National Healthcare agenda from what our agenda should be. That is the challenge. This is really looking at a bigger system. Thank you for those comments. On page ten, so leaving from this discussion we show here highlevel spectrum of design and contracting strategies. You see the words at the top, simple on the left and complex on the right. We classify on the more simplistic side helping to guide people you see a couple of examples there. Whether they are Transparency Solutions are hightech navigation platforms. The support to help individuals navigate an extremely complex healthcare system. In the middle, we say insight into emerging network solutions. One example is platforms that they have two rate providers. Have identified provider designations. We can talk all day about their methodologies. The highest level of trying to collect combination of cost and quality information on Services Providers that are delivering. And how the health plans collect that information and make affirmations. You also see in the alphabet soup of healthcare comments li like, Accountable Care organizations. We focus on that a lot with blue shield as an example. The blue shield hmo platform relies heavily on their partnerships with for instance the Health Physician group, and their partnerships with Dignity Health. This notion of primary care medical homes. Taking an advanced view of how primary care physicians can guide a patient through the healthcare system. For a types of services, centers of excellence strategies. On the more complex side, taking an advanced view of local contracting strategies that could include things like incentive designs. Instead of having in network and not outofnetwork or there might be different layers. Referenced base pricing. For Certain Services, lets say knee surgery, your setting a certain price by which you wont reimburse over that. And if the patient decides to go to a lower cost provider, you know, having access to quality data as well as their selection, that could be fully covered. If someone chooses to go to a very very high cost provider they may have to pay for more of that service themselves area direct contracting. Certainly that is always on the mind of sfhss. Looking at opportunities to consider direct contracts. This is something we will want to think through, you know, pause it as we develop the questions around the rfp. Specific to helping people navigate the system. Helping decide what may be the best approach to Network Based strategies. On this slide, where would you put us now . You do a little bit of each of these. I would say more in the middle, because that is where we focus especially with the Accountable Care organization platform. Thats been the primary focus from a blue shield standpoint. I would say from akp standpoint there is probably elements across all of this, certainly from what you provide within sfhss itself, the support you do provide two members certainly fits into that high touch advocacy. The fact that people can call, and visit the office on the third floor, and receive support with sfhss, with guidance on their needs, certainly as an example of how that is being t to delivered today on the left. I think we also challenge the health plans to think through as a result of this rfp, how can we elevate this aspect of their service . They are all providing it to some degree today. I think it is fair to ask for an elevated level as we roll out the expectations of the health plans. Actually eking i welcome abbys comments as well. Sfhss the degree that we might be taking the first step with the guiding people. Insight to emerging. To take as an outcome. Are we really trying to step back and say we want to use all of these tools . I think we are evaluating all of them, at this. What we are learning more how to do is to really measure quality so that we can pay for quality. Regardless of the outcome we pay the same price. How we design that, i think a few months ago we were here from catalyst for payment reform. They and the group on health, the National Business group on health and many others. Whether it be for certain kinds of cancer care, joint replacement. Those types of things. [please stand by] we cant look at our robust data base, i think, and make those determinations. There are some best practise examples around the nation of purchasers that are doing these practises and pacific Business Group on health has a model of centers of excellence that its a model that is worth looking at. There are some areas where these measures are in place and we certainly can consider how to do that. So could you kind of we want to get to the point where the since this is about our members input today we want to make sure we get to that so maybe condense some of these and point out the high points. Ok. I will just hit keys on each one. On page 11, just trying to show that theres been annie involving the Market Assessment has evolved so the process of looking for vendor partners and what we looked for in the 80s is different from what we look for in the 2000s and the 2010s currently and then looking into that future is really, as we roll out the r. F. P. Thinking about current as well as future and making sure were set up with the right partner to achieve those. Page 12 is kind of saying similar message to page 11 and so with the evolution, we need to manage costs and away want to maximize value for our membership across our five strategic goals. Page 13 we recapped our five strategic goals because those are going to be core components we want to consider as we move forward. On page 14, moving into ideal state, we framed this around the triple aim to minimize healthcare costs and improve population, health and then optimize the member experience. We have several key statements we want to focus on and weve captured a lot of these and some of the conversations that weve had so far today. Of course cost is going to be important, costs to the system. Cost to the member and making sure we understand that and were using money wisely. Improving Population Health and recognizing we have a diverse population with varies needs and making sure theyre getting the right care at the right place and time. Integrating with communitybased organizations and social services that third bullet and weve had a lot of conversations about social determinants on health and the impact of that on our membership help. Thinking about the person and how were integrated with Community Programmes available. You talk about our population and everyone we have is in the city or county or School Director it has attention or retirement so it isnt like the general public for social determinants the way i see it. It isnt people that dont have means or dont have a job. I mean, when you talk about social determinants, in our population, what do we have . We may not have the severity of our uninsured population but we have concerns of seniors living in isolation, persons whose pension sounded good at the time and they retired and perhaps is inadequate today. And theyre making choices about food and drugs and all those types of things that people are making choices for. Its important that we recognize that and attend to those needs where they exist. Do we have any idea . How many people we have like that . General population . Im going to carry because we did with the retiree survey and we asked questions about good security and of those that responded at least 2 indicated that they dont have adequate food and thats of those that responded so it was a red flag that we need to delve into deeper into that. Its one stat i know off hand. There are other good questions we should be asking to determine the need. Its vague to me. Its one that is really kind of well understand and theres San FranciscoFood Security task force and theres a lot of experts on that and it really points to that question that you dont have adequate food and you are having to make decisions on whether to buy food or pay rent or whatever. You have to make decisions around food for most of us that are we have resources, its really not a question. Its more about food choice and its not about whether or not you can afford to buy the next meal. Also, social determinants goes beyond economic. It goes how far do our members have to drive to get healthcare . What is their Family Structure . What is there religious or ethnic background . What is their their sexuality. There are all kinds of social determinants that we have to address beyond simply the economy or economics of healthcare. Quite frankly. We can imagine that our employees who have to drive 90 minutes in each direction to get to their jobs have very different requirements in terms of what we can provide and should provide than someone who can walk across the street to their place of employment. I dont know how many people would do that. So we have to think of a very broad scio logical stance. Meeting with the wellbeing champion at police department, theyve described to us to our community what the officers are doing before and after work and the long shifts and the stressful work and when do they have time to take care of themselves . And those are really important matters that come into play and to have a direct impact on health. They are. But theyre things that cant being changed a lot of the times. They cant change it if someone has to drive two hours to work. You cant change their culture. These are things that you can talk about but, you know, how would you influence them . It isnt so much of trying to influence it its a matter of recognizing there are factors that a person is engage in that do in deed impact their need to be and their use of the healthcare system. Over a period of time, long commutes a commute is a commute but over time it may stress that person out. Not having sufficient time to exercise. So on and so on. Its really a construct of saying here are other factors that, in your everyday living, which in deed impacts your health or your ability to use the healthcare system. Thats true of a lot of things. Whether you can do anything about it thats a question. Its a matter of recognizing which of those factors there are and and could they be undressed by something that were doing in our Health System. Thats the question. Exactly. Right. Its where we have opportunities to meet people where they are and what their needs are. Just the third item on this page 14 is optimizing the member experience. So always wanting to keep that in mind to make sure that care is convenient, coordinated. Weve talked about advocacy and navigation previously. So those are all underlying components of what we want to look for in an ideal state. I want it to be noted inoperability is on every page. Can you spell it . Its not appeared once. We have that on a word search. [laughter] all right. Page 15. Again, just considerations as we think about the ideal states about the current relationships that we have. I am going to talk a little bit about this slide because it will feed into what well talk about later. Looking at what we refer to as health plans. So health plans being blue shield of california, United Healthcare, so the carrier or insurer that are interchangeable terms. Looking at Health Systems, so, kind of the delivery systems. There are programmes such a as s canopy, anthem, and merger of Dignity Health and integrated plans systems. Examples could be kaiser which is a fully integrated system. Cchp is a health plan and a Health System and then sutter of course has their Health Delivery system and their health plans. So, again, we have a lot of things that well look at. The Network Provider and facility contracts data and inter operability. A range of connection points so looking at inperson virtual and tele health opportunities. Support staff to meet people where theyre at. So with that slide we come to a section break so i want to pause for a minute and we have thrown a lot at to you see if there are any other comments before we move on. Id like to go back to slide number 12. After that. Where you have the table of slide 14. So id like to focus more on that and look into the consideration on the r. F. P. Coming forward and we have discussed the items. The ideal one is to minimize healthcare costs and optimize member experience. Id like to have the members take a look on that slide as we move forward and ask questions because you have a lot of mergers and everything but what really drives us is really to minimize healthcare costs, improve the Population Health of the members and the member experience. Id like to go to that slide. Thank you. All right. So mike will walk us through some concepts for consideration and well get into this model. So slide 17 illustrates a model construct from a spectrum around care coordination and management at the top. It is correlated with cost the at the bottom. You can see the highest cost tends to be associated with models where you have a minimum amount of care coordination and management happening. Contrast that cost contend to be optimized where you have more of them happening. So, from the left side of the page, the open system approach so the United Healthcare p. P. O. Is an example of that. So no surprise its the highest cost plan on your platform. As an example, theres an out of network availability, which helps to drive that. The pricing with the hospitals and positions tends to be discounted fee for service. There is care coordination and management but not as i would say inter operable as you have so even though that word isnt on the page i had to throw it in. That is true. Its true of the other models on the right and more individual driven. When you get into kind of the little blue box organized systems of care, what you have in the middle with the Accountable Care organization or Patient Centre medical approach its basic with your blue shields plan with discounted fee for services but Certain Services, like primary care, subject to fixed costs, where theres incentives for those providors to guide care in a certain way from a quality perspective but also from a cost perspective to kind of maximize the financial benefit to the partners through the ca model to deliver a certain set of services. On the right side, the staff or the group model. Kaiser is a great example of that. So much of what is driven we put capitation in quotes so you are playing a flat rate for everybody. That delivers the financing that kaiser needs to deliver on care coordination and management to the organizations. This is an example of what you have in place today. With some examples of which each of the systems delivers in their care approach. When we talk about the network models, so, network only is commencerit and you will see with the foot note on the network is for Emergency Care only. Services are delivered inside a network of physicians and hospital and other practitioners that are contracted directly with those plans. Ra additional, that would be commence rit with the United Healthcare today, p. P. O. Where its delivered in the network and theres the opportunity that the member has to Seek Services out of network. We talked about industry jargon but a tiered Network Place out nicely. Within the internet work framework you actually have a significantment within that of High Performance where the cost of the member for services would be less if delivered by a practitioner on the High Performance circle than the network. You can see examples at the bottom of the page that might be High Performance. You dont have this in place today but it could be an avenue persuade going forwarpursued gof this process. Im not sure of the term advance primary care practises. Primary care practi