>> good afternoon, everyone, i would like to welcome you andy i would like to call this meeting to order. would you please say the pledge of allegiance with america and to the republic for which it stands, one nation, under god, indivisible, with liberty and justice for all. >> >> thank you. item no. 2, please. >> 2. roll call: president randy scott-

excused. vice president mary hao- commissioner karen breslin- commissioner chris canning- supervisor matt dorsey- commissioner stephen follansbee, m.d- commissioner claire zvanski- with that, we have quorum. >> thank you. agenda item no. 3. >> 3. general public comment - an opportunity for members of the public to comment on any matter within the board's jurisdiction that is not on the agenda, including requesting that the board place a matter on a future agenda. before we begin, i will be reading our public comment instructions allowed. >> for anyone who is waiting, you can approach the podium.

public comment is available online and in person. the board will hear 30 minutes of remote public comment. and accommodations for disabilities will not be counted for that limit. members of the public attending the phone can call in by dialogue in.

2 remote meeting access the health service board welcomes public participation during public comment periods. there will be an opportunity for general public comment at the beginning of the meeting, and there will be an opportunity to comment on each discussion or action item on the agenda. each comment is limited to 3 minutes. for those attending remotely, the commission will hear up to 30 minutes of remote public comment total for each agenda item. remote public comment from people who have received an accommodation due to disability will not count toward the 30-minute limit. watch at 1:00 pm on november 9, 2023 (via sfgovtv schedule) click the link to join the meeting - november 9, 2023 hsb regular meeting webex link public comment call-in: 415-655-0001 / access code: 2660 317 0055 webinar password: 1145 listening to the meeting via phone 1. dial into 415-655-0001 and then enter access code 2660 317 0055 then # 2. enter webinar password: 1145 then press # 3. press *3 to be added to the public comment queue and you will hear the prompt “you have raised your hand to ask a question, please wait to speak until the host calls on you.” when the system message says “your line has been unmuted” - this is your time to speak. 4. you will be muted when your time to speak has expired. watching the meeting on webex 1. join via hyperlink november 9, 2023 hsb regular meeting webex link 2. click on the raise hand icon

to be placed in the queue to speak. a raised hand will appear next to your name. when you are unmuted in the system, a request to unmute will appear on your screen, please select unmute to speak. 3. when you are unmuted in the system, a request to unmute will appear on your screen, please select unmute to speak. once you hear me say “welcome caller,” you can begin speaking. 4. when your time has expired, you will be muted. please click on the raise hand icon to lower your hand. members of the public are encouraged to state their name clearly although you may remain anonymous. you will hear an audible warning when you have 30 seconds remaining. when your 3 minutes have ended, you will be placed back on mute. best practices when calling in for public comment: >> public speaker: good afternoon, i want to speak about delta dental. this is really outrageous. i had a tooth extracted but they say our plan isn't protecting the gum because it was an emergency, if it was a non-emergency, the plan would cover. so i don't understand. i have given the staff the codes and i'm not sure if this can be included or how much would it cost to add this to our plan, these three codes or at least

two of the codes, and the staff needs to look into this and provide to our board and members as to why the protection of my gum was not included in our plan. my dentist says that delta dental has been sued several times. and about kaiser who wanted to know my prescription and i'm not with kaiser and with glasses, i think we should have vsp, our providers put our eye glasses

prescriptions in a database so we can easily access them so when my doctor at kaiser asks for the prescription, i can just download it and email it to her. and i had to fax her. we live in an electronic age and i don't see why vsp can't ask its providers to put our eyeglass records in a computer system so i can access them or have my doctor access my medical records. my kaiser records are all online, even ones i don't even know about. so maybe next year, we can ask vsp to put their

records in a database. thank you very much. >> thank you. >> thank you. anyone else can approach the podium at this time. public speaker: good afternoon, i'm a director with local firefighters union 795. my name is jeremiah, director with the firefighters union local 798. there has been a lot of concern from my members about delta as well. a lot of their local dentist are no longer accepting it. they are being told that their dentist does not take delta anymore. just to put it on your radar. that got brought up today in

today's general meeting and heard it anecdotally through the firehouse several times saying hey, my dentist doesn't accept our plan anymore and lacks an alternative. just so you are aware. that's what's happening and i have heard about it for six months now. >> is this active or retirees as well as? >> i have been hearing it from active members in the firehouse. >> thank you. >> public speaker: fred sanchez with protect our benefits. speaking from delta dental, i get it from our retirees and in the handbook you get two cleanings a year, but what the complaint is it has a rate in

there something like $175, and the delta dentist that you go to, he might be charging you $325, a cleaning. so you get this thing where the 175 and they will go, well, the literature says it's free, and i said, okay. i can bring this before the health service commission and how is that rate set? it is set by charter? how do we close that gap? i don't know how you do that. that's the question we get all the time. it says it's free, but it turns out it's not really free. >> thank you. >> with that, anyone else can

move to our podium now if not we'll move to close public comment. >> >> madam chair, we have two callers on the line. >> we want to make sure that caller is muted. is that something you are able to do moderator? i can check in if you are not.

>> please check caller 3. >> thank you. just a moment. thank you for your patience. we want to be sure our public comment line is working. >> welcome, caller, if you can hear us.

can you speak louder? public speaker: i'm wondering if you can hear me. i'm calling about remote comments and coming before this body because i'm presentlily in assisted living. i can't make it to the meetings as i normally would and also there are people out of town and they can be a distance and they have concerns about their benefits. i would

like to see this continued because there is any other languages. >> there are no further callers. >> thank you. public comment is now closed. >> thank you. next agenda item, please. >> public comment: 4. approval (with possible modifications) of the minutes of the meetings set forth below: (action) presented by president scott documents attached: september 14, 2023, health service board regular meeting minutes

>> colleagues, do you have any questions? >> they are grammatical. i will send them. >> i move approval of the board meetings. i'm not sure what date it was. >> second. >> it's been properly seconded. we'll open up for public comment. >> public comment is now open.

>> we have three callers on the line. there are none wishing to speak on this item. >> we'll take a roll call, please. >> [roll call]

>> thank you. the next agenda item. >> 5. president's report: (discussion) presented by president scott >> thank you, we did have open enrollment and i want to congratulate the team. i know that abby will have more in her report. then i want to just say that we have a full agenda item including a closed session on appeal. we have a pull agenda and we have a commission coming

in after us. i wanted to let everybody know that abby will be at the conference and will be presenting friday morning. i will be attending and i know some of you out there from our carriers will also be attending. we are looking forward to hearing from them. that's all from my report. >> did we approve the august meeting minutes? >> they were approved in september. >> okay. >> 6. director's report: (discussion) presented by abbie yant, sfhss

executive director >> good afternoon, commissioners. abby, executive director health services system. i wanted to reemphasize and congratulate the entire hhs team. a lot of work by everybody on the open enrollment that was successful this year. we were able to open our doors and help real people. we have a lot of retirees who were able to make appointments with us. not always tomorrow because we are pretty booked, but it's working out very well. i'm going to defer any detailed report on this until next month until the team will be giving a highlight on how it went, but it was very successful and we had a

bump in the early weeks but smooth sailing in the last week which is always challenging. congratulations to the entire team. i also sadly want to note the passing of a former staff member, ernie, he started there when i first started and a very pleasant person and worked as a critical part of the i.t. team and was a joy to work with and retired i think in 2018. so the staff that had an opportunity to work with him can't say enough about it. also, on good news as you know we have had many many openings in our department and our department of human resources has been terrific in supporting us in bringing in new people and

some of them are here today. so i want to welcome them. if you wouldn't mind standing. kimberly yu, kimberly yadama, jerry wong and jane deguzman. thank you and welcome. >> welcome. on the announcements, we are also talking at the board of supervisors meeting and a member of the board is very interested in understanding the trends in healthcare and we put together a pretty robust presentation. she as the chair of the committee, wants to be certain that her colleagues appreciate the environment that we are currently working in so that when the rates come before them

in july, they will have that context within which to review those rates next year. we are certainly looking forward to a different year than we had in the past. the next item on the agenda, as you know there had been a problem with some of our members being turned away for care or having complex discussions about billing with the medical group, not the center, but the medical group. they had been what's called a willing provider that didn't require a contract with the united healthcare, but they have determined that they wish to engage in a contract with united healthcare, so the two parties have been negotiating. as far as i know, they have not

resolved that yet. we are hopeful. and to some of our members that got some messages from the ucsf medical group, i think have for the most part been able to work things out. we have not heard of any problems recently. so it was our expectation that the medical group would not change their practice without affording us some heads up opportunity to see if there was anything we can do. at the moment it's in the back burner, but we are keeping a close eye on it. i reported out to you that i stood on the california state healthcare affordability board advisory committee. it's a mouth full. it's a very heroic effort on the part of the governor and legislation to put together a

workgroup, a board to actually determine how to add the increases to total cost of care. it's a pretty complicated effort and there is a lot of meeting time at the board itself and the advisory committee and i watched the board meeting, and it continues to go forward. the way that the regulations are written 2025 will be the base year. so and they will fairly soon determine what their methodology will be and bench marks will be for how they will cap it going forward. it's a pretty large effort, a lot of us involved. there are 29 of us in the

advisory committee and all voices as you can imagine around the table since it's a very rich process. our cfo has done an annual review of with an audits we have done or in process or plan and looking forward to next year as well, and the audits that we are talking about are planned audits generally and you will have a report on the external audit. also in their packet is a blackout notice period. we will speak to this with we talk about our medicare. the blackout notice this year comes early because we will issue it tomorrow after this board has heard what our plans are, we are doing the rfp. that will continue through the entire benefits season through june of 2024. we have some great information

in the board packet about our celebrations with the different native-american population that i encourage you to read. holly has helped us put together a report in email that come directly to the board. i will just node that many of them had to do with the usb ucs f medical group and i appreciate you writing the board and we are tracking that and they have kind of settled down. the last thing i want to highlight, telling captain canning on the way in, i don't know if you heard the news but there is a skate park across from us on the plaza and it's so refreshing to hear the sound of skate boards. i never thought i would say that, but the whole atmosphere

and the energy is so beautiful. i would encourage you which i probably wouldn't have done until yesterday to walk through the united states plaza. i really enjoyed it. there is a really nice fitness center. if you have seen one around the marina boulevard. it looks very much like that. these efforts to enhance the un plaza civic center is well underway and i encourage you to check it out. any questions? >> >> one question. one of the supervisors is contemplating a proposal to streamline city government and i understood there were over 300 commissions and committees, etc. i'm curious if you heard anything about that and what it would take to actually accomplish that in terms of this

own board, but also the intent. i understand the intent, there are thousands and thousands of commissioners and appointees, etc. have you heard anything about that? >> we have not been approached about that and that would take a charter amendment to change that. >> yeah. >> any other questions or comments? if not, we'll open up for public comment. >> public comment is now open and instructions are on the screen for those watching on webex. for those callers on the line, press star 3 to be added. for those watching on webex, please indicate to comment to be placed in the queue to speak.

public speaker: good afternoon, again. richard, also follow the school district in the previous meeting, the director mentioned that the health system was having a problem with members from the school district and i wonder if that problem has been resolved or if there is still a problem and other problems with the school district because i know they have had a really big problem with the human resources system. i was wondering if it was still affecting our members in the health service system. thank you. >> fred sanchez again from protect our benefits.

united healthcare, you ucsf medical group for the retirees, they heard that no new patients would be seen there but existing patients would be able to get their services there. it's on the back burner that it hasn't been resolved. i'm trying to because we continue to get the call. they have always kind of honored it but nothing in concrete in writing. we are trying to do -- new patients and are they honoring them because we have written them numerous letters to unc as well as uc sf medical group and neither have responded. >> thank you.

any other speakers in the audience? >> can i make a response. i was curious as well and i went through electronically as to who was listed as providers in the plan and there were no uc sf providers that i could identify with uc sf addresses. the medical center was listed, but the providers are not. a member was trying to find a new provider, there was no access. that list was two of my former associates and panels of primary care. i was a little surprised. that list needs to be updated in general. there were no uc sf providers. >> with that, we can move to our remote public comment. our moderator will notify us if

there are any public commenters in the queue at this time. >> there is no public comment at this time. >> public comment is closed. >> next item. >> skip 7. sfhss financial report as of september 30, 2023: (discussion) presented by iftikhar hussain, sfhss chief financial officer documents attached: sfhss financial report as of september 30, 2023 memo and presentation >> good afternoon, this is a presentation for the first three months and we are expecting that by the end of the year, the trust will decrease by $11 million. we expect that to be built into our rates is the use of

stabilization which would have caused us to go down by $15 million almost. this is as expected. we are seeing some high claims in the first three months, but it's small, $1.5 million which is a pretty small amount and mostly medical claims. the dental claims are favorable. for the pharmacy we are expecting a $15 million rebate this year. we have not received any these few months but nothing alarming because they come throughout the year. we are expecting about $3 million in interest income this year built into our forecast. the healthcare sustainability fund will be a net decrease, net use of $2 million based on budget activities. the general fund is favorable with

vacancies. there is a presentation today after this. as you look at the audit results of the medical trust fund for the fiscal year end 2023. i'm happy to answer any questions. >> thank you so much and thank you for your diligence in managing these funds too. i think the fact that we are ahead in the budget for the general fund is not necessarily good news because of the vacancies. we hope to see that shift. >> great. >> not under your control, but just a comment. any other comments or questions? >> if not, we'll open it up for public comment. >> thank you, vice-president hao. public comment is now open. for those callers on the line, please press star 3 to be added to the queue.

for those watching on webex, please raise your hand. no one has approached the podium. our moderator will notify us if there are any public commenters on the queue at this time. >> we have two callers on the phone line, one caller has entered the public comment queue at this time. elevating the first caller now. public speaker: i'm sorry. i was commenting on no. 6, and for the commissioner with concerns about the streamlining report put together by this group called together san francisco, and they are accessible on the internet and they have had some

public meetings about this. this is for information and one is a proponent of the proposal is supervisor of district 6. so i apologize for my comments. >> thank you, caller. our moderator will notify us if there are anymore callers in the queue at this time. >> there are no additional public callers in the queue at this time. >> thank you. public comment is now closed. >> thank you, agenda item, please. >> 8. annual audit report: (action) iftikhar hussain, sfhss chief financial officer, craig harner, mgo, and yia yiang, mgo >> good afternoon, i want to

introduce craig and yang. ngo has been doing the medical trust fund and the auditor's for the city of san francisco. greg is the partner on-the-job and yia yang is the manager. welcome. >> thank you. >> i want to be sure the slide is correct. >> thank you for the introduction. i'm craig harner, ngo and we'll

present the audit for the benefit trust fund for year-end 2023. >> so as part of our audit, we issued three reports. there are two attachments today to the agenda item. the first two reports are independent auditor's reports that covers a financial statement which is in front of the financial statement packet, and the second report is a report on compliance which is the last report in the packet. our last report is our report to the health services board otherwise known the communication to the governance which is required by our audit standards to give the board a summary of the audit and the findings that we had and that's the second report that we are presenting today. we'll go ahead and go into the

audit results. the very important thing and key thing that we are contracted to do is perform our audit. we issued our audit report october 31, 2023, and happy to say we issued an unmodified opinion. again unmodified opinion is a highest level of assurance that an auditor can give to any organization regarding their financial statements. the second auditors report that we have in the back there are our auditor's report on controls and compliance and this is with auditing governance standards and additional report and we don't provide additional assurance, but if we come across any deficiencies in the internal controls or any non-compliance that could materially affect the financial statements, we would have to report those to the

board here. we are happy to report that there were no such internal control deficiencies that arose to material weaknesses or nothing to affect the determination of the financial statements. our last report, the required communications, again, this is what we are required to communicate to the boards at the conclusion of our audit. the first couple items have to do with what are called qualitative access to practice. the first one being significant account in policies. these are important because management has discretion and accounting policies that choose the appropriate ones and we make sure they are appropriate and all the policies used are appropriate and no gaps and

policies used that are where something can come into question. and no new policies adopted during the year and nothing that went generate occurrence aicpa, rules or guidelines. the second one has to do with accounts and estimates. the financial statements themselves require a certain balance in the financial statements where the manager is required to make an estimate of that balance and we are required to report on the most sensitive ones and that is the reverse for claims in the financial statements and incurred but not reported as of june 30, 2023, calculated by aon. we actually contract with our own actuarial specialist to review the information that they got from the membership data and

triangle and historical experience to project their own calculation of what that liability is and compare that with the results. we did that and it was found to be reasonable and no significances and nothing to call into question with what management was. that is the most significant estimate there. the remaining required communications i have. there were no difficulties during the audit and no issues dealing with management. they provided us a fine representation letter which is a piece of auditing information we need for the report. there weren't any corrected auditing adjustments and misstatements and no uncorrected misstatements as well. all in all, it was a boring year which we actually like because that means everything is good. with that, i will take any questions. >> thank you. we like boring.

so colleagues, any questions? >> i want to thank you both. this report we find in detail is incredibly fascinating and more than the dollars and contributions and deductions that go into the business of the board and the health service system. so to outline this down to the penny, i find monumental, maybe boring but it's monumental and was actually incredibly clear and helped remind me again of the responsibilities that we all have to our members, to the employers that represent particularly to the health of our members and the community. so i want to thank you very much. >> thank you very much. i would have to give a lot of that to most of the content is the management report and ours is three pages but we do look

through that stuff. i would like to thank the team and the audit process. it goes for a few months and we ask a lot of questions. >> and i found no typographical errors to my abilities. thank you as well. >> i second your thing on typos. i'm always looking for them. >> it was a very finally detailed report. still blew my brains out. >> madam vice-president, if i may, a compliment and a motion. thank you for your team and i recognize the thorough and quite daunting task that this is in the way it is synthesized for me to understand and a way to share with our members and it's very much appreciated because i know a lot of eyes beyond the management of our commission and

of the health services look into this system. thank you, and our gratitude and my compliment. with that, i will make a motion that we accept the audit as presented. >> second. >> it's been properly moved and seconded. we'll open up for public comment. >> remarkable. thank you, gentlemen. >> thank you, vice-president. public comment is now open. instructions are on the screen for those watching on webex. public comment will be first in person, for callers, please press 3 to be added to the queue. we'll begin with in person comment. no one has approached the podium. well will move to callers for public comment.

>> we have two callers they are not wishing to speak on this at this time. >> thank you, public comment is now closed. >> i appreciate the hard work that you and your team made for this even though it's boring. thank you. >> >> roll call, please. >> [roll call] >> it's unanimous, and we will now take the next agenda item. >> 9. sfhss medicare plan request for proposal (rfp) for the 2025 plan year: (discussion) presented by abbie yant, sfhss executive director, and michael visconti, sfhss contracts administration manager

>> >> hello. >> it's a pleasure to be back before you. i wanted to kick it off by reminding us of what the situation is now. we have our current, what we have done in the world of rp's. in august, we talked to you about the consideration of competitive bids, and then in september, we told you that we were proceeding with medicare rfp for the 25 plan year. today we are here before you to update you on the process and talk to you about the scope of work for the impending medicare rfp. in past practice, we went over the medical plans for the 2022 medical plan year. in september of 2020, the

governance meeting reviewed the rational and timeline and on september 10th, the health service board discussed the competitive bid process and february 11th, you approved the results of the rfp that was recommended by the staff. so currently, we have the united healthcare, mappo available to medicare eligible members in all geographies with 17900 covered lives and we have medical coverage for most hawaiian locations for 2018. 14,000 covered lives. today we will talk to the about

the expected outcomes of the rfp process, the material to the budget, what we would hope to get. the rfp scope, the eligibility and the qualifications to bid, in other words the gate to get into the bidding process. we'll have the schedule and provide a conclusion, remarks and hope to have your input for further discussion. now i will turn it over to michael visconti. >> can i ask one question, abby. was the addition in 2016, united healthcare, was that a result of an rfp prior to that? how many times have we done an rfp for this population? >> i don't know.

that was prior to my time and i don't know if the team knows. >> thank you. that is all i was asking. >> >> thank you. michael visconti, management healthcare system. part of this is that we get into a much more routine process so every number of years, on average 3-5, we get through the benefits and that's a lot more work for us and not exciting and we do the same process every time and highly transparent process and the same thing here for the 2022 plan year. so again, we'll start off with these expected outcomes and i preface these with my previous presentation to the board and the real highlight here, the

material impacts this city. as we discussed and presented to the board of supervisors and this board, the greatest material impact to our budget as the city when it comes to our budget here that 89% of the cost of the benefits to retirees is on the city and this is discussed in a later presentation today. one of the things brought up here by both the members of the public and our team is the need for comparable or improved provider network. we talked about this and it will be presented to you later by mike clark on any willing provider and what we have currently for our ppo population. we'll go over that, we have the term passive ppo, is that you are paying as a member in network or out of network, no

confusion. as discussed we want to be sure what is in and out of network is as good as or better than we have now to give our members the opportunity to receive care from the best providers. i want to be sure we have the same or better benefit design than we currently have. we are not just talking about the financial layout. we are talking about the cma innovation programs that we presented before, meals programs, transportation, we know our membership really appreciates those and a benefit to our overall health and priority. and we want to align this in a well thought out and strategic plan. we want to make this transparent and want to be sure that for all of our members it's something that they can predict every year. that will require some 3-5 year rate guarantees so we do not

have any surprises year to year and nor to our members. going into this -- i will go into a quick description. >> these slides got shuffled a bit. >> i'm going out of order in my presentation. one of the things we are talking about here is the material outcome to our members. when we presented to you back in 2021 with the rfi that we did, is the minimal increases for united healthcare or significant decreases year over year and we

have seen about a 15% increase, we have seen a less severe increase for hmo or kaiser senior advantage plan. having seeing these, it changes the underlying from rfi which we have chosen not to do medicare. 89% of this cost is for the city and we are addressing the ppo population which has had the largest increase and you can see from the slide in front of the you now you can see it has the greatest delta between the member share of cost. all right. we are back on schedule. again, this ppo population, about 17,000 covered lives, these are our retirees currently

enrolled in united healthcare medicare advantage. we want to be sure that this rfp covers our members for the most part that are in part a but mostly part b. there is no extreme variability year over year in front of this board and for our team when we are negotiating these. we know we are in a very unique environment right now that again we were not seeing in 2021 when we did our rsi. again, we want to be sure we are supporting our companion plan members. these are the non-medicare eligible dependents or the non-medicare members or retirees with a medical dependent and want to be sure that they continue to be administered by the rfp and we don't want it to be a significant administrative burden and more complex for our

members than need be. we want to have a robust and stable network. we discussed this recently with comments from the public and public meetings as well. we want to see a selective provider that has longstanding relationships with these providers with these hospitals. as i mentioned the cms innovation programs, meals, transportation, over the counter an allowance, transportation, programs, we want to be sure we continue to offer those. when it comes to prescription drugs, we want to be sure that is a focus for us going forward and we want to have compared formulary and increased transparency for our cfo and

that process that begins in december of every year and goes right through this board in presentations and we want to have transparency with rates, costs, revenue amounts and claims. finally as we have mentioned before, we do want to ensure that we have the best in class and services from our selected ppo carrier and we have experience in transitioning not just retirees and their dependence from their plans but experience in moving large groups of retirees and their dependents and here to support the healthcare system who reach out to members who are not medicare eligibility but approach and they understand what is involved in that process and we get to them in a timely fashion to make sure we have

that smooth transition. finally, we know that we are here with the access to programs and plans and that we have expertise to provide us another area for our approved members. finally, we want to be sure we are narrowing the scope of who can be a prospective bidder for our rfp. we know this is a difficult process for our partners and members. as such, we narrow who will be qualified to bid and this is indicated in the rfp that we will release sometime around december of this year. we will have specific requirement with their experience with mapd populations

and size of populations and to make sure they can meet our need with passive ppo, and requirements and game sharing agreements. we presented again, on a shared savings agreements to you previously. i think this board is familiar with those with the counter partnerships or bundled payments but gain sharing is to allow us to have a situation to focus on focus reduction and provides incentives to physicians who may not be with the hospital or be with the hospital as an employee to decrease patient costs and improve from prior performance. this is a much lower risk because it does not require reductions and utilizations of

services and partnerships with carriers and physicians. >> again, supporting our medicare a and b as well as part b only members and reducing the need for split families and meeting or exceeding the financial transparency. all right. the high level, this is our rfp level. we will be collecting within the next month information and i will ensure that everything is done in writing. it will be in writing and you may mail it to us but also sent by email. we will collect that input that will inform the final rfp which will be released sometime around september 8th.

we will have a preproposal conference with prospective bidders and expecting to have interest from some of the largest carriers in this space and in california. we are going to have that preproposal conference around december 15th, and a deadline for specific legal requirements to be sure we are confidently and confidentially speak with prospective bidders, share the necessary claims and sensitive information to get the most responsible and informed bids. in the next two or three months we will have a process by which we receive non-financial questions and review those responses with the panel. finally, we will present the observations, summaries and recommendations to this board in may or june of next year and

will be the board's determination to accept that recommendation or not. >> do you mind repeating your email address again? >> absolutely. michael.visconti @ sf gov.org. my information is available on this report as well as all of my contact information. thank you, commissioners. >> now, we are open to any questions, comments from the board or the public. thank you. >> i have some questions.

no. 1, the staff will make a recommendation for one ppo group, or is there an option for two if the provider networks don't necessarily overlap. can you address that? >> thank you. there will be one selected carrier as a result of this rfp. there is a number of reasons for that, but the two leading ones, one for lack of complexity and eeo plan and the way to get the most effective responses to this rfp is to say that we are guaranteeing that 17,000 population to the selected respondent. >> thank you very much. as a panel, i know there is an independent panel carrying out this process. has that been chosen. can you let us know what the composition of that panel is?

>> what i can tell you about the panel is we are following the same requirements from prior panels. we hold ourselves to a higher standards from other procurement processes but to ensure the panel is no more than 50% representative of hhs and also the panel is representative of the people of san francisco and our employee population. we want to be sure it is diverse, representing a lot of different demographics, but finally, we want to be sure that the panel members have the subject matter expertise necessary for this scope of work. we are not expecting every single panel member to be a subject matter expert in this rfp. the panel works together as a team and discussions together as a team and we provide ourselves in that panel discussion to answer any technical questions that may arise in their subject

matter expertise. >> you are consistent and where are you in the process of developing this panel? >> we have a number of names that we are looking into right now, but again, we have not finalized the names nor would we actually disclose the names of the panel until the end of this rfp process to be sure there is no impropriey no unfair communication. that's the kind of information we do not want to be disclosed. >> thank you very much. >> you know, i think one of the criteria that you said robust and stable provider network which i'm assuming includes both medical centers and hospitals but also the providers. this is something that we have heard from members over and over again, not just with this population, but all of our

vendors as well including dental. i think that's quite a challenge. so i guess i'm curious to know what criteria you use and how that criteria might be validated because we seem run into road blocks. >> with this previous plan year, we had an extensive review, a list of what additional provider facilities, physician groups, etc would be included that were not previously including with prior hmo's. we will do this with the panel and when we do present this to the board at the beginning of may that those changes will be highlighted for you in our

presentation. >> great. thank you. i'm sorry, one more question. sorry. you talk about benefits. of course there is open enrollment for medicare plans. so anyone who turns their phone on or tv or whatever, just see's a plethora of organizations that are supposed to help you decide between the hundreds and hundreds often for profit medicare plans out there, and they all talk about all kinds of benefits. one of the questions we have asked as a board and still looking for answers is that we'll approve certain benefits in terms of meals and transportation. but what we haven't heard is the actual utilization and benefit that has come out of it. it makes sense, but we haven't heard a lot of feedback. so i think hopefully with this plan if you are looking into these benefits we'll also see what the plans are as to the

benefits that are working or not working and we ask our dental providers to do this all the time over and over again and would be nice to see this expanded to our medical providers as well because i think this is critical. one last comment under the best in class issues, and i would put wellness in there. wellness, i think is something that we all think, speaking for myself as a board member but other board members, wellness in terms of health activity weight, we know that obesity is a disease, not a lifestyle problem but impacts all kind of health problems and heart and kidney. we want to focus on wellness programs that are provided as well within the applicants. >> to make sure i got these

right. not just covering the programs but the utilization and how they are going to do that utilization for the population? >> yes, your category for best in class list and there are a lot of diseases which i understand but also wellness is sort of a refocus, away from disease but also a focus to health. >> thank you. >> >> any other questions or comments? >> a compliment. a compliment to the presentation. i think it's very clear and outlined not only for us as a board but for our membership as well for the process and thank you for communicating those concerns to the team.

>> thank you. >> i have a quick question that you said something earlier in your calendar of the presentation that you will bring something before our board to adopt or to approve or not. just totally out of curiosity, what happens if we turn down your recommendation? >> great question. one thing we are doing right now is we are going to continue our rates and benefits as we do every single year. a little bit of added work for us but we did this in 21/22. if anything happens and this goes off the board and the board does not agree with our recommendation, that's what we'll default to. >> thank you. >> thank you. >> no more discussion? we'll open up for public comment. thank you very much. >> you're welcome.

>> >> public comment is now open. instructions are displayed on the screen. public comment in person is first and then callers and then online public comment. we'll begin with in-house public comment. public speaker: good afternoon, commissioners. one thing that wasn't covered at all that i was wondering if it could maybe get some explanation of is kaiser with design changes. what that entails, what that means. seeing how one in three people in california probably belong to kaiser. i was just wondering what these changes would be, and then again the second part is early retirees. i didn't hear much about that. is this in the rfp process, and

that's why it hasn't been really discussed, and if there can be any explanation of that, i appreciate it. thank you. >> thank you. >> thank you, mr. krueger. may i answer the question? >> please. >> thank you, vice-president hao. as with regard to kaiser, this will be part of our second presentation to board in june and we are focused on ppo population now. as to early retirees, our early retirees are covered by our non-medicare plan which was addressed in the 2020/2022 plan. however, they are a component of this rfp in the sense that there are a lot of people who are early or non-medicare advantage

members of ours who will become medicare advantage members by the time this plan will go into effect in 2025. i discussed earlier how a key part of this will be a transition process for preparing them for medicare plans, but again, those are covered by non-medicare plans and we have our multiple hmo options and ppo options as well. we are on a very nice cycle with rfp's that will include our non-med car plan on a routine basis. >> so i understand completely. no. 1, this rfp is for the medicare population only, and there are two types of plans, there is the hmo plan which we have kaiser which is not part of this process. so there may be other medicare hmo plans out there, but we are not addressing any of those. this is only the medicare ppo options for which there are

undoubtedly a number of plans. the question, the follow-up, how many of those plans do you expect might be interested and you are outreaching to and how are you out reaching? >> great questions. let me start with the question, director yan started with the breakdown and the senior advantage population. obviously the big difference here again is the united healthcare is a nationwide ppo. for kaiser permanente and washington, oregon and hawai'i locations. we are starting with that nationwide ppo. the second part of this is that we are going to focus on this ppo population with respect to

the outcomes that we have discussed. we want to make sure that -- can you repeat the second part of your question, real quick? >> the second part was how many medicare ppo vendors are there out there, and obviously they will self select, but how many will you expect to be interested and may fit the first cut of the criteria towards the financial size or something? >> thank you. this information from our team but we are expecting responses from at least the respondents to our rfp in 2021 and it was anthem at the time, etna, and we expect a response from humana and we could also see responses

from cigna, blue shield of california and health net previously. for based on 2022 data for the total medicare population broken down by firm or affiliate, in this order, we are locking at united healthcare 20%, humana 18 percent, blue shield plans overall 14%, cds health at 11, kaiser permanente, 6%, health net, 5 and a lot of smaller insurers. the largest numbers of groups here, we have already had responses in our rfi or expect to get a response. we will be reaching out to each of them independently. we will post this publically, we have a lot of connections to this and will be done very transparently as well.

thank you. >> thank you. we'll continue with public comment. >> if anyone wants to approach the podium, you are welcome to do so now. public speaker: hello, fred sanchez from protector of benefits. and we know you will have to choose one single which is united healthcare or anthem or whatever. but i know that's easy for hsf to administer when you have one entity, but the lack of more different providers will keep that cost down. we are always going to be in

favor of always getting those multiple providers to keep our cost down. when i try to get a 3-5 year rate guarantee, i wonder how they do that. is that in writing where they specifically say, hey, it's annualized and like you get a 2% cost-of-living increase every year. this is only going to be for the medicare people. but we talked about these early retirees. obviously there was no rate guarantees for that group because who even represents that group, and they got a 14% rate increase this time, and it's like, that took their cost-of-living away for about the last 3-4 years combined. how do we get some kind of guarantee for that group? i mean, that's not in this rfp, i

understand that, but how do we address that group? the astronomical rate increases for that group. who represents them? because it's not the active unions. how do we address them? i'm trying to figure it out and i don't know if you have an answer for that. >> i would like to defer that. we are having a discussion on the early retirees. if that's okay, michael? i think there is better context in that discussion but we'll keep that in mind. >> to go through public comment, maybe you can come at the end to address all the outstanding matters. >> i will be happy to. >> thank you. >> anyone else? in the room can approach the podium for public comment. no one has approached the podium. we will go to callers for public

comment. our moderator will notify us if there are callers in the queue at this time. >> we have no callers at this time. >> thank you. public comment is now closed. >> thank you. we'll have a very in depth discussion in how these rates are generated for the medicare population as well as the non-medicare population. i will refer to our folks for that description. but i think one item brought up by mr. sanchez is very top of my list is the schedule that we are doing right now. this is the opportunity for stakeholder input. that includes items that members of the public, members of this board feel are important aspects of this rfp that should be considered. these are the kinds of items that we want presented to us so we can take them into consideration and if appropriate include them in our rfp to make sure the respondents address

those aspects of care for our retirees. >> thank you. >> thank you. >> so to be clear we have kaiser and united healthcare and there isn't a plan to have a third. >> currently there is no plan to have a third. >> too bad. >> begin, an item for us to review. this is the kind of stakeholder input. i have it written down from your comment and the public. we will take that into consideration. thank you. >> >> thank you for robust discussion. >> next item. >> public comment: 10.blackout period notice november 9, 2023 through june 2024: (action) presented by michael visconti, sfhss contracts administration manager

>> what we'll see on the screen is the blackout memo. >> hello again commissioners, michael visconti. we will do our usual blackout notice to prevent improper notification and we want to be sure that any member who can be a panel member, any member on this board who will be ruling on this rfp and members of our team

who are going to be working on this rfp have no ex-parte communications apart from what is documented and part of this rfp process. this will begin today. it will extend all the way through the end of the rfp process and the end of the rates and benefits process. as for the question from vice-president hao earlier, as we know, there are two possibilities at the end of this. the results of the rfp or if the recommendation is rejected by the board, again the simultaneous process going on with rates and benefits. we want to be sure that that communication blackout period extends through both of those timelines. thank you. >> thank you. colleagues, any questions? comments? it feels like we have

just emerged from a blackout period. [ laughter ] >> i will have a motion. >> i move that we accept the recommends for the blackout period from november 9th through june 2024. >> second. >> it's been properly moved and seconded. we'll now open public comment. >> public comment is now open. instructions are on the screen. in person public comment and then remote public comment. for those on the line, please add star 3 to the added to the queue. for those on webex, please raise your hand to speak. >> we will begin with in person public comment. no one has approached the podium. next callers for public comment. >> board secretary, we have one caller on the phone line.

zero callers have entered the public queue at this time. >> thank you very much. public comment is now closed. >> thank you, >> roll call, please. >> [roll call] >> unanimously approved. thank you. we will take a ten minute break before diving into the two board education items, followed by update and closed session. it is now by my computer, >> >> please take a roll call vote. >> thank you. >> [roll call] >> with that, we have a quorum.

>> thank you very much. please call the next agenda item. >> action: 11.board education: benefit design benchmarking and plan design influence on member plan use behavior: (discussion) presented by anne thompson, senior account executive, aon, and mike clarke, lead actuary, aon >> good afternoon, welcome. >> anne thompson. we have engaged in a series of benefits in the past month and we will include benefit plans and benefits behavior. to touch up on the background

and board of education modules and looking at the impact design of utilization and landscape and planned design programs to drive optimized behaviors and we'll close on where we are going in the next couple months on that education. page 4, and a little repetitive because we have to remind you why we are here. we will dive right in. on page 5. when we look at plan design changes, there is really 2 elements that drive recommendations. one is to generate lower renewal rate increases. so when we modify the plan design, the premium or the budget rates will be adjusted and that then flows through to contributions that the employee

early retiree or sponsor pays. that is one approach or reason we would look at plan design changes. others encourage shift inside care decisions that are clinically appropriate meaning when there are different cost structures to say an office visitor urgent care or e. r. visit that we want to ensure that we are encouraging the urgent care needs and e. r. for emergency needs and maybe to wait to see your primary care provider and rather than inpatient or hospital facility. then we talked about outpatient surgery versus inpatient surgery at hospitals. page 6, we want you to take a

look at your benefits. with -- we do this in our planned cycle and we look at the main design. you have three main health plan structures. that first column, your active employees, early retirees and hmo plans and ppo plans and medicare advantage and ppo which is what we spoke about on our last agenda item. we have key features across each of these plans. the network is in network only and with the ppo, out of network coverage and for the care advantage plan for network only with hmo and with uhc, the provider and under that ppo plan. preventative care, no member

cost share under these plans, deductible, generally on the ppo plans, not hmo's and coinsurance, you can see here across one, i'm not going to read all of this to you and with an out of pocket maximum as members. page seven, a little bit deeper on your planned designs and hmo and care plans. so these plans have pretty much the exact design. there might be minor nuances in conversations but in terms of key features, they are all the same across these plans. for kaiser, hmo, a lot of the things are similar but some are

different. for example the physician visit for kaiser is $25. the out of network coverage and coinsurance and you can see the last two columns are the medicare advantage, no deductible and primarily co-pays with the differences between the two plans. that was level set on where we are today and what does research say on plan design and member plan use. we went out to our favorite google and talked to a lot of our subject matter experts that within aon to see. so there has been a general concern over the years that when members have to pay significant portions or all of their healthcare costs, they may not seek the care that is needed or

purchase the needed prescription drugs. there has been a lot of research as far back as the 70s with the studies which we'll talk about in the next page. when it first start to introduce the cost share, before that, you went to the doctor and there wasn't that cost-sharing aspect. then research did accelerate and understanding the impact of those behavior of utilization. page 9, the big one everyone talked about is done over 1871 and 1986, and there were five key findings and a lot of

information here if you really wanted to dig into it. the five primary findings were the cost-sharing for healthcare services and those who paid for cost-sharing made fewer visits, reduced spending from less use of care, the cost of care were not affected, cost share were less effective services about equally and cost-sharing had no detrimental effect on health except the sickest and poorest patient. there is more information should you wish to dive in. this was some of the more recent research out there that was really looking at high deductible health plan and what they originally noted. where deductible first before you have any kind of coinsurance or co-pays and looking at the

impact of those on behavior, and really there wasn't, you can see the information that was shared here on the results, but since you do not offer these plans, it's not entirely relevant to your structure and plan offering today. now, i'm going to turn it over to my colleague. >> good afternoon, commissioners. mike clarke from aon. we are going to talk about benchmarking in comparing with hss, planned designs and contributions into a number of different benchmarks that we evaluate. you are talking about two things, plan design features, co-payments, deductibles, as well as contributions and plan sponsors could certainly vary where they put their emphasis on

the cost-sharing. you see the pages on the plan and the majority of the average cost-sharing is through a number of contributions. page 12, this is a chart reproduced from our annual health initiative marketing study that was part of the executive director's report in april to the board. we focus on hmo's because 97% of hhs employees are enrolled on the hmo plan versus the ppo. you can see where i have indicated in the rectangles, where hss falls on the employee plan design out of pocket overall average $608 for 2023. relative to a set of national

comparing to labor market which is northern california for hss as well as the full study of 600 employers. you will see that the employer cost-sharing overall at 83% is higher than the other national bench marks, but when you flip to the next page, we also took a look at the ten county employers that are part of the ten county survey that's performed every spring as well as calpers hmo data that we collect. we never talk about calpers as part of the ten county survey, but if you look back at the appendix of the study, calpers information for resource information. so very helpful here. when you look at the hss planned designs, if you look at $1 of

total cost of care and how that allocates between the member of the planned design portion, the co-payments versus what's paid for by the plan, the plan is paying on average 96.6% of the total cost and services and the members are paying that remaining 3-4%. that does represent the percent what employees do pay. when we look at calpers and ten county data on the next page, the designs were similar to what we observed in the hmo data for public sector and large counties in california as well as calpers. on the left side you will see the plan design features and the data that it collects on an annual basis and the deductible

for physicals and payments and emergency room and pharmacy. you will see four columns worth of data. the left side are the hss blue shield hmo plans and non-medicare plan and you will see across these services for each and the kaiser permanente, hmo plan. the right side is the range of typical features so that when you look at the ten county employer data, that's contained in that annual survey most recently produced by hss and march, what the typical feature and the maximum feet and that's where you are compare the level of plan elements as far as co-payments among the public

sector employers that compare to sf hss and you will see the foot notes at the bottom of page 14. when you look at the actual plan costs for these services, are they influencing plan utilization choices across these data and this is what they use as a background for the renewal process and report on the average cost for each of the service types for the planned year in this case, the most recent completed plan year of 2022 and how that compares to the copayment and the percentage of total which is the member of co-pay divided by the total cost. what you will see is for the highest cost services, the plan is paying in the case of

inpatient admissions and outpatient surgeries over 99% of the active costs of those services for active retirees and 99% of the cost. this is 2022 data. on the next page, we worked with kaiser to take a multiyear view of how the cost of total services has changed and we picked 2019 on purpose. we wanted to alleviate any of the concerns around what cost did around the pandemic in 2020 and 2021. so looking at a comparison of the year right before the pandemic started, 2019, versus 2022, you will see that some costs have actually decreased over that three year period. the annualized changed on both physician office visits and

generic prescriptions reduced and the cost on an annualized change over the three years were the same three elements i pointed out on the last page where the member of cost-sharing is the lowest percentage of total average cost 1-2%. we also have some data from both kaiser and blue shield showing for sf hss for inpatient hospital admissions, outpatient visits and prescription drugs are higher than those overall business northern california health business and the graph in the blue line. the business for kaiser is the orange line and the sub set for public sector employers is the gray line. what you will see is that sf hhs

is closely to the public sector but which is higher in the overall utilization and prescription. on page 18, this is data that blue shield provides us. most recently, the data is from the timeframe of services incurred april 2022, through march 2023, and what you will see here is you look at the data and what i pointed out on the right side is the variance from the northern california book of business for blue shield compared to sf hss is all of those utilization metrics are exceeding the blue book of business data for the professional categories.

on page 19, the utilization choices, there is that accountability for use of services and prescriptions. part of the goal is to where clinically appropriate and trust where clinically appropriate and lower intensity of lower communication, if someone can be addressed in an office visit in lieu of an emergency room, certainly helps to encourage that, now, on the flip side if you go into an emergency room and you need to go to the hospital, that copayment is waved. and certainly available for plans and strike that balance between sharing and between contributions and plan design sharing features.

page 20 captures the two of the most previous designed recommendations by myself to this board and just indicating the recommendations were not approved. just showing what those recommendations were for kaiser active in early retiree hmo plans and what the financial impact was behind those recommendations that you will see on page 20. so, there was one in may 2020 for the 2021 plan year and the second on may 25 of this year for the 2024 plan year. so in conclusion, four key points that anne and i want to

make. in the 1st discussion features, they are required for members and we see this in the national health benchmarking but they are in line with large public sectors in california and what we saw in the calpers data. the use of flat co-payments in the sf h ss and hmo care plans, it means the burden of those healthcare cost trends fall to the plan. plan design changes are considered for two primary reasons, cost savings to the plan, as well as encouragement of that care redirection element, and then as sf hss considered with the rfp, we consider a prudent and periodically evaluate on the role-playing features pay in terms of the type of provider and the plan enrolled and

consider those periodic increases as appropriate to keep up with healthcare cost trend increases. final slide, this is module two, there will be a module three on future state opportunities for sfhhs and the board in january and employers in february. we are happy to field any questions that you have. >> thank you, mike. any questions or comments? >> yes, this is quite comprehensive and very detailed and a reminder of what we are already doing and focusing on the future as well and the rfp process as well. when we take out the emergency room issues, the question for

each health plan is what service do you provide to help members triage to the right service? i know that as a kaiser member i can speak that if you go to the emergency room, you get screened and if it's appropriate to go to the urgent care and you avoid the emergency room cost and chaos. you go immediately to urgent care and whether that is to say accountable. where can members find non-urgent care? how many contracts do they have? at least in my neighborhood, there are several urgent care clinics available that are all private and have contracts with different health plans, not kaiser, but others. we need accountability in all this to help the health plans get the members to the right

time. members can't be expected to self triage necessarily based on their own medical background or lack thereof. >> thank you for bringing up the urgent care. that is something that we are working on bringing back to you in december. and to look at the urgent care map and some other questions collected over the last couple of months. we'll be bringing back more for that. >> i would appreciate it. i'm not asking for it now, but i'm saying that these are the kinds of things when we begin to screen vendors in the future will help us make decisions about appropriateness of care, the miss steps and the correct steps that are a cost to everybody, not only the members but the employer groups, etc.

>> >> i know in our neighborhood, we have 2-3 urgent care. >> i can't hear you. >> we have urgent cares in our neighborhoods for sure. that's where i usual go before i go to the e. r. . some people just go to the e. r. ? >> yes. >> that's urgent care. they will refer you to e. r. if urgent care can't do it. i know that. >> anyway. >> is there any effort to encourage more urgent care centers in various neighborhoods? because what i find is most people don't have a

sense of the difference between urgent care and emergent care because of the panic of whatever is going on. they are seeking, immediately if there is nothing you can make an appointment for, they think of emergency. but urgent care is equally as competent and much less expensive, but i don't know if medical groups are considering having more urgent care options or what's out there in that way if medical groups are organized sufficiently to do that because it's not inexpensive to set up that option. somebody has to have that office and the staff and ability to do that. so is there any trends that you noticed or not? >> i said in the director's report today that we are going to map out the urgent care

centers and look at the capacity issues that may or may not exit. we all have personal experiences but we don't have data. we are going to put that together for a future meeting. >> okay, we are going to be doing that. thank you. >> so i have a question and i'm not sure i know how to articulate. the thoughts are swimming in my head, but it seems when you reminded us to our past and recent effort to introduce the plan design changes, they weren't necessarily to change behavior. we were seeking some of the relief for the premiums for that year. how would you encourage the board to think of plan design? is it to encourage different behavior or what? >> from my perspective, it's a

couple different elements when you look at considering plan design changes. we definitely talked about the cost saving element, but i do think and what we've worked with other employers on through plan design changes is evaluating what are the downstream shifts that we are seeing towards for instance emergency room care that maybe is not emergent in total with how a health plan will categorize those type of visits. are we seeing more of those non-emergent visits shift to primary care urgent environments with inpatient hospitalization would an increase in copayment do more to encourage more surgeries that are being

performed in patients that could be performed in an outpatient setting. are we seeing shifts in those services. i think there is a recollection that clearly care in these settings, there is definitely care that is appropriate for those settings, but through plan design shifts, trying to help members assess, could there be an alternative care setting that delivers a similar or better clinical outcome that the financial differential and a plan design copayment could go into the factoring of a member working with his or her physician to decide where is the best form of care that could

deliver a quality end cost optimal outcome. >> i feel like what you described requires lots of lead up conversation behind the introduction of a particular plan design change because i think what has happened in my memory of these past two events is that the conversation immediately shifted is who is going to bear the burden of the additional cost and that was the driving force of some of our decisions. i'm not suggesting that is not important but want to consider all the elements. >> i think you characterized the most two recommendations well. they are designed in somewhat response to the level of renewal that we are getting in this case from the kaiser organization because both of those recommendations were for the kaiser active and early retirement plan.

>> if i can just point out, even with the data for the effective co-pays. it was 2014, i think. i'm hoping it will be a lot more recent data. in fact, the information that you quoted from that study showed exactly what the board was concerned about. the higher co-pays had the biggest effect with people with chronic disease and that is what actually led our decision to reject the staff recommendation which is we were concerned about our members that were the most ill who would bear the brunt and that ran corporation data from 2014 if i'm not mixing apples and oranges from my memory, but these are the things and they are very complicated and limited by the timing of the data gathering and much of it has changed.

what got my attention was that in office charges for lab and radiology, may be cheaper but they are not clear license for quality. they don't go through, yeah, you may be getting a cheaper analysis, but where is the quality and who is measuring the quality in an outpatient office for your analysis and same thing with x-ray. cheap may not be quality and how do we document the quality that is being delivered independent of the cost necessarily? >> yeah, i think working with our partners, kaiser and blue shield to understand that. i think to your first point is part of why we wanted to show

the data for the average cost given by the numbers and on slide 16, the fact that the highest increases in cost over the last three years are also affiliated with those services where the member is paying less than one percent or in the case of the drugs 2% of the total cost and as small as those percentages are, they continue to reduce as the overall cost increases take hold. essentially it's the plan that's bearing those increases that we illustrated on page 16. any other questions for mike or anne? thank you very much. we'll take public comment. >> public comment is now open. instruction are on the screen

for those watching on sf govtv and webex. for those present, please stand up near the podium. and for those on the line, please indicate by pressing no. 3 to comment. >> no one has approached the podium. we'll move to our remote public comment. our moderator will notify us of any public commenters in the queue. >> there is one caller on the phone line, no caller has entered the queue at this time. >> thank you very much. public comment is now closed. >> thank you, please call the next agenda item. >> public comment: 12.board education: determining city contributions for sfhss retiree medical plans: (discussion) presented by mike clarke, lead actuary, aon >> mike clarke, aon.

there was a request at the last meeting to talk through the determination process for city contributions for the sf hhs retiree medical plans. in august, i did present on healthcare transition from active employment to early retiree status. the document here and the discussion today will summarize the approach to determining those city contributions for the retiree health plans. where we focus more on the early retirees in august and including city charter language today. the city does cover some or all of the cost of retiree health coverage on the formula on the charter and that depends on the plan and coverage. to contrast with the

determination of retiree healthcare, city contributions being done through the charter for the active employees with the memorandum of understanding and you will see the charter to this language and it's on the bottom of page two. from a total rate perspective, one question that often arises is how are the total rates determined and specifically why are early retiree rates higher than active employee rates from the same plan? why are they higher than advantage medicare plans and why are they higher than active employees. the methodology looks at the plan per claims and per member for

retirees and employees. healthcare increases with age and this is the most significant factor that contributes to this. there is also a government accounting standard that was first announced in 2004, and became effective a couple years later where cost rates are essentially determined separately for active employees and early retirees for accounting reasons. there used to be a pay as you go or cash base accounting for these plans for a cost other than benefit pensions in other words retiree medical and those that are on an -- accrual basis. when you are a medicare

individual, the government does fund the majority of those costs. those payments are determined through the centers for medicare and medicaid what we call cms. there was a nice illustration back in june that showed how that played into what mapd renewal was and i encouraged page 8 of that material for that information. for early retirees on page 4, you can see a couple of visual examples through these bar charts of the three elements of the city contribution formula. you start with the ten county amount, then you build upon that what is called the actual difference which is the difference between the early retiree only total cost rate and the active employee only total cost rate.

then there is also a prope contribution and that provides incremental funding for the retiree only but also the retiree independent. you will see the prop e amount is higher than retiree plus one and versus the only tier in those examples and for the kaiser plus. those dollars paid by employers goes to retiree coverage. that prop e portion does provide prop e coverage. for the first dependent is the lower dollar amount and there is no city contribution from charter language for the second

for the dependents in retiree coverage and there is why it must pay more to cover those dependents. the charter defined elements you will see here on page 5. the section references are here, and where they translate to in the labeling of the rate cards. footnote no. 1, in that case with the city contribution exceeds the cost rate of the plan which is why the county amount and the medicare advantage plans equal the retiree only tier rates for the medicare advantage plans. the prop e language, specific for dependents, you can see here in section 8, which is why the prop e provides funding for the first dependent of the retiree.

for medicare retirees, it works the same from a formula standpoint. the application may seem a little different, but it's again because the total rate for the plan is less than ten county amount. that's why ultimately you see 0's for the retire early plans and there is no difference because that ten county amount is funding the retiree and the prop e portion is providing 50 percent of the first dependent's total cost rate. you can see here how that plays out for the two medicare advantage plans and in particular on the left side for the united healthcare ppo plan, we show the various combinations of retiree for two or more

including those for split medicare families. so the early retiree is paying higher contributions for dependent coverage than active employees. that is a real difference that covers the difference in cost and the tiers, but the city contribution versus the city formula for retirees. the chart here looks at someone who is an active employee, mou, the city is paying 93% for self only, 93% for self plus one, 83% for self plus two or more in most plans except that highest cost plan which is the ppo. and how that translates into early retiree for the self only, the actual difference bridges that entire rate difference for the self plus one, the city is

paying 50% of an incremental cost for the first dependent and no incremental city contribution for the second and additional dependents. then also noted here at the bottom of page seven there is an important appendix page that i won't read, those hired after january 2009, that is for those individuals after those hiring dates. that table is in the appendix. so overall, when we look at the distribution of retirees across the three tiers, about 9% of early retiree and medicare

retirees cover one or more dependent. you will see that there is 802 new retirements in 2023 and the vast majority are individuals that are not medicare, 80% will become medicare and 58% within five years, but three out of four are retiring before becoming medicare eligible and over half will be medicare eligible within 5 years. and looking as police employees and fire and all through august of this year were not yet medicare eligible, recognizing 18% will be within five years and there are 14 members who

waived coverage. there are a total of 1237 medical retirees who are sworn fire and police officers and will be 40% within five years. in closing, our team will continue to calculate city contribution amount for health plans based on the city language and there are important appendix pages for your reference. first some rate examples and you can see the application for the city charter elements for the early retiree plan and specific language for each of the three elements that determine those city contributions for retirees

and contributions for those retired after january. >> can you show what people will be paying in 2024. >> commissioner, breslin, you requested to see the rates for the current 2024 year plan? yes. i think we can pull that up. i believe that is on slide 7 or 8. >> you might need to hold the microphone. >> i want people to really pay

attention to this because especially the actives who may be retiring early to see what they are going to actually be paying here. blue shield will be $1575 per month for two. that means anybody over 65 years old that retire and there will be a number of people retiring. it's important that people from the active union know that which is what happens when you retire. and that's good to put up there from that's my main concern that people can see this and what's happening here. kaiser, of course is cheaper,

but blue shield is even more expensive than the city plan. $100 cheaper per month. >> i think this points out the importance of preretirement seminars that some of the unions hold, and what we do at health service with regard to educating members who come for that information. the seminars are vital for distributing that information and alerting people. sadly, most of those seminars and i have attended a few and a lot of times the people who attend are already retired or they are so close to that retirement date that they don't have sufficient planning time, and it would be helpful for those employee organizations to publicize a little bit more

through their members that people really need to take a look at this six months or a year before they retire, because these rates are shocking especially when it comes to dependent coverage. >> very shocking. >> if i can piggy back to those comments to add my own. thank you for the clarity that you have brought to the issue where most members from the police side, i know we have had preretirement seminars that i and other commissioners have attended and seeing the math to what the expense is and the cost

for early retirees for planning commission. given some trends that we are seeing with our workforce, it's not uncommon for some to transition out of city employment to early retirement >> it may be helpful to have some sort of educational material to socialize really what we are seeing now that is incorporated within some of these before people pull the trigger on retiring, they should know what they are getting into. i should compliment you for the very robust and clear presentation and would like to thank my colleagues here on board. >> thank you. >> when it gets complicated to me is the 50% that was added on. i have an old charter here and it says application of section, blah, blah, blah,, city and

county shall contribute 50% and the charter was clear. that 50% of the monthly contributions required, but the old charter says 50% of the retired person's remaining monthly contribution which was confusing to me. >> anyway, it's a little bit complicated. i can see where this is shocking. >> we don't hear you. >> i can see where this will shock a lot of people where they retire. $19,000 a year is a lot for health insurance if you have two dependents. >> from my perspective, i think this is really an important discussion. i think it's important based on some of the comments we got in

the last rate cycle where it's like just say no. i think it's quite clear to me from this presentation that hhs and the board operate from constraints on the charter and the mou's and they are not something that hss created or that there is leeway in our interpretation of mou's and that we have to live within the constraints of this. i will say vis a vis the conversation we had already was my last employer is the first preretirement program for my peers five years before retirement. five years. so we can begin to think about what our options are and that would go into decisions around what those options might be, everything from leaving the state to retiring at that moment, whatever. but five years is not an

unreasonable window for people to start thinking about this, no two days or two months or even two years before. >> any other comments or questions? >> thank you for explaining the math to us. you are the only non-city person that speaks charter that i know. [ laughter ] thank you. >> you're welcome. >> if there are no more comment or questions, we'll open up for public comment. >> public comment is now open. instructions are on the screen for those watching on sf govtv or webex. those in person will comment first, if you are calling to make comment, please indicate that you wish to comment to be placed on the queue. anyone can approach the podium

now >> public speaker: fred sanchez. very complex. obviously the charter, difficult to change the charter. it's some good comments. maybe they can look to see if they can mandate some kind of 3-5 year requirement. just a thought. if that could be somehow mandated because who is going to protect these early retirees. a lot of people end up in that category and have a 14% rate increase that is impossible and unrealistic. i think you might have mentioned

how many people opt out to just not take health insurance anymore because it's too expensive. you said something like 14%? >> the number of people who waived? >> yes. >> i would be cautious about interpreting that because many people have spouses that have employment that offer insurance. we have a number of people that waive in the general membership. >> anyhow, thank you for the presentation, very complex. maybe we can work on that suggestion. thank you. >> thank you. any other members of the audience that would like to speak? we'll move to our remote public comment. our moderator will notify us of any callers in the queue at this time >> >> we have two callers on the

phone line, zero callers have entered the queue at this time. >> thank you very much. public comment is now closed. >> thank you very much. let us now move on to the next agenda item. 13.reports and updates from contracted health plan representatives: (discussion) any of our program reps can approach the podium. >> good afternoon commissioners and directors. i want to take this opportunity to introduce to you our new vice-president of client management at united healthcare. i'm monica, united healthcare representative and here we have jeff who is new to our leadership team.

he will be new to sf hhs although not new to the team. he has been with the organization over 20 years. >> thank you, good afternoon. jeff franzy, vice-president. i have been with united healthcare for the past 22 years which i have spent in client management and the public sector space. i appreciate the opportunity and looking forward to working with all of you. >> welcome. >> thank you very much. >> anyone else? >> all right. >> cate, kaiser permanente.

i wanted to say to the board that we did have a dmac find given to us a couple weeks ago and we will be working obviously started over a year ago and working to rectify that and we have made significant investments in major medical healthcare including hiring over 600 new therapist and invested in new buildings and contracting in the community. we will keep the executive director informed as we move forward and wanted to let the board know that we are taking this very seriously moving forward. >> thank you. >> absolutely. >> all right. we will take public comment on the report. >> thank you, vice-president. >> public comment is now open. instructions are being displayed for those watching on sf govtv and webex.

in person public comment is first then remote public comment. please indicate to be put on the queue, for those on webex, please raise your hand to be placed on the queue to speak. no one has approached the podium. we'll move to our remote public comment and our moderator will notify us of any public commenters on the queue. >> we have two callers on the phone line and no one has signed up to speak. >> thank you very much. public comment is now closed. >> next agenda item. >> public comment: 14.vote on whether to hold closed session for member appeal (action): >> we have an appeal and we will vote as to whether or not to go into closed session.

may i have a motion? >> so moved.. it's been properly moved and seconded. do we have public comment on this item? >> we will call public comment. and -- public comment is now open. instructions are being displayed on the screen for those watching on sf govtv and webex. in person comment will be called first and then online public comment. for those watching on webex, please raise your hand to be placed on the queue to speak. we'll begin with in person comment. no one has approached the podium. we will now go to online public comment and callers on the queue at this time. >> we have two callers on the phone line, zero callers have entered the queue at this time. >> thank you. public comment is now closed. >> we will take a roll call vote, please.

>> [roll call] >> >> all right. it's been unanimously approved that we recess into closed session. thank you, everybody. that means all parties not party to the closed session must exit and we will do all the virtual shutdowns as necessary. >> we are now in the final moment for health service board meeting and back in open session. would you please call item 16? >> thank you vice president. it is 453 back in open session. vote to disclose any or all discussion held in closed session. this is action item.

>> madam vice president i move we discuss nothing or disclose nothing discussed in closed session. >> second. >> do we have public comment on this item? >> we'll open up for public comment. and public comment is open now. instructions are displayed on the screen for those watching on sfgovtv and webex. in person is firks r first then remote. for those on the line press star 3. those watching on webex click on the raised hand icon to be placed in the queue to speak. no one approached the podium so we'll move to the remote public comment and the moderator will notify of call ers in the queue. >> there are zero callers on the phone line and zero callers in the public comment queue at this time. >> thank you, hearing no callers, public comment is closed. >> thank you. roll call vote, please.

[roll call] >> item 17, please. >> thank you. item 17, possible report on action taken in closed session. government code section 54957.1 and san francisco administrative code section 67.12b. action item presented. >> colleagues, we need to either have a motion to report or not. >> i move we do not report on action taken in closed session. >> second. >> public comment, please. >> public comment is open. instructions are displayed on the screen for those watching on sfgovtv and webex. in person will be first and remote public comment. for those on the line press star 3 to be added to the queue. those on webex, click on raise hand icon to speak. we'll begin with in person public comment and no one

approached to the podium so move to remote public comment. the moderator will notify of callers thin queue. >> there are zero callers on the phone line and zero in the queue. >> thank you. public comment is now closed. >> thank you. roll call vote, please. [roll call] >> thank you. we have come to the final item which adjournment. i now call this meeting of health services board november 9, a marathon meeting adjourned. [meeting adjourned]2023.)

>> slaefl. >> this meeting safety and neighborhood services committee meeting this morning at 10:00 am., thursday, november 9, 2023. >> i'm supervisor stefani chair and to my right supervisor engardio and left supervisor engardio clerk mr. john carol and thank you, john at you may also watch live at www.sfgovtv.org for staffing this meeting mr. clerk any announcements. >> public comment will be taken when our item 6 interest comes up please line up to speak on

the right turns and i invite you to e-mail your public comment to me and my e-mail j o h n period plus or send our written companions to dr. carlton place san francisco 94102 or a writing i'll anytime your comments and add it to the fill you are speaking please make sure you lines our cell phones and if you have any documents you can hand them to me. items acted tobacco on the board of supervisors of december physicals stated and

december physicals stated and please call please call one. >> regular agenda: 1. [liquor license - 1123 folsom street license - 1123 folsom street street (district 6), will serve the public convenience or necessity of the city and county of san francisco. >> i see supervisor dorsey on the roster. >> thank you supervisor stefani i want to mention before this has been a link time coming and i'm gratified for the long journey to reopen as part of the what we're hearing. one of the most storied and famous pays in san francisco it goes back back from the breaking days and it was a setback for your lgbtq+

one of the drag bars will you get establishments doing everything we can to support this and awning a opportunity in any district i'm excited the box changes to make that that possible with that alcohol effort stakeholders came together to thank you all who made this possible and particularly entries any gratitude to the collective for keeping this alive and for doing everything we can to enrich our lgbtq+. >> thank you supervisor dorsey i believe we have officer from the sfpd alliance unit with us today. >> good morning a report for

the universal life corral llc have zero letters of protest at a high crime area 1123 folsom street and 7 station has no opposition and recommends approval with the following conditions. nonexistent as condition two no noise shall be an bell and with the noise conditions so number two, any noise that is subject to the provisions of an act by itself entertainment commission shall be limited by the permit including any limitation an hours during which entertainment sound is permitted a violation

noise condition for the entertainment permit as determined by the entertainment commission or and any noise beyond the scope subject to the conditions above and entertainment permit means the following or yeah - just add music permits for the will permit a live treatment permit similar such permit issued by the entertainment commission. number 3, which said patio her area of the premise is used for alcohol beverages employees shall be in attendance and maintain continuous supervision at all times to make sure the conduct is