rates and determined where facilities should be located in hands of us in the community and the public sector. we have paid very able department of public health. this is an intermediate step along the road. i think we need to recognize, and i have seen other information? acts. i think the combination of system reforms we are starting to put in place may, in fact, may be bringing down costs. is important to keep our options open. there are neighborhoods in san francisco where there is literally no access to prenatal care. there is not a provider in the neighborhood. we need to continue looking at those issues as we think about the expansion and the consolidation and support of

maga hospital systems. -- mega hospital systems. >> your answer sounds like hundreds of more hours. >> we have been asked this for hundreds of years. >> the health-care system is in a transitional point. the key to make our health care system as transparent as possible and not lock on to an unsustainable configuration that we cannot afford, that will preclude future progress. speaking about the lack of infant health care, prenatal health care in some neighborhoods. i would assume my neighborhood would be at the top of the list.

>> absolutely. supervisor cohen: it would be an important discussion given the examples or suggestions on ways we can make that happen. >> how we can make that happen. we have the health care services system master plan task force, which has revealed a tremendous wealth of information at the city -- that the city and county can act on. we certainly can demand, and a short-term -- in the short term, greater transparency and information. if we are paying providers hospitals, doctors, for health care, we should know what their unit rates are. i think it would be perfectly reasonable to request a much higher degree of transparency, to understand what goes into the dollar -- $1.81 cost of a couple

of aspirin. there are answers to that. there are answers to that that reflect the fact that nobody knows. in san francisco, hospitals, insurers charge a price which most folks don't know about. kaiser facilities charge a little bit less than that. we really have no good idea of what is contributing to these charges. in the short run, knowing more, and i think in the long run, really understanding and demanding that we as consumers take control of the health care system. we can -- i know this is a long answer. i think we can look to, and there are examples of rate settings and other states. in maryland, for example. we can start to explore here.

maybe it is something we can do on the county level. supervisor cohen: are you suggesting beginning a conversation to have some kind of a uniform payment for hospitals? >> it seems like something that could work. supervisor mar: if the ucla study is true and sutter charges 37% higher than other chains, with consolidation allow them to go even higher? >> i would think that it certainly would. supervisor mar: any other questions for dr. schaefer? thank you so much. the next speaker is tom moore, jr.

>> thank you very much. i was invited year -- i was invited here by mr. campos office. we are an unusual organization and that we are committed to developing and improving the strategies used by purchasers of health benefits, rather than efforts to directly transform delivery systems or bring down prices. the reason we focused on purchasers is over many years, in my case, decades of work in this field, i've become convinced that the only thing that is less orderly, more dishonest, more deceiving then functions of a broken delivery system is the way we purchase

care. we have a market of enormous strength and economic power, which is full of money, almost without challenge or question into the billions of dollars without knowing the cost of what we are paying for, the quality of what we are paying for. or whether there were cheaper or better alternatives. we are absolutely ignorant of where we stand in the market. that is what we believe has to come to an end. i will spare you the rest of my ranch, although i have copies of its -- rant, although i have copies of it here. i promise to be brief. the difficulty we face as purchasers, especially the unions, which i represent primarily. we worked as a 501-3c.

what we have encountered, and ability to develop a consensus of what states -- of what steps to take on. the last few years, however, have been periods of enormous change in the information and quality of information that is available about the quality of care. beginning with the institute of medicine report, 2009, which is estimating 40% of the cost of for medical care is for services that are either dangerous or do no good. that is 40%. we have set out to test whether or not that is a valid number. we have done studies for oregon health authority, the organization for local governments in montana. calpers, the local 1245, and

what we have found is that 40% is about right. that is to say, within a large population, the range of error or inappropriate care is going to probably account for about 40% of cost. that presents a special opportunity as well as a problem for all of us. it means that regardless of knowing that, without knowing exactly where these cost occur, where this waste exist, it is impossible to focus the health plans or the providers on remedies. our history boils down to this strategy. we have recommended that we

begin the development of a voluntary, multiple-pear data set capable of recording in great detail the actual financial transactions, the claims and other transactions that are the structure of what we pay for and the benefits we received. the reason i say voluntary is that we have been waiting a decade or more for the state legislature to do this and they have failed. there is no evidence inside the bair going to produce such a system. on the other hand, they did there is no evidence they are going to produce such a system. they do not have been listed you said it. we have a situation where we could build a data organization that would provide almost real

time basis monitoring data of the quality and cost, the actual cost paid in the claims process for care. that would become a tool. if you want to see competition, i guarantee you, let us bring to the table recorded cost and quality data side by side and put it in front of our members' families and working people of the bay area. you get competition. it will be set in and swift because we have seen what happened on a small scale in other situations. i want to do one other thing. i want to tell you that you should listen to dr. schaffer for more than 10 minutes. she brings such a wealth of understanding to this. she has paid attention to the quality as the underwriting

court issued to be resolved. we will not stable costs without improving the quality of care. we will probably not improve the quality of care, however, until we change the way we pay for it. they're linked fortunes. that can only happen if it happened at the local level. this federal legislation, which i applaud, does not provide a remedy for the cost and quality issues that the community level. that is up to us. that is why we're trying to organize unions into force is to take control of their own payment, to take control of the position they are in when they face these increases. we are looking at increases of 8 or 9% in premiums around the state. that means there will be roughly a doubling of premium cost in

less than 10 years. the cost of medical benefits will be equal to the medium -- median family income of californians. that cannot happen. we will start with the information. we cannot move legislation in this environment without better information. we cannot depend on the legislature to require that we get it. we will have to do it ourselves. i ask you to take this step of adopting a simple policy. if you want to do business in the health care in the city, agreed to full disclosure of all -- full disclosure of all actual cost, charges, and a full reporting system that will allow a purchasing committee to evaluate the quality of the care

you are providing. neither is available now except to long delays at the fact at great expense. supervisor mar: thank you so much. i should they'd said burke -- supervisor david campos for providing suggestions for expert speakers. the last expert speaker is dr. rene shoaw. she is a published author on numerous impacts of provider consolidation. she is going to focus on the impact of the emergency services, keeping emergency services accessible. >> i am an emergency physician at san francisco general. i am assistant professor at ucsf. i am not speaking on behalf of any of these entities.

i published ostensibly in the area of emergency department closures. i was looking at over 2400 hospitals over the past 20 years and the united states. hospitals that serve low-income and poorly insured patients are twice as more likely to close their emergency rooms than their counterparts. this is even after controlling for things that market competition, profit margins, and ownership, and population density. my team performed a state analysis to determine if these national trends are similar within california. hospitals serving a higher proportion of minority patients and poorly insured patients had a highly -- a higher rate of closure. there is a federal law that states that all emergency

departments must see patients regardless of their ability to pay. this is the only place where you can get care regardless of your ability to get -- paid. as a result, what happens is you have two different types of emergency departments. if you are a hospital and your e r is located in a geographically affluent area, a highly insured patient care mix, that emergency department is the revenue center for the hospital. it is the entry point for admissions. however, if you're hospital is located in an area where the patient care mix is poor, the hospital is more likely to close its emergency room. what happens when the emergency rooms close, when somebody has an emergency and their nearest yard is closed, it does not mean there emergency disappears. they go find the next emergency

room. that can cause crowding. last year, i presented a piece of research at the national scientific meeting at the academy of health. we showed using data from the bay area, san francisco, part attack patients who were admitted on crowded days actually had a 21% higher death rate at 30 days. even when you control for all factors. patients who were admitted on noncredit days. we used to think, if the hospital is crowded, a means that patients to have a sore throats, instead of waiting three hours, they wait six hours. we have increased morbidity and

mortality from serious conditions when you are admitted on a crowded day. it is clear the hospital and emergency department crowding enclosures are not isolated to a single zip code or neighborhood. they certainly affect a larger community. i will provide a few pieces of data regarding emergency care that may be relevant to this discussion. even though st. luke's account for less than 5% of inpatient beds, they saw over 10% of the traffic in the city, a 26,000 patients. in terms of prodding, one proxy we use is ambulance diversion. if you are in an ambulance, you go to the nearest hospital to seek care. that hospital is crowded, there is no in patient capacity, but hospital is on diverge. ambulance needs to be rerouted to the next nearest hospital. when you look at the data, in all of california, san francisco

is in the top four counties with the highest diversion rate. in all the hospitals combined, the number of hours on diversions was more than 4300. on average, everyday in san francisco, we had 11.5 hours of diversion each day. during these times, each patient that had to go to the hospital in an ambulance had to be rerouted because one of the hospitals was so crowded. of course, crowding is not evenly distributed across all hospitals. if you look at were crowding happens, it happened most in hospitals located in the southeast part of the city. san francisco general, because -- we are on divert 25% of the time. santa lips was third highest in their version -- st. luke's was third highest in the diversion. if someone in my neighborhood needs to go to the hospital, they have to drive further to

the next hospital. it is not only that patient to is affected, it is everybody else. it is clear that closures affect emergency care for all, insured and uninsured. these closures affect access to care through increased distance and also by increasing the patient load at neighboring hospitals. er crowding degrades quality of care. it can also set the stage for additional closures by displacing tens of thousands of poorly insured patients to other hospitals. as you are aware, this discussion of st. luke's is only one consideration and it is part of a much larger discussion.

supervisor mar: any questions, colleagues? thank you for the presentation. [applause] colleagues, we are ready to move towards public comment. i also mentioned the last hearings, if there are seniors and people with disabilities, i would ask them to come forward first. i will start reading the names of the people who have signed up. [reading names] i will call the rest in a moment. >> thank you.

i am kind of flabbergasted to hear all these conversations about markets and competition and lowering costs. it is a fundamental rule of capitalism that competition leads to a monopoly. cpmc rebuild is a perfect example of that. this kind of monopoly is going to lead to more charges, higher charges for health care. it will directly hit city workers and retirees since the city seems to be determined to pass these increased cost from the cpmc rebuild on to the current and future workers. in march of 2011, at the l.a. times roadwrote, " northern california's most populous

counties collect 56% more revenue per patient per day then hospitals in southern california's largest counties. northern california hospitals say their prices are going up for labor, supplies, and other necessities. leading health care economist said that most of the disparity stems from a lack of competition in the north. a wave of consolidation has given a handful of hospital networks unusual powers to dictate what private insurance and the customers pay for care." supervisor mar: that is 30 seconds to go. >> the article continues -- "the driving force of this is sutter health." this process of trying to figure this out up until now has

failed. everything has been revealed shows that what you need to do is to plant things off six months until the beginning of 2013 when the city's own master plan process and the needs of the whole city are taken into account. supervisor mar: thank you, next speaker. >> some of you know that for years, i worked in one of the most dangerous jobs around. i worked for a company -- an individual i was working with was moving steel into a building. at some point, when he was rolling that card into the building, one will of the cards caught on something on the

floor. together, they took his thumb off. that individuals brought immediately to the emergency room, san francisco general, where they did a fine job of stabilizing him. however, when the emergency room decided that it could be reattached, they immediately sent him to davies medical center. that was where the still resided for microsurgery. that is an instance of how san francisco's own health care system considers cpmc an integral part of its delivery. that is something we need to bear in mind as we consider how best to preserve this institution. he was heard criticisms of the health-care system in general -- you have heard criticisms of the health-care system in general, but cpmc is an integral part of

san francisco's health care system. i ask that you keep that in mind. supervisor mar: if i have called your name, please come forward to the middle aisle. thank you. >> i think i am next. i am with sf cares. i really appreciate some of the speaker's earlier today, especially talking about competition and making sure that we do have competition in our health-care system. also, the location of st. luke's and sf general being south of market. for a long time, i've never spoken here before on this particular subject, but for a long time now, i have realized, and i used to work at st. luke's. for a long time, i felt like st.

luke's has been so criticized. when you look at the city and the sea south of market and their only to hospitals there, we need to keep things in talked. the idea today that was brought forth about having this huge hospital on cathedral hill and all of the beds being drawn away from st. luke's. if we only have 80 beds from st. luke's, it is meant to fail. that means -- that really scares me. i think about earthquakes and other things like that. if all the hospitals in existence are within a mile of each other, and there is only st. luke's and san francisco general. it is going to be very hard for of honorable -- for our vulnerable to get help. the other thing that bothers me is when people have loved ones and are needing care and they

have to take many buses to get their combat such as from the bayview. if st. -- minibuses to get there, such as from the baby. it does not seem very wise to me. i would urge that the board think about this. supervisor mar: i am going to call a few more names. [reading names] next speaker. >> thank you for hearing this matter again today. i am with the construction employers association. we represent over 100 union building contractors in northern california. several of which are located here within san francisco and

many of which are performing work here in san francisco. what i would like to talk about are just the immediate construction jobs that are badly needed that could be brought on as soon as this project and as forward. the day that this project starts, there will be union laborers on the ground taking down the old building. there is no question about how much the union building construction markers have suffered over the last few years with the economic downturn. these jobs are so important, not just to these people, but to our economy, locally to rebuilding our health care infrastructure and also a mission district resident, and i know how important is that we continue to upgrade our health care infrastructure and build this new seismically safe hospital in a neighborhood that is really in need. i am representing a contractor who has been selected for this

project to has done -- more time and resources to workforce development and helping to develop workers in this city. i would urge you to move this project forward and get these construction jobs going quickly. thank you. supervisor mar: i would like to remind the speakers that are focus today is on health care. in the last hearing, we dealt with jobs. my hope is that we focus on the health care system today. >> good afternoon. i am also a resident of the mission district. i am the research director at the national put union of health care workers. i spent about 15 years of analyzing the health care industry. i want to offer several experiences and offer a cautionary tale. i can say without equivocation that sutter