race on the office portion and office on aging. so you can see from this slide, the division in terms of who is in these two various programs. ihs is a mandated program. if you qualify for the program then you receive it. office on aging is open to anyone, although we target low income people. but, it is again open to anyone who seeks out this service. unless there is questions? >> there are questions? >> supervisor wiener? >> thank you. i just want to thank the department and the mayor's office for first the increase in wages for the in home supported service workers. these are people who are in many ways brought a very hidden

and critical service to so many people who are now able to stay in their homes and more integrated into the community and these are embarrassing in some ways and this is a state issue more than a local issue in how we pay these folks and i want to thank you for that, and i was also happy about the enrichment enhancement. i know they were advocating for reimbursement in increasing meals. that was a concern for me. it looks like we are increasing the number of meals served and i know there are some organizations that are doing a tremendous job in accepting new seniors into their program and i just want to make sure we are supporting them. i was very pleased by that.

>> supervisor avalos? >> thank you for your presentation, your work for the city. a question about the top. i heard from my district that the top programs are being eliminated and i heard from coming here and from yourself that through our expansion of t top. can you tell me what changes are over the years. i know we are trying to back funds? >> we are as far as i know the only backfield that is taking place is for the senior program. there was a 7.9$7.9 put into our budget. 3 plus went to dos and the others went for programs in the city. at this point i believe that we are the only one who has put

forward a proposal for continued funding related to or it's the only one that i'm aware of. so we are not looking to reduce the number of sites. because we've just, the last of the sites just came on board in december. that's six months ago. we are looking to this into this next year to put a strategy in place that really helps to bring the numbers of people who are using the sites up but at this point we are not talking about closing any sites. that's senior sites. yes. >> okay. thanks. >> mr. president mar? >> yes i'm happy about the community centers as well. i also want to say that in hope supportive service workers,

those it's a small increase, i think it means a lot and i'm hoping that we can continue to pay them adequately because they do tremendous services throughout all of our districts. in district one i know there is quite a few patients and few workers in my district. and also given the different task force and technology and the huge boom in the senior population, i think this enhancement of food for older folks, the 45,000 additional meals is important but we need to think about how we are going to meet the tremendous need that is out there. thank you for the budget. >> all right. supervisors. picking up where i left off on

the human services enhancements onto slide six. in the housing homeless division we are proposing $6 million expansion under our hud continuous care with the application which increases funds from the feds which supports housing and annual growth in our grants. we have taken on administration of the hopwa program which is basically a section 8 for homeless individuals with aids. as i said we previously administered by the housing authority. we have initial general fund for new supportive housing for families and 44 new units for homeless youth and then smaller amounts of

additional money to have our first friendship family shelter run year-round as well as fund to go provide access to the emergency shelter system through the 311 system. the next slide represents the significant new responsibilities that we will have under the affordable care act and that is significant expansion of medi-cal specifically in january of 2014, single adults who are single indigent adults 19-64 will be eligible for medi-cal. we will be required to enroll these individuals and families as well into medi-cal. there is an indicated growth. obviously to do this new level of enrollment we are going to need new staff. we've added 30 new

staff for 13-14. and that will allow us to do the enrollment and take advantages of the businesses processes to make the enrollment seamless and stream lined. these positions are 100 percent federally funded. in our cal fresh program similar to medi-cal, we have seen growth and we'll continue to see more growth largely due to individuals who are coming in for medi-cal also being certified eligible for cal fresh which used to be called the food stamp program. we are adding staff to handle the increase load here. the governor has had a big rein

investment strategy. the governor has proposed significant in enhancement to more rapidly enroll into cal works and jobs now. so this increased funding will help us to expand subsidized employment and more robust standardized assessment process. our family and children services which is our child welfare, child protective services is now funded through realignment and less subject to ebbs and flows to the fiscal situation in sacramento and has a dedicated revenue stream. the vehicle license program has grown and that program is supposed to

grow as well. i know the committee is interested in over time spending. we are not over time spend ers. with that i know it's high level. i have been before you a number of times and the budget reflects a lot of what i represented back in april. >> colleagues, any questions? okay. hold on a second. we'll get to our budget analyst report. we'll get back to you when we get our report. >> mr. chairman, members of the committee, mr. chairman do you want me to comment on the two items? >> save time supervisors in that we maybe for the first time in 10 years have agreed

with the budget recommendations in the program. >> our working partnership has dramatically improved over 12 years because of our professionization of our staff. >> let me make a statement. i'm glad you brought that up because anytime the committee compares with the budget analyst means that we left money at the table. [ laughter ] i think it would be great if you comment on the two items as well. >> on page 58, item 12, 130542 regarding the represented pay which would increase to $39. we are recommending approval.

regarding item 7, file 130553, page 59 of our report. this is the human services agency proposed expenditure plan for their human services care fund. we looked at that and do recommend that you approve that resolution. regarding our recommended reduction on page 59, that amount $378 are on going. this would allow 3.3 percent of the budget. together those recommendations will result in a savings of 1$1 million to the fund. there are other revenues federal and state that finance these cost.

our recommended reductions of 391.026. that would allow a 1.8 percent in the departments. those recommendation result in 131 savings to the department. the department concurs. >> do you need anymore information on the care fund item? i'm happy to walk you through if you need it? >> i don't. >> i just want to say it was a pleasure working with the office this year. it was really good interchange and sharing of information. >> okay. much appreciated. >> colleagues if there are no other questions we'll hold off on the items until after public comment. we have some proposed adjustments from mr. rose. can

we have a motion to accept these. >> so moved. >> without opposition? >> thank you very much. >> mr. clerk, it's 1:21. why don't we go >> good evening welcome. welcome back to the san francisco board of supervisors budget and finance committee meeting for june 20, 2013. we are continuing with items two and three and we have our department of public health and i see greg wagner. thanks for being here. come on up.

>> i wanted to give you a overview of our budget. it's 1.$9 billion for this existing year jeer and increasing and as you know san francisco general hospital, laguna hospital primary care, jail health services, mental health, substance abuse and public health are our major services and just please note in substance abuse and mental health is where the majority of the services are and that is almost $260 million. the question of equity. most of our services are focused on equity and access. about five years ago the department supported

three major equity groups,an african-american leadership group, and chicana group and api equity group. these were organized to help us with advice and direction in meeting the needs of those populations and we have many other advocate groups that work with us. internally and on site we have telephonic and language services that supports over 80 languages including american sign language at san francisco general hospital, clinics and laguna honda and jail health. internally we are looking at programs and trying to really bring them together to leverage as much of the services we can, particularly around african-american health and

populations, and so one i wanted to highlight is our trauma and mental health system. we are really looking how to ensure that our entire mental health system looks at trauma for the clients and ensure that the provider is educated on mental health health status. other programs that address disparity are the women programs and the nurse partnership focused on the most vulnerable families and our new comers program that really looks at immigrants that come into the city. the major drivers of our change in dph's budget is our need to invest into the affordable care act. we have had a historical structural short fall and that is also corrected in this budget. the furniture and

fixtures for the new san francisco general hospital and negotiated salary increases per the labor agreements have really created a need for a change in our budget. just a quick overview of our -- what the impact of affordable care act on our department. on insurance status what we will see is the number of insured will go up. the majority will get medi-cal and some will get cover california which is the new insurance program that the state is developing, and the number of insured would go down. that would reduce enrollment in healthy san francisco and [inaudible] in the past but we will keep healthy san francisco for those that don't qualify for aca primarily for the undocumented so healthy san francisco will continue to stay within the department. one of the challenges that we do have and we were at the hearing this

week is that our state revenues are going up and down. from health insurance they will of course go up but large leer our uninsured moving to insurance through medi-cal but because of that the revenues that support the uninsured will go down so the waiver dollars will be reduced. our dish dollars, which are dollars that we are given for the hospitals will go down because now the federal government is providing more access, and realignment dollars that the state has given us for many years to serve the uninsured are going to be taken back by the state due to the fact that we have insured community members. one of the most important things for the future is the way we're reimbursed for health care. we will be getting capped payments and part of the medi-cal expansion it provides a fixed

number amount to manage the patients regard regardless how frequent or infrequently they use the service and we are starting in january and we have a group of seniors and those with disabilities who are already on this type of payment. we are seeing that they get one payment per month to manage the care of individuals. that is making us reorganize the way that we provide care. the affordable care act is really focused on the capacity of primary care to provide medical homes. i think we did an incredible job of that through healthy san francisco. all of the uninsured are already in networks -- at least the majority of those, and they already have health care homes, so we will have to continue to look at expansion of primary care to insure that we are able to meet the financial future of

the department and we have some of those initiatives within the budget including insuring that we are able to provide more access as an example during nights and weekends. to continue to invest in our delivery system we now will be required to have contracts with some of our providers and we will continue to have contracts with our health plan, so we must create an office of managed care to enhance our data collection and improve outcomes. we are strengthening our care through management and access to clinics. we will increase staff to reduce wait times. the federal government is requiring a certain length of wait times that we have to meet so we have to increase specialty care and we have requirements from the government and the funding, but not the entire funding that we need to incorporate electronic

health records and those are going to be required by the federal government in the next few years. with those challenges on one side of our department, particularly on the delivery system, we do have to look at services that have not created enough revenue for their service, and we i think we're doing a good job of reprogramming our behavioral health center for the potential 8.1 annual savings and go into a skilled nursing facility and 24 beds in the facility to psychiatric respite beds. we find many people are going into the psychiatric services that don't meet the level of acuity but there is no other place for them to go at that moment and with the new beds the psychiatric emergency system can use these beds as a way to help people reduce their anxiety and not have to be hospitalized. this realignment of our health

care services at the behavioral health center will allow the department to better utilize the beds and create beds that are in short supply in san francisco. through this initiative staff will be reassigned and there is no loss of employment expected from this realignment. one of the difficult and also i think important processes that we will have to look at is our community program services. we're looking to try to reduce in that area by $17.6 million in this two year budget. we're already currently looking at the service delivery system. this is the time for us to reorganize and prioritize services. the change will be effective in fiscal year 14-15. we hope to maximize coordination across the department. although we haven't totally created the focus of where we're going to put the rfp although we have a

focus for the services not being able to create a revenue source for themselves. they will be focused on the behavioral health services, housing and urban health, hiv services and prevention and other programs and those that will come through a rfp process. and we will now have our chief financial officer talk a little more about our restructure. >> may i also read item five. >> please do so. >> item five and the patient rates and other services provided by the department of public health. >> thank you supervisors. greg wagner chief financial officer. a couple of other points about what's included in our budget. a big thing for the department is the issue of our structural deficit and salaries. historically we have operated

with a budget that is less than our actual staffing levels in the department. that's happened for a number of historical reasons, but with working with the mayor's office we have been able to get to the point where we're able to correct that in the budget for the coming two years that's an investment to bring our budgeted levels up to our current levels of existing staffing. it's about a little over $50 million per year that is funded partially through internal reductions, partially through increased revenues and partially through general fund support in our budget, so that won't solve all of our problems going forward by any means, but what it does mean we will not walking into day one of the new fiscal year be starting off with a deficit in the budget so that

is a significant positive for the financial stability and management of the department but also for the general fund. other changes, some of which you heard about. we have a significant appropriation in each of the two years for the budget for furniture and fixtures and equipment at the new san francisco general hospital. we are $49 million budgeted in 13-14 and $55 million in 14-15. we are currently in the process of adding to that number through private philanthropic donations to support that program. that will allow us to have modern functionality at the new hospital. we are approaching that through a combination of cash purchases and financing of certain items in cases where it's appropriate to do so. other items that you heard

about at the hearing earlier this week as you know there are significant reductions to hiv health services and prevention services in the federal budget that have worked their way down to the county. the mayor's office did back fill these but new cuts have been added on top of that and have left gaps in both years. in addition to that we have other federal reductions in the budget. a notable one is to owb tuberculosis programs. we back filled those in part by the budget submission but there is a gap remaining which you saw in the documents earlier this week. lastly just on legislation that will be coming before you. one item that was

read today is the patient ordinance and adjust the rates that we charge to commercial health plans predominantly. those rates don't affect our medi-cal or uninsured programs, but what they do do is generate revenue from the commercial payers that use the facility and that a significant item and we have an annual process that we collect our known and recurring grants and ask for approval for those in the legislation so we don't have to come back for approval for each grant. the last thing i will mention is on overtime since that was mentioned as a topic of interest to the committee. we have worked very hard on overtime at

the department. we are currently within our budget for the current year and expect to stay within it for next year on overtime expenditures. those constitute approximately 2% of our total salary budget within the department, so we have worked very hard on keeping that down. the challenges for us are when we have inability to fill positions at 24/7 requirement our staffing needed to back fill that with overtime but we worked hard to do that and we have programs to minimize the overtime use and thank you and we're happy to answer any questions. >> colleagues any questions? supervisor mar. >> i just wanted to ask if ms. garcia or mr. wagner could

respond. i know they submitted a very late request. they emphasize that their physician's pay is so low compared to other hospitals and they're having always have a hard time with high turnover and what they all unfunded non discretionary physician increases -- i believe range adjustments in the salaries that they say is not included and i am wondering what advice do you have for them and it's about 3.1 million dollars amount and lead to increases and be competitive with other hospitals? >> i think it's an important topic. we've been working with them since i have been the director. we have increased the contribution to them. in this year's budget we couldn't provide the whole amount they were asking for. it is true that they do have some problems in competition but we always can't fulfill every need that they have so we will work

closely with them if they don't get additional funds with the impact as we do every year but we had a gradual increase in their costs over the last three years i have been working on the budget with them and we continue to try to meet their needs. this year we couldn't give as much as they needed. >> and i should clarify the physicians at usf general. >> it's for the general hospital the positions in the hospital. >> okay thank you. >> colleagues any further questions? why don't we go to mr. rosen and the budget analyst report please. >> did the department comment on -- >> no. i was going -- mr. wagner do you want to -- >> we are working on it so with the committee's permission and mr. rosen's