and had a manage that. became a challenge. and some key decisions and i won't make anyone read through the small print but i will point to it and a few of our ski decisions and we have established a community advisory board for our transgender health project, and we have created a transgender health portal within the san francisco dph, website, and which is kept updated with the current information for the potential clients for the people who are patients in the system and for providers through the system and that is kept updated with the resources and with the current policies. we decided that the criteria for uninsured patients for surgery would be the same as the criteria by the san francisco healthcare plan and we work closely with the san francisco health plan on making

those criteria as evidence based and sensible as they could be. we have developed guidelines and trainings that we have been rolling out across the healthcare centers both the dph and the health centers and the jail health service and to help and providers understand what our criteria are and how do we access those services. and we are currently developing a and we will start this week, our first series of education and preparation sessions for the patients who are planning on under going transgender surgery within our system and specifically four, three-hour sessions that we have developed in collaboration with the center to make sure that the special challenges that are faced by our public health

patients, who are resource poor, that they are getting the same education and preparation in fact, we would like to think that i... and more effective and education and preparation, than patients who might have the means to pay for these surgeries on their own. and so we are very excited about that program starting. and i want to establish a contract with dr. curtis crane to provide surgeries for our uninsured patients. and that contract has been finalized for the first year of this and it will be finalized for the second physical year of this in the near future. and finally, establishing a goal that we would be able to previed all of these surgeries in our network at san francisco general hospital, and a task force has been formed to solve

the problems that and present a plan that would allow us to be providing these surgeries all in network, soon after the opening of the new hospital, allows us more or time, and capacity to actually provide these. and so that is a big project but we are on track with being able to do that. >> just some details as far as the expansion of surgery, and as the health commission knows, funding was established for this physical year and 300,000, and the next fiscal year, 500,000 for paying for paying the surgeon on a contract basis to provide the surgeries and there was also funding to provide, particular surgeries in network at san francisco general. and to pay for the salary of the specialized plastic surgeon in the department of plastic surgery to do that. and thus, far, as of i have got

the numbers of january here, and but i believe that we have got slightly elevated numbers in a hand out and we have had, and thus far about 85 patients referred to our program, through our centralized referral. and about 15 of those patients have completed surgeries as of this point. and those are both medical and uninsured. and both in-network and out of network and we have broken that down in a table for you a little bit more. and we are keeping those numbers updated as they are changing every month. >> some changes this year, to pay attention to? aca, if you have not heard enough about that yet this morning afternoon and a lot more people have medical and are working with san francisco health plan, and with anthem is even more critical and we have had very good working relationships both with the

medical director at san francisco health plan and the staff there who are working on this. and more challenging working relationship with anthem, but developing the relationships there as well. so that our patients do have access to the services that are medically necessary. >> i should mention that this all exists in a parallel process, with services for privately insured patients. and they, the state insurance commission and managed care, commissions, have set out regulations that prevent exclusion of these services from any of the healthcare plans in the state of california. and this means that all of the healthcare providers in california facing the same challenges of how do we effectively provide the transgender surgery services when we have not been doing that before? and it is given us in the dph

an opportunity to work closely with the providers at kaiser and providers at other sites, on kind of facing the same challenges together. and being able to develop a city wide kind of a wisdom on this. and so that has been exciting. model of care, very briefly, we are seeing surgery, as a means to improve our patients' over all health. our referrals originate with the primary care providers and it is a little different than the conventional model in which the referrals or in ated with the mental health professionals and we think that since the system is primary care centered that that makes sense and we have needed to train our primary care providers, as well as our behavior health providers in how do we, and what do we do this? a requirements are very much

insync with the international guidelines put forward and there are a few very exceptions now to align this with the san francisco health plan policy and considerations and at this point, those exceptions are, i would say, very minor and we have been able to really align this with the international guidelines. and we focused on training the additional health staff and to meet the need and we have done a number of trainings and have done a number of training of consultations available and as i said we have focused on the patient education and preparation to assure the best out comes and we have developed the curriculum for education and preparation that i think is going to be actually a valuable for our patients in san francisco, but this is a model that we are going to able to desiminate locally and nationally and so i am proud of that. critical steps in this, i am not going to go through everything in the small type,

but, we have needed to graple with what is the scope of services? some of these surgeries, are quite expensive and how do we provide them to the patients who need them? and how do we make this work for all of us? we have, struggled with services that i have thus far been excluded and that, clinickly, might be important for some of our patients. and again, much of this is stuff that needs to be decided at a state level and we worked with our advocate colleagues who are working on trying to make some of these happen, things happen so that it makes sense, both for our patients, clinickly and for our community and it is not something that we end up myered in controversy or

we have something that is going to bust the budget. and so, that is where i would like to end except to say that direct people to our transgender health services website. and it is on the front page of the sfdph website. and sometimes when i don't have the patience for that, we are the first hit, if you gaog the sfdph transgender health services that is a quick way to get to the website and the contact information is available and i particularly like to thank my colleagues in the san francisco department of public health transgender health program, conrad wensel our coordinator and julie gram or mental health coordinator and candy pat ter son and the go to person for just about everything and we have added the new staff today. and montica that i am pleased

will be joining us and also thanks to the community advisory board, special thanks for commissioner chung who has been a great advocate for this project even before joining the health commission and especially to our community partners advocates and to our patient whose we learn from every day, so thank you. >> if i may before president chow, to thank dr. barry zevin he is a great advocate and one of the founders of transgender tuesday and he has done an incredible and the stake holders and i want to thank him as well. >> and i want to join garcia to give dr. zevin the accolades because we recently celebrated. and i think that that is

something that as a city and we as a health department with be proud of because we are leading the way for good and really appropriate transgender healthcare and with that i actually have a question. and it is really about the role map that that you have mentioned at the end. and the providers of the surgeries and i believe that there are some conversations happening before, and at ucsf which is teaching institute. and so, creating a center of excellence through this partnership. >> i think that is a great question and i think that the workers working on this, and

includes carlisle and the chiefs at san francisco general in plastic surgery, and urology and obgyn as well as the? >> the first words is that this should be a center of excellence for transgender care in our system. and i think that it is way essential that we are working with the high degree of medical expertise at ucsf. and i don't need to be the first one to say that a large academic medical institution like ucsf has its own processes in politics. and i don't feel like i am... or that the one who is going to be able to navigate all of those processes but i do feel like i know who needs to be in

the room to be able to navigate those processes. and i think that we have got a very good start. to be able to say that let's not setting up competing systems let's set up a system certainly, it is of the interest of administratively at san francisco general hospital. to not only be a center for or within our own network and to look at this at the opportunity to be a center of excellence because all of the counties in california are facing the same issue of patients who require these medically necessary procedures and not a whole lot of resources in those counties to be able to provide those surgeries and okay. and we have got the surgical at san francisco general hospital to be able to train up our surgeons to be able to do this and possibly do this in a way

that is helpful to our other counties and frankly helpful in a way to as a business model. >> so... that is i think it answers that. >> and also, because we when we adopt a resolutions we have brought up this is, you know, like we support this entire process because we believe that this would be help to improve. and it will help in the department of public health and i believe that you have a plan on how we can track that as well. >> we absolutely have a plan for this, and as many of you know i can be ambition in my ideas about how are we going to evaluate how this has improved

people's healthcare in the biggest sense. and but, that is the very ambition kind of evaluation is something that we continue to discuss through the divisions in dph about how are we going to look at transgender healthcare and the out comes. but we do step forward with a very practical kind of evaluation plan for each sfep of this. and how well is the referral process gone. and asking our primary care partners is not working for you and how well is the preparation program going to work. we have an evaluation and then follow up the plans with the patients and did this problem and met your expectations and then looking at over all, and how has the health of those people continued? and so, that evaluation plan is

in process. and i am more ambition i would say, as far as how much evaluation i would like to do, but i think that it requires resources and times so we are working on that. >> thank you. >> commissioner melara? >> yeah, i want to go back to this concept of of a center for excellence and the possibility that not that i want to give more work to the department, but considering that this is something that we have initiated that we might want to be the lead in developing in the center for excellence if we are going to level off the cost of these surgeries in the future. it is going to come from us growing new surgeons in the community. and it is not going to come from god and additional general fund sources and we need to reduce the cost for the more people have access to it and the only way that we are going

to do it is to insure that we have more people and there is more providers. because the less providers that you have obviously the costly it is. so i would encourage you to really think this true, and possibly under the umbrella of the department. >> and i greatly appreciate that is in the alignment on it and it is in alignment with the chiefs that i have spoken to at san francisco general great. >> commissioner taylor-mcghee? >> thank you. and clearly there was a paradigm shift in 2010 when medical cited that transgender surgery or sexual reassignment surgeries were medically necessary. so obviously that obviously helps to pave the way particularly that it relevant you lated the insurance

commissioner and the healthcare plan has been medically necessary, i am wondering is that still a challenge for you as you look at additional resources to make sure that you have it. and i asked this question because this is a great model as we look at other healthcare challenges within the healthcare system in terms of looking at looking at holistically and being necessary for the health and i am curious as to whether or not you find it to be some what of a challenge. >> that is a great question, and i will speak to that challenge in two ways and the first place of the challenge is it does not matter what would youer policies are or what anybody's policies are, people need to be educated and reeducated and we have to have a strong commitment to that. and i think that was a very much and i very effective recognition on the part of the department of public health and

that was going to be something of key importance. and julie gram, who i think is here today. has really led the way on a clearly recognizing that education at all of these levels from the community level to the level of our providers, and professionals and non-professional staff that that is what was going to change how much of a challenge this is to us. and i want to just as an example, we have been able to do a tremendous amount of education with san francisco health plan. and ye started out with good intentions but very little knowledge and now there is a lot of staff at san francisco health plan who are really on board with this and understanding it. second part of the challenge, i think is the ongoing challenge in terms of what the scope of services. clinickly, i have very clear ideas of what is medically

necessary, world guidelines have set standards for what is medically necessary, but that is always a consensus process, and that is always weighing of the various what is the medical evidence, how strong is it and what is the cost of things, and that is an ongoing challenge, and that we just need to stay evidence based, and as much as we can. when we talk about i give you an example of an area of controversy and should faloplasty be a covered procedure? we have a lot of controversy about that, the more that the discussion stays around what evidence based the more effective to get to a solution of those challenges of scope of service, yeah it is ongoing but i think that the key is staying with the medical evidence and keeping that in mind. >> and commissioner, if i

could, there is 2010 was not a magic moment because transgender law center has been really pushing this from a legal perspective to the health plan to medical for many, many years. and so they just turn it on and really, and an issue of really getting advocacy and what has happened in the past it was a medical necessary was being denied over and over again. i want to recognize the partners in the center who really assisted us. and it also took us time to develop this program.

>> there was a lot of advocacy and there was a lot that we are we were on point and we want to move on because they did help us in moving this process. and the most timely planner that we could. >> thank you. i also want to thank you for the work that have you done. and i am curious, because we are talking about the potential of centers of excellence, and that several questions, but, first i also have to commend the department that often we pass resolutions or ask for programs, and this is one that is really there. and on the table. and very viable. and i encourage that we not just continue dialogue on what you are going to use as out come criteria but begin to try to apply some of them so that we can get a feeling about it. so, within the state, because

you talked about and is now a mandate to the health plans, what other areas that may have similar centers of excellence that the plans are using in order to in your discussion with the plans because this is a very highly specialized area, and what interests has there been to do, like, we were suggesting that perhaps this is not only a center of excellence, but can we self-sustain and those are the two questions that i have. >> i am sure that i can't speak to everything that is going on in the state, in this area, and in the bay area, i think that kaiser has had a real lead, along with the ethic dph, and is both getting a lot of demand and is trying to develop the systems to demand and they have worked very much in parallel

with us in terms of having to send the surgeries out of the network including sending the patients to arizona some of the time or bringing a surgeon in from arizona some of the time. and have faced some of the same challenges that have come to many of the same conclusions in terms of model and we learned from each other in that. and i understand that there are similar efforts in los angeles, and i don't know, as much about how they are meeting this need, and at least based on the phone calls that i get from other areas, we are way ahead, of both a lot of the other counties and a lot of the private sector in this and the people are calling me sam, well how did you do that? how did you do this? >> i tried to control the amount of time that i spend on

that stuff. but, those are the kind of questions that i get. >> thank you. >> i think that on that latter point, as we are moving towards having a more integrated system, this really represents an opportunity to a market more of this program, that we have, and i think that it is not your job to do that. and i am trying to move it into the right areas that we will then actually make this one of the services that our managed care system can do. and i am pretty sure that many of the plans really are seeking areas of expertise and california is a managed care state. and that there really is an opportunity at this point to be able to make this truly one of the centers of excellence, and certainly, it sounds like, within northern california, and we could be, and certainly along wkaiser and thes a closed system and so you have the

opportunity of many plans looking for that type of service and that we not burden you with that and make that one of the business issues that our manage care office look at. >> yes, commissioner chung. >> there are a couple of other points that i want to make, the first is that whole myth about you know, like if we build it and everybody is going to flock to san francisco and request that service. you know, as a transgender woman myself, my experience is that every single surgeon has their own signature kind of procedure and so not all kind of people will feel the same level of comfort it does not mean that all from new york city are going to move to san

francisco and register as homeless and sign up for the service if we are going to look at how to sustain the system we have to look beyond just the private public partnerships between the surgeons and our own city budget to do that. and the third point that i would like to make here and we have transgender service and i

am relevant will you curious about what lessons we have learned from that and also, because we have a parallel system which is you know the health, and service, system for the city and county of san francisco and what type of procedures are being considered as metically necessary? and you know, in terms of transition related?

>> we have the people working on that too. >> thank you. >> commissioner chow i am not sure if your microphone is on. >> thank you. >> item 8 is the other business. >> so, i know that under the other business is that we had spoken of having the committee assignment that we are continuing to work on how well we are going to accommodate everybody and i am asking our commissioners to maintain our current assignments through the month of april. and that, in the next meeting, we will then, have assignments that would become effective may

one. so, it also, i think will help the staff know who they are working with in terms of the chairs and all. and i want to thank everybody for the input that they have had and we are working to see how our committee structure we will be able to accommodate additional commissionerers that may wish to sit in on certain topics and weigh in on those and that is also part of our attempt here at the same time to see if then, some of the commissioners desires to understand certain other areas, and being limited by our committee structure would be able to actually participate in topics that they would like in the committee. so we are working on that to see if that can come out and be able to be added on to our agenda, and we will have our assignments finished by and published by our next meeting. >> and is there any other items of business that the commissioners would like to bring before us? is there any public comment th