chief medical officer at ucsf, we have jennifer kesh yann, representing dignity health and patty hobart representing ucfs medical center. >> we are on tv here, so if you stand, we'll see you. can you all stand. >> we have dr. margaret bead representing blue shield. >> thank you very much for your dedication and input to this effort also as well. and brown and toll an, do you have a colleague here as well? would you please stand and have them identify themselves. please stand up. all right. we thank you all.

>> all right. i would like you before you leave today to get your names and affiliated titles to our secretary so it will at least be recorded in the minutes that you were here affiliated with this presentation. if you do that, i would greatly appreciate it. if you don't care to be recognized, that's okay too. we are public. >> are there any other comments that you would like to share at this time? >> commissioners, bob muss skat, chairman of the public employees committee and local

21. good afternoon. >> can you bring the microphone closer? >> i wanted to come by and thank the hss board and staff for their leadership vote on kaiser and blue shield, the work that you have done has been terrific. if you remember it seems like a week ago, but the last time we went around with the kaiser rate increase, i think it was a very intense time. it wasn't particularly comfortable for all of us and in the end it really took a leap of faith to believe kaiser's position with us that going forward things would be different. i think our trust in peter and the other kaiser representative seems to be the right decision. i think the employees are very please d with the outcome. we are very appreciative of your diligent effort. i know there is more

work in the future to be done and we do appreciate the effort and leadership that you are demonstrating. thank you very much. >> thank you for making that a public comment. we appreciate it. are there any other questions? >> i would be interested in hearing from brown and toll an on the risk justadjustment. if you can talk about where we should be going in that regard. the other question is what your perspective on the population health challenges. and what we are all facing. we are not asking the doctors to solve the problems in terms of what our communicating is creating in terms of health and in terms of approving the health of our employees as well as our residents. >> all right. please identify yourself again.

>> richard fish, background and tollen. the risk adjustment is near and dear to our hearts. it's not at a patient level we are talking about. it's when you have 5, 10, 20,000 patients in a pool being supported through one program. the resources that it takes really dramatically vary by the demographics and health status of that population. one of the things that technology has given us and all the data around and the insurance organizations around this is much much more sophisticated tools in measuring and predicting what the predictive modeling and what that is going to cost. the tools are out there and it behoves anybody paying for care to

use those. second, pricing to that and making it all the way down possible to the employee contribution. at the population. if the folks choosing brown and toll an are 10 percent healthier, then the employee cost. if the premium is 10 percent less, then the employee cost is less. if it's 10 percent the other way, it goes the other way. if we only look at the premium price and say one is more and less expensive without understanding the expected cost of that population, you are only looking at, you come to one set of answers and if you look at the divided risk score you come up with a different set of answers versus what was the value and what is more or less expensive. >> i think we understand the concept of risk judgement. are there other methodologies that you are using? >> we do with medicare. they

use what they call hcc category by diagnosis. the exchange is uses a retro spective looking back. we do a light underwriting. we are not as sophisticated within our group but we have a team that looks at the cost, expected cost of the population and we do price premium for that. >> to be specific, do you have other employers who are actually using a risk adjustment in their payment structure with you? >> i don't know because we don't contract directly with the employer. we do that, the population we are covering --

>> insurance companies? >> insurance companies, absolutely. >> the second question is the population. >> andrew schneider from brown and toll an. the question of population is new in health care. in the case of what it's done in 2 years perhaps radically changed payment reform and now we are trying to change delivery system reform to match that. that's what this is all about. to do that you have to manage your whole population. not to over simplify a population, but if you put into big buckets. we know some of the statistics five 5 percent of the population are 60 percent of the cost. all the programs you hear about here about the interventions we are trying to

put into place mostly are directed at that 5 percent. that is the bulk of the cost and that's where you are going to get early and long-term successes when you have expandible programs. the population health has to stand the population of your employees. that is a different set. the first set is high intensity in their actions. that's the infrastructure required to truly individually help each patient with that level of a need. on the population side we use the same robust analytics to identify the sick population to understand what preventative measures haven't they gotten that they should get trying to get early detection. that's the long-term strategy of trying to keep health care cost while you are still managing. it's making it an interesting concept. i appreciate the question.

>> thank you very much, doctor. >> paul brown. i'm area vice-president for premier accounts at blue shield. i want to answer commissioner fraser about other customers. we have other customers that do risk adjust. it's increasingly more common to recognize the risk that richard fish talked about. in particular those that have a self funded plan that they feel like is being selected. that is their risk. they will set that contribution on their level. i would be happy to identify them. >> okay. thank you. and you, doctor? >> terry hill, once again and commissioner fraser we do not contract with employers as

richard said. we don't have actuaries. but i do want to make the point that we like brown and toll an use pretty sophisticated risk tools to help us target interventions and some of the outreach that we do. let me just say one thing about the limitations of those risk. they are worth using and we are committed to them in this industry standard. we had our epidemiologist to look at the utilization of health care services in city and county. it turned out the two populations on the risk tool looked similar actually quite identical. what was unique about the higher utilizing population is the population they needed more care was that they were from socioeconomic

areas that were rated lower by using standard federal techniques. so there are, so to economic differences that don't show up in our diagnosis and age based etc risk tools, but and that i think is one of the keys to moving the movement towards population health to the next level. you probably heard of hot spotting. who are the people who really need help? how do we find those people? we are absolutely committed to moving this whole agenda to the next level. >> all right. thank you. are there other questions from commissioners? commissioner lynn? >> yes. my personal opinion what is missing in discussion related to health care is part of the discussion is the

population here where we are changing the environment where we are doing integrated care management and that's the focus to really list the readmission to the hospital. thank you for bringing it up. i would be remiss, thank you for all your work and thank you from blue shield from brown and toll an dignity and health physicians, thank you for extending the affordable health care and thank you to lisa and staff for getting involved in the affordable. aco. i applaud what you are doing. thank you. >> any other questions? >> blue shield? do you have any comments that you care to share. please come forward

and identify yourself. >> thank you. margaret bead, blue shield. thank you so much for an allowing us the opportunity to speak. this is an exciting opportunity for us at blue shield to be involved in this aco. a lot of it has already been said. but this is very unique because we have a four way partnership. really you don't see that. this is my first time being involved in something like this where you have the employer at the table, a big hospital, two large medical groups sitting around the table sharing their information, looking at what works and what doesn't work and really getting in under the hood. that just doesn't happen in health care. it's been very exciting and we've been able to do some really

innovative things. you heard about our transitions manager. that's fabulous. this person walks that patient through even before the patient comes into hospital as an elected admission and hold their hand and takes them to the outpatient and makes sure they are settled at home and is available at home if there is a problem so that the patient doesn't have to get readmitted or from their perspective doesn't have to leave their home, their family and they can stay at home. i just want to thank everybody for allowing me to talk about this. it's a wonderful thing. i appreciate all our partners coming today. i want to leave you with 1 story. this is one of many stories that we have with respect to our patients and this one is one that dr. green from ucsf provided for me. we had a 66-year-old grand mother, very active had a

stroke in july. the care transitions manager met the patient on her first inpatient day and did a discharging follow up call to make sure the transition home was safe. because the relationship established by the care transition manager, the patient and her daughter felt comfortable to contacting the ctm. her blood pressure rose which is what caused the stroke. she called the provider and she called the transition care manager. that transition care manager was able to located the doctor on call and was then able to help patient manage the blood pressure on home and was able to follow up the patient and that patient never left the house, never incurred a

hospital visitor readmission. we made a difference in the life of this patient and a lot of other patients. i believe that's what this is all about. >> thank you very much for those comments. there is another comment? all right. >> anna lisa from blue shield. i want to thank you again for the opportunity of this partnership and thank you for your financial support to help make this option more affordable to your members. as a result of this unique model that started here in san francisco, we have been able to successfully repeat it in 16 different aco contracts across the state of california. we now have 245,000 members covered by an aco model like this. those

partnerships are starting every 6 months, every year and we are continuing to expand this model. it's proven to being effective and we thank you for the opportunity to being innovative here. katsdey, thank you for your nudging. it's helping us to deliver affordability care across the state. as you see in this model listed in this presentation there is a balance of efficiency, affordability and quality and all the work that we've done to get us here has truly set the stage to accept the challenge that i heard from katherine that is harder. we are ready and we are going to take the challenge and the success you are getting us started and we look forward to continue that challenge. on behalf of blue shield, thank you. >> thank you. this is an action item and there is a

recommendation before us. >> quick question. the $500 is that the target? we have the target that they are one target where blue shield with aco's? it started back in 2012 when we started with the aco? >> hewitt. sir, they may have had those embedded in their fully insured premium. but i didn't know what they were. the ones that i'm aware of are the ones for last year and the ones for this year. >> okay. when we started the flex funding. the recommendation we are putting a policy to start for that we hold related to aco that will

be doing it starting 2014. that's your recommendation, right? >> because you are so pragmatic and thorough with your policies, we are all hss believe you should have a policy that says why this money is on the balance sheet. the reason is to pay out the incentive targets. there is a maximum pay out that's calculated prior to the final whatever happens for a given year as part of the negotiation. say it's $5 million. we need a policy to allow us to put that money on the ballot sheet and write it and pragmatic and sound financial. >> was it included in last year's financial? >> yeah. we brought that to your attention that it existed. it was part of the premium. >> for 2014?

>> yeah. it's all built in. but i think we are going to codify it that it's very clear. >> if i may ask. if i can have the recommendation shown on the camera that you have made to us. if you do that, then we'll all know what we are talking about in terms of what's being proposed today. >> okay. >> i appreciate the questions and the recommendation. this is the recommendation base on what we have heard all the representations that have been made, comments about this, this is recommendation that you are making out of this presentation. would you recite the recommendations for us. >> hewitt recommends the board of hss staff for the aco incentive payments. any unused funds will be released to the stabilization reserve for the

blue shield if aco targets are not met. >> all right. that is the recommendation. do we have a motion? >> i will move the recommendation? >> second. >> there is a motion and second to adopt the recommendation. is there any further discussions, questions, clarification that are needed? >> i just have a question. where was this documented? >> we brought it to your attention as part of our explaining what's on the balance sheet when we reviewed the audit is the last time we did it. we said, we held this money and then we said we have let the auditors know. so this is our first time to rigorously create a policy behind it. it's so new that we didn't get a policy written. because we are if --

responsible we want to write an apologize about -- policy about it. >> does it show up? >> it shows up on members on your balance sheet. >> all right. is there another question or comment? >> public comment? any additional public comment? hearing none, we are now ready to move to a vote. all if favor of the recommendation as read and stated please indicate by saying aye? >> aye. >> all those opposed? this ends the rates and portion and benefit of the committee. i would like to

>> the meeting is back in session. >> city clerk: president's report. >> i have nothing to say. is there any public comment on this item? >> on behalf of the hss staff i would like to thank you for representing us. thank you very much. >> all right. item no. 7. >> directors report. lisa got tb. >> this is my report. hss

personnel, the whole department is very happy to see director dodd back. i have an update. the last bill it says the five open positions. there are now four open positions. we have filled both of the wellness positions. the health programs coordinator, the offer was accepted that the individual will start on the 14th. all of the open positions are in the civil service process in the testing process. we are working as quickly as we can through that process. it is a long effort. hss operations, we have been really quite business since we opened our new location. i'm not sure if people are coming to see the new digs and visit the new office. we have really had a lot of new hires and a

lot of retirement. it's been busy for us. all the feedback is that it's been wonderful to have private offices for conversations and it's great to see the members come in and talk about family memberships which we want toen encourage. we have some signs coming. that will be reconciled in the next month or so. the communication, we've been doing a lot of work on promotional opportunities with the wellness effort. we are doing the biometric screening and the health coaching efforts and she's also completed the communications rfp which should be released next week. we have automated,

we have temporary hits who will it the 40 hours and are eligible for benefits. we may have an automated process to them that say that you have now reached the eligibility point and please come to hss to enroll. before it was reliant on the human resources personnel to inform the member of that and there were a lot of times when that didn't happen effectively. really we are looking forward to seeing that anyone who is eligible for benefits is now informed of that. the retiree dental survey was mailed and i want to show you preliminary results we'll bring the full survey back to you at the next meeting along with recommendations. there is no clear winner. so we mailed out a little over 20,000 surveys and we have 1500 surveys back as of today. about two-thirds of those came

by the web, monkey survey and third by mail or fax. that was interesting. first of all a lot of our retirees are very good at the computer. really the choices were due to my financial situation i cannot afford to pay an in -- increase in retire dental premium or i can pay the $5, $10 or $25 and the $25 will get you the active employee. 25 percent of the respondees say they can't afford 18 crease -- an increase in the premium. so that means a percentage say they can

afford. a 5 percent an increase. there were for me a few surprises in the data already. we are still collecting and the due date is not until the 15th. we'll have a lot more full surveys. it maybe that we have to balance the fact that we have people that we do have retirees who can't afford the $25 and we have retirees that can't afford any additional increase. it's good to look at that statistic going forward. the finance management did a lot of work on data analytics. we got additional resources

dedicated and we are starting to make significant changes to that system that are felt by our membership. thank you for your support and thanks to all the board members saying that the team needs to step up. we are beginning to see that already. we are beginning to finalize the specifications for the prop b and the old prop c which is about when you retire if you were hired after 2009, the contributions of the city will vary and that has to be built into system so we know it automatically. we have to bring some members to the board or some notice to the board of some reconciliation we are going to have to do as we start identifying everyone who falls in the levels correctly. the data base, the panel will begin in the next couple

weeks to actually select an an all claims data base. the data manager and i were on a call today where we listened to risk adjustment and how it's being done across the country by the states that have exchanged. there is a lot of work that goes into it and a lot of effort, but i think i'm expecting that california will be doing their risk adjusting at a state level. we are building our data base to also be able to do risk adjustment and i'm supportive of the comments of the team today and that is the way of the future. a lot of efforts around data analytics to go with the negotiations and the units. the marriage certificates that were received for partners who had paid income over the last prior years we've now