he unions adapting the stream this was part of the overall payment it was 80 thousand 774 to total $3 million 805 for 18. >> and your recommendation adaptation? my recommendation to approve our report this is done in in accordance with an audit that occurs >> are there questions from the board. >> so we spent the whole early program do we have to do some reporting or subject to anti audit. >> subject to audit. >> the office the entity that

animal this closed its doors. >> oh, and turned off it's lights so this is in the event that we are - >> all right. thank you other questions from the board about this item i'm ready to entertain a motion. >> that's the difference of the churns or insurance program. >> it's been properly seconded to adapt this as discussions hearing none we're ready to vote in favor of the motion please signify by i. >> i. >> all opposed nay it's so adapted thank you, commissioner for staying and giving me 5 minutes. >> thank you very much we'll see you next time. >> all right. so we're now

ready to undertake any remaining items under the agenda we were at decision item 8. >> 8. >> we're going guilty of negligence gun on this item since it has my name attached to it we heard the controller and director of finance pamela talk about sing nicaraguans the budget with the general budget process to that he said i think any discussion of education or items for volunteering text evaluation should be incorporated into the 205 discussions and hence i am requesting that if at all possible between now and the presentation of the budget in february and if not then pam and dobd will give us guidance that

a few minutes meeting be convened to discuss those matters toy come up with a fulsome recommendation to share with our city attorney's office for making sure we're clear about what we're recommending and if it's don't believe anticipate all of that to meet the requirement of 205 as described if our minutes and at the same time trying to accomplish a larger goal or effort here so this is really what i have to say about this item at this time i'll be more than happy to entertain questions. >> it's a very good idea we've talked about funding for education for almost ever meeting every annual when we've had the board or self-evaluations we've not gotten to it we had it when i

came on the board did you that hadn't happened it is very important to look at it this and i'm interested in consulting money for the consulting firmly we can't get though the governance issue without their help so i think this is a very good idea we used to have budget and finance meeting more frequently i this years ago am i right. >> thank you very much commissioner that's my request that dobd and pam levin to come up with the principles of the finance committee that is myself and commissioner lim and sfooefrl and two out of 3 ain't bad we're trying to get that done we're ready to go on to the

next discussion item. >> item 8 discussion item presentation of calendar for plan 2015 dobd. >> you have before you a revised calendar the addition are the dental vendors are up at the end of this year we're quickly looking at doing rfps for vision and dental not able to nail them when those will be ready hope is he we'll be able to do one in april and one in may that's not clear at this point. >> okay. is there any comment or question from the board regarding this. >> i remind all of those who

are in our listening audience and viewing audience that the rates and benefits effort of board is done as a committee as a whole, however, there are any number of meetings that sometimes require members particularly the chair of the rates and benefits committee to participate along with the staff as they're having discussions with health plans o plan vendor and a artillery requires or i say vendor or health care partners and their representatives there's work that goes on between meetings as outlined on this calendar their innovate representing here and it's a lot of effort toe kind of get us to june we're able to say okay. here it is we had the great whisper and shrines by kaiser and i want to say that one more time and my hope is

that working with all of our health plans we're able to accomplish the same resulted including the rfps with that having been said you don't know i don't have comments from other board members. >> so you you'll be the chair of the rates and benefits. >> until decided that at this point, i'm 2, 3, 49 first two hours of my presidentcy we'll see what happens so presuming another commissioner coming broad wherever that happens or the interests of other confirmations my hope as we do this work we can call upon others for their time and talent to get it done any public comment on that item? okay. if not we'll go to the next discussion item. >> item 13 discussion item 2014

health care survey ann hewitt. >> good afternoon barbara whatever likelihood this is a followup to a decisions we had in september of 2014 we presented survey data and you had a number of questions to follow up on there was it fell into two categories one questions about a couple of topics and the other follow-up on data i'm not able to still pull together the relevant comparable dalts you were looking to compare year to year trends on certainly materials we presented i'll still he trying to you pull that together but at this time i'm presenting one

topic the topic of value based insurance and pricing the reason i'm presenting s it is there are questions about those concepts really meant the interesting part of about vail based is the words value based we're hearing a lot in health care katherine dodd and her team are working on a value based contract the concept about the value for the quality the cost for the services today, we're really talking about two topics that came up in our presentations the first one was the value based insurance design the concept of that is really about either spending more on a service or maybe spending lessen a service a

health care service or a health service at sometimes in in this case it might be a strategy around trying to identify different health populations a clinical group trying to encourage behavior or courage use of centers of excellence and the value based concept the insurance design you encourage the behavior by changing the costs lower the costs to encourage people to go to a center or courage them to take a prescription by lowering the costs basic concepts of insurance design their driven by either service based or participation based and it is in simple terms it maybe we want people to use

the center of excellence we know the quality is there wife done due diligence and we know that we might design the plan by lowering the costs for using that service or center a condition might be everyone would high blood pressure i'm an example everyone you change the co-pay on your bp meds to zero so that value based design is you encouraged compliance by lowering the costs and then participation based is something like that what we talked about smoking sensation maybe there's encouragement because we either make programs assessable or no cost or possibly some other kind of financial configuration so again, this terminology is in

the marketplace and we wanted to provide some clarity to the public and commission next slide i will touch on slide 5 and again service based i want to point out that example this is an example of taking value based from slithering different angle maybe we've determined with the appropriate resources and data through different kwiefz resources that concern procedures are extensive active too many of them like emergency room utilitytion vitamin d testing and imaging services for low back in that case the position is this insurance design is actually make those

services more expensive to discourage the high utilitytion of what is over utility listed the design can work from both angles as we move on from there i'm not going to go over the details but we provide information from data and research about what organizations maybe doing in eliminating this concept in their medical benefit programs like organize program employees and the university of michigan and so on so those are websites if you want to read information or like me to follow up with research on our on behalf of. >> is there any questions. >> commissioners any questions. >> thank you. this is a good presentation it is focused more

on the value based design because it impacts how we design our programs facilities going thoroughly to 2008 and those steps will be coming so i think we need to go farther and research more. >> we believe the same thing i think the purpose is to as you said commissioner scott we need to make sure the audience understands little terminal i want to make one final comment on the other terminology reference based icing this terminology goes back in time dobd will know this the best probably with medicare about really setting a price on a service and saying this is what we're going to pay okay. so in simple terms that's the concept

c sections we're going to pay $35,000 and anything offer that you pay for in real terms the way reference based pricing to used with planned designs organizations design and determine conditions that are appropriate for pricing and falls that can deliver the quality and care at a price point and they draw people there by essentially doing reserve deduct we pay it up front if you go outside the network you deal with that probably a really good example i apologize i did not bring the article but david the chief of the center at cal hearst recently pushed

information they found dealing with their data warehouses they've identified the cost drivers and focused on where there's regional variations they if you do with arthritis knees and hips was 1/3rd the cost in that category over a period of 2005 to today it went up 39 percent they determined that knee and hip replacements were a good type of program for reference based pricing why? because there's great variation in the marketplace with similar outcomes okay procedure can be skementdz not an emergency participated can make choices and the procedure can be performed at high volumes so what they did was organized

they're first programs with knees and hips they found that they basically induce enroll he's to go to lower cost facilities and found significantly generally lower implicates and significantly lower thirty day infections and similar follow-up with about a 26 percent saefz to so theirs conclusion they're to expand the concept expect and the facilities and their next line up will be covering objectives and can't say that those are works i hope that provides clarity to some new

emerging terminology and think about it while planning with the health plans any questions. >> i will say this is helpful and informative i hope there will be ample opportunity whether or not to incorporate those approaches with our health plan narnz a good starting point for information we'll be coming back to make it more of an educational. >> yeah. knee and hip surgeries i mean, you're saving look for the lottery cost doctor; right? >> e and this experience whoever recorded that the outcomes were better? basically from those >> this particular study i was

referring to i'll give you the specific article. >> that is a broad statement. >> i'm not sure i heard your question this is an area that is a category that is prevalent high costs i've got two hip replacement this was $100,000 before the reduction i didn't go to a center of obsolescence e.r. excellence it's a condition and procedure you can plan there's a lot of procedures and there's a fair amount of wide variety of costs in the marketplace with what they found in their data to be the same outcome in other words outcome was the same but costs were ranging from here to here it's a perfect category to

reference based price and negotiate with the facilities and create an environment that lowers the costs and keeps quality high and you know really gives the result that reference based pricing is trying to achieve achieve. >> i know i if were looking for hip replacement i would want to talk to my friends. >> they're doing the due diligence on behalf of their members and their understanding that they quite frankly the outcomes are not teller different but the costs are thirty thousand to one hundred. >> so you would have a list of doctors that are are reasonable

price of good outcomes. >> i have to be familiar with that effort by cal vices they invited the university of california to participate when i had responsible for their health care programs it's not price dreeven it really was about quality and outcomes and what you did what they decided to do to find a network of providers that met those criteria and said okay. if you're a member we're no. you go to the other person you found through your friend if you wish but the reimbursement is not as much or you can do this and we have proves of boo outcome and quality that match the very same thing that the high permitted provider is providing at least in the

initial round they loud people to make a choice and tried to encourage folks through their physician network to go to the network they've identified for those procedures but if a person said i'm absolutely not comfortable with that they fixed the reference price as the reimbursement and you'll have to bear the resting for oourts if you disdecide to do it go ahead this is the reference price. >> so a list of doctors that were checked outer as a group. >> yeah. we're really talking about the concept and the concept - >> i understand the concept. >> and how it actually molesters. >> quite frankly our colleagues with blue shield might have a better way to articulate it by the concept of a facility of john meyer or whatever in terms of you go there or the list of

those ten facilities and we pay one hundred percent up to say $40,000 if you go outside which i did i have to deal with the additional costs it's a concept we're seeing it's been around no many, many years and seeing it come to the private health care market. >> to follow up the aspect which the facilities are provider are doing procedures on a repetitive basis their skill sets improve and it may seem counterintuitive to say it sounds like a meat factory only hips that's all they do but the quantify side can be strengthened you can say the same thing about the heart or organize transplants that's in

part the driver they looked at a lot of procedures in the network and began to look at outcomes and infection rates a variety of other measures and said okay. here's a subset of people that are doing well. >> again, i'm referencing this one study you know for purposes of demonstrating but when we see 1ik9 lower you know complication and sixth lower infections that is at least something to think about those are big areas so and dobd. >> i've actually been approached from a company called cast light enhanced in san francisco that does our pricing for you you our problem in san francisco is for example, if you're looking at orchestrating that he e.r. outpatient partial

knee surgery sometimes total all it out patient centers are owned by sutter there's no reference they all charge the same thing and i know we worked potentially ask blue shield to look at how much it costs for someone to drive to santa fe to get our collin option or nevada e.r. to get our total knee depending on where the locations of frequent high quality care at a lower costs i've not been convinced our members will be willing to drive more 20 minutes to have the same day surgery and you have to get out of san francisco

and alameda because there is a monopoly. >> so sutter oversees. >> they own every outpatient surgery center. >> and you may recall when i first came here they bought out the last two in san francisco and the cost of total knees in 35 to $55,000. >> so st. francis didn't do that. >> i'm talking about surgery centers it's not part of the hospital hospitals about do the same day surgery but a surgery center is much less expensive you're not he paying for the hospital. >> i had a friend that had a hip replacement at st. francis and went for hip x rays and he

went somewhere else. >> that makes the point. >> the variation cast light i know very well this organization because of the data they garner from the medical community is shockingly on a number of topics but we'll continue talking about it obviously in this area because of the location it's not the easiest concept unless there's another questions something else i want to comment on the vitamin d. >> i knew someone would ask that so i the my homework i'll submit it now. >> this is a big topic vitamin d. >> any other public comment on this item thank you very much

for your follow-up. >> public comment on this decision item if not we'll move to the next. >> item 14 decision report on 2018 excise tax. >> i'm tom. >> good afternoon. i'm here to present a deck on the affordable health care act in 2008 excise tax referred to as the cadillac tax as you tom spec speak directly into the microphone. >> we can't extend it up to you you're going to have to lean and the x kiss tax is one of the last big items interest the affordable health care act yet to be implemented so on slide 2 we've outlined the basic concepts of tax effective in 2008 a 40 percent x

kiss tax if premiums are above preset told her the excise tax will be passed into employers for their participant premiums are employer and prepretax under the cafe plan when we say premiums that are compared in the told her we mean the employer and employee he totally costs of the medical care the thresholds set in 2018 are 20 thousand for a single coverage increased inform 11 thousand plus for premedi-cal retirees like the police and firefighters the thresholds is 27 thousand in 2018 this is increased to thirty thousand plus for employees or

premedi-cal employees as well as prerisk progressions and family coverage on page 3 we include more nuances of those concepts so you you know a high-level is every dollars above 11 thousand for a single you're going to have to pay x kiss taxes the thresholds are to the price index this is a proton we know that medical trend is traditionally much higher so that in and of itself is representing there's taxes over time that's important for the board to be aware of as i mentioned the increased threshold for high-risk occupations and premeditatedly retirees so the previous slides we said health care premiums and the coverage is much more broad so