last month that the pharmacy costs of speciality drugs specific to the period went up 21 percent in the record what are you going to do that pharmacy costs and fourth your long term strategy and fifth the big take away how commented are we with those 5 questions i'd like to call up to the podium mr. richard fist. >> as they approach the podium were those questions shared in advance. >> we're one hundred percent transparent and rigorous. >> thank you good afternoon. i'm richard thanks for having me do you want me to hit all 5? >> do your thing. >> how committed are you.

>> if you don't mind can i do them in a little bit of resources order and on a couple of them examinations for 2015 indulge you to have our head of the program the people speak to those with me i think your commitment to this as you've heard me over the years we're all in we building in foich /* fif and the uniqueness of the patients with us the main thing for us as we go to things we'll do next i'll work my way up to the questions we've had good success are activities you've heard me described impacting the managing disease and applications more

effectively we've shown a trend a significant reduction we've shown increase in excuse me. a daers if e.r. patient are better managed and shown increase in genetic compliance on the pharmacy side and next move to other sites of care more inches for the board burner activity to continue and double down and continue to do those are things but increase those are working with our hospital partners i believe i've speaking for both but working with the hospital partners on the stay there is the admission rates and the stay at the hospital part of what we've seen in 2014 that drove the numbers was a higher number of can have tropic patient cases

and it only takes a few to make a dramatic shift in the numbers we're not happy with the 11 percent increase we want to see it closer to three or four but that's our success with blue shield to achieve and make this program successful along those looirngz undermines a patient experience we've increase the access to after hours care so people don't have to go to the e.r. in the city we've partnered with folks coming out of the hospital partnering are walgreens and to make sure that people have the prescriptions in hand and have the prescription not having to pick up them up and not to be boring this is what makes a difference in having the patients that need the more

expensive care versus the well management of them in the facility i'll ask the inadolescence of ann to talk about the things we're looking to do the subsets of the population but the populations we believe we'll insure we hit those numbers awhile improving the quality of the patients health care. >> thanks richard ann marie for brown and i've been terribly alone and forgotten in manhattan i'm here to talk about the program the question how it is impacting the quality costs and patient experience my answer to those questions have through care management brown and i've been terribly alone and forgotten in manhattan has hired the corridors to help them understand their medications and identify symptoms and manage their

disease their - the patient can call the number one way we get patient into our program is following an event an emergency room visit or stay we have a route call we make to the folks after discharge or an emergency visit and often can identify small problems if we identify bigger problems we move them into the case management program and that program we coordinate the care with the physicians and do a lot of teaching and help the patient manage their disease and void costing admissions i'm going to bring up an example of a member urging a member named mar not a real name but a patient in the city and county

of san francisco maria 64-year-old woman that went to the emergency room and one of our care coordinators called her and she went to the emergency room following a car accident when emily called her 33 she was very upset and in a lot of pain and a laundry list of conditions not management well emily recognized she needed a higher level of care so she talked to inning gay was able to assess her medical records through our electronic medical system and can you the recommendations for care that come out of that intrrm visit but all the other medical issues inga worked with mar to get the appointment and got to attend those appointments

cooperated with the physician to make sure that mary understood the instructions did she know what to do with the medications they talked with mary weekly and coached her through her ienth and teaching her about her medical conditions it's been 6 months and mary has not returned to the emergency room and pain free this is an example how we can affect quality and costs we voided we made sure her care was well coordinated and voided costing admissions we're proud of our program. >> thank you just a request about the future a couple of programs we've developed a home visit program a team of practitioners and nurses

that deliver medical care inside of patients home if they're fragile they get x rays and lab services we cooperate with the physicians another quality that we're working on for 2014 is many patient who go out of the hospital go to skilled nursing facilities those facilities have a couple of issues they have a high rate of return to the acute hospitals and sometimes their length of stay is longer than it needs to be and costing and also the communication with physicians that are going to care for those folks once out of the long hospitalization we've partnered with the physician that are working in the nursing homes and hope to effect those are outcomes in 2015. >> all right. thank you. >> thank you.

>> sure happy to talk about pharmacy pharmacy is very excited in 2014 we participated with blue shield and have hired a pharmacy i thought at brown and toland they've been working on the programs to make sure we're maximum missing the program but looking at those high costs drugs and seeing if we can make changes. >> and that group of drugs is called what speciality drugs. >> some are bio logics. >> so jim looked at them and identified 4 cases in the month of march that involved things the direct was ordering the drugs and rounding up the doctor looked did patient and made adjustments are the patient wealthy and made a smaller dozen

he looked at 4 cases and he just for the month of march and estimates tweaking getting the same amount of drugs saving an annual cost of $36,000 >> we had him looked at those were for the city and county of san francisco employees we deal with employees and your retirees many of the programs frankly are more geared to the retirees and heart disease like the home visit program but we have to do all of that and lastly on the pharmacy general the risk associated with the patient population that brown and toland is take care of it is pretty high and you've heard me make a plea to consider your contribution strategy tied to

the risk of the population we're serving so the financial comparisons are balanced and i do think the speciality pharmacy is american people area that is a perfect example of that wonderful treatment we can do for patience are hepatitis c and aids but a few more pool population can make a difference in the cost analysis to a plea i can't help but make the plea i'll hand to jerry. >> thank you. >> thank you it's a pleasure to be back terry hill vice president at hill physicians let me start with commitment can i do that and here with me are people from both uc and dignity

health dr. kevin if you can stand up from ucsf and others and one from dignity health they've authorized me short lease to say their one hundred percent committed to continuing this effort i would remind the group katherine mentioned a few minutes is it fair to say several years ago it was birth analytic in july 4th years and i can't commend this board enough for its long term commitment to this it takes time for the efforts to mature we're happy to being on all cylinder and the benefit of the entire

population i have to say personally that is a real personal commitment i went to school at ucsf it was a city and county employee for a number of years i would like to see san francisco on the cutting-edge of the policy in the country that's the commitment piece we're in that for the longs haul we've invested a lot of open the brown and toland and ucsf side and will continue to make the investments as to what let me just say 2014 was a great year for us on our side of the picture again, the ucsf hillside of the blue shield partnership we had richard mentioned issues are catastrophic a small

population roughly 5 thousand patient we had a couple of bad winter in a row i had to stand up here and talk about a few bad long stayed and destroyed our finances for the year fortunately, we doesn't get hit with the bad luck and the programs are maturing we saw decreases utilization and ed visits decreased in 2014 and in fairly robust ways i'm happy about them. >> we also actually continued to focus on quality and i think our quality interventions into both in the ucsf clinics and for the patients seen physicians in the communities have been robust over the last year and once the scores for 2014 come in we're

going to see significant improvements we also on the outpatient side focused on patient experiences one of our interventions is successful having years like case management follow patient through the hospital stay and then follow them telling phonetically afterward and extend that program into the nursing skilled facilities and been quite successful we've dloiltd a fairly large interest group of pharmacy i was over the term of the program and those i'll come back to the pharmacy costs but the interventions that the pharmacies make excluding include medication management genetic but also closings gaps of care so pharmacy itself

reaching out to patient pharmacy i was and nurses both quite effective but we our pharmacy i was to get their screening, etc. in addition to medication adherence and medication management let me just mention that you know we've done a lot of things we sort of knew we had to go anyway that 4 year effort has put a speciality on for us a small population and yet it has been our keg for the innovation creativity but i do have to give ucsf credit in its clinics they've going up and down done heavy lifting findings of the years and have all their

patients certified this is an enormous amount of work and building on that we very narrative teams within those clinics with highly trained let me use lingo here r s p smart people not licensed but who are very highly trained and integrated with the clinics and the patients love them so i can't be more tickled than that with our hillside practices we've wrapped services around the practices but now have patient and advisors and pharmacy i was and case martin luthern king, jr. we're dogging those around quality and experience so we're happy with that coming up we feel pretty good we struggled around behavorial

health, i you know it is a campfire out to open tim it has come we put up - >> you know this is why we have people in the audience actually they've been more cooperative. >> this is on the public record. >> thank you, commissioner and i feel okay about that. >> it's fine (laughter). >> it's like uncracking an egg. >> what we've done on the providers side has been focused trying to focus attention on the health care providers in those groups who we had a list of that are available to be responsive to the primary care physicians

and developed two source of behavior therapy which against my i think stinks is incredibly effective so on the hillside we've made that available on our website to the hill patient and ma glen on the blue shield side this is part of what will give us traction to hit our numbers in the future focusing on behavorial health and those are intensive strategies lemon close by saying i you know and by the way, dr. did a great job talking about case management we have an obligation to do let me something on the

table about pharmacy we nail jen ice cream and good at medication management and preauthorize the more expensive drugs and it's been in a rigorous way and we monitor adherence this is all well and good implementing from the experience those this last year the drug that i'm is existing and terrifying i have friends that are alive because of the bio logics and clinton their exciting but we as a country do not have our arms around cost control for those drugs and that's true for every simple system in the country there is a lot of conversations i think we need to work on a

strategy we can do those tactics all day long and get creamed only pharmacy costs. >> thank you, dr. if you'll remain and doctor please come back some of the questions are going to be joint. >> i believe that dr. shoourt lee vin has a couple comments. >> that's fine. >> thank you for having me i'll be much broefr. >> who you are. >> dr. levine the chief financial officer of blue shield i'm privileged to speak you than i was at the white house last week i'm here to talk about health care transformation

someone i spoke with obama and a lot of people task force including rick who was the head of c ii i want to thank katherine doing the right thing i met three or four years ago awhile driving her to the airport it is how i side health care as an opportunity for the united states and other people have been partners some of the things i wanted to speak to was the importance of not blue shield as an insurance agency but as a force and con glom factor around health care transformation when we look at what is happening with health care our kids and grandkids will not have a health care system we have to make that better and cheaper if

we don't do this now is it so our last chap anticipate hopefully the role we at blue shield have helped to put together not only the great work by the folks here but all the medical groups in california what those best practices are and use this place as a that he hady dish for transformation san francisco being extraordinarily special place that can embrace the people to do things differently in city and county of san francisco for the transformation we do a lot of things not terribly fantastic we don't pass the time we work in so silos we don't moot the patient where they are they come to us we have pcm h or so rather than a patient in a medical home

you figure out a way to give them if you smoke cigarettes i don't wag my finger another you i try to figure out why you want to how to stop smoking we want to be the fabric this is not about blue shield but us as citizens and physicians to work together to make a difference to change how we look at things not just trends or dollars but actually make a difference if looks at the - if the united states could trim 1/3rd of health dollars if we got all the economics out of the system and what you're doing through this program is allowing the system

to be molted across the walls abused those hospital and decreasing walls and insurance walls to continue to not only do better than c pi but continue it transformation that is an example across wisconsin they have a program where ever we can personally person onion every street is responsible for that better health care programs 86 percent that have a plan 3 and a half percent of people die in hospitals what you're doing as citizens and rep citizens of san francisco and collaboration with us as he hospitals and the health plan to allow us to meet patient in different places the care transformation they're talking about home care programs and high-risk clinics it is

getting away from systems being run by doctor no and into systems by doctor yes and spending the time to talk with them and lay hands on them not only test this transformation takes a long time not only do doctors but you as citizens and representatives of the citizens as well as the constituents we are looking for the partnership that katherine embodies to and say here's it becomes of the united states into a system of care as traditional providers we hope you'll stand behind us to be partners to help us look at the future to make a difference in ways we've talked about today

and hopefully engage in an ongoing dialog to make a difference. >> so if you would stand by you may be called back but the represented from brown and toland come forward i'm a bit swept away by the as permissible message but after all us are concerned we'll be in sustainable investment and sustainability looks at past the next year and the outcomes and i would like to have some recognize of the fact that we have certain risk targets we try to meet month to month and the recorded shows me we've not done

that this year i wanted to acknowledge one we need to work on number one and my profound question how do we get closer to the risk targets as we going forward the facts are we have taken an innovative step i don't sense anyone willing to back up from it we know this is a long-term relationship and the integration of our services and outcome the things you do are 3r0u67b8d new with new things it takes investment and i'll daresay the past 3 years have a level of investment expectation of concern i know there are risk factor we had a risk targeted target for brown and toland for

$516.75 on a per member per month basis we have exceeded that target every month during the past calendar year by 50 bucks it's sustainable and in the case of physically that was $29 plus and we have exceeded that by thirty bucks or more a month and that is sustainable this is not possibility change we say per member per month and multiply that is something on a month to month base it is an operational question how to layer focus and get closer to the mark this coming -

>> that's the next question, i think we addressed some of that earlier i attempted to insurance risk with the high concentrations some of the 2012 we were significantly blow we have four of those cases if we acknowledge that we're going always going to see that having said that, we're going to manage those and manage the overall care the headwinds are not going away we're phasing every one the doctors will have their rent tripled the the overhead money spent needs to be reduced we are going to use metrics to have the bed moved from the low 2