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 hundred in aggregate needs to be down in the 145 or one 90 i did not introduce we vp have an additional to the ucsf dignity house our colleagues from mp c that share a commitment i'm submit across the board we have achieved the goal of length i didn't stay down closer to the 4 rage and another reduction on the pharmacy side we've talked about jen ice cream we're 13 to - but we need to do that and as

ann marie said the subsets of patient that are very, very expensive if you shave 57 and 10 percent off by not achieving having a better clinic outcome and save thousands of dollars in the episodes of treatment those are the activities we'll put in place as i said the last 3 years have been a year of success across the board it is down 10 percent from we were a few years ago that is not down from an increase but an actual how many patient per population adjustorer had to be not limited to to the hospital our rate the er visit rates have gone up

dramatically it is a financial result we're not so proud of but we have to achieve those kinds of things to achieve that despite the flying costs of labor and drugs going up we think that is doable and those metrics are achieveable we've made those investments and we've talked about the ftes we need 5 more nurses wish or social workers and coordinators people people the phones than we had when we embarked on this 4 years ago we've made the investments we're not trying to drive up the cost but that has to be adhere quality but out of a lower costs that's our commitment we believe it is doable. >> i think you've done a very,

very good job in outlining the scope of the metrics needed i guess my question i will leave this to the board and staff to figure out a way to be recorded on periodically throughout the year to mark whatever the process is so as we come to this discussion next year we'll know the results of the things you've described today dr. hill. >> if i might the economics dr. las vegas vin talked about the economics of running a business as brown tom nolan and hill the investments we've made the only way for a pay back is under the economic taeshths we've set while meeting the quality goals so if we need a pragmatic do we have skin in the game we have

dramatic interests in achieving this goal along with maintaining the goals so the doctors can continue with the patient at least the interests are aligned and in right direction. >> commissioners, i asked the same question by my bosses those it is true for all of us in favor operations we get asked you know again, just like each of the provider partners hill has invested a tremendous amount of money both this investment where no expectation of making our future it was a chance to drive the innovation engine so we believe that we will as an organization reap the benefits and you know our patients will reap the benefits system wide we

feel good about making those are commitment our overall with brown and toland and hill the blue shield risks has gone up 10 percent or percent on the hillside a small 5 thousands went up dramatically this past year all right. we explicit hit target i got it and i promised to come back next year we've done better or are we're going to hit the altercate i'm not going to overseeing go on the record but we better continue the reason i feel okay about saying we're going to do better our folks are heading in the right direction despite the increase of risk we have a number of programs we've had out there for three and four years and programs for one year

their maturing and taking time to mature i feel good about what we've done i get this is big finance and for the city and county you've been got a lot on the line we'll deliver. >> okay. thank you i'll open up for the other members. >> there their is a best practice it generally requires 15 percent of the health care premium being invested this is primarily focused on the sickest patients with 25 percent of the sickest patients it is the programs their describing but it is also way more importantly than any of the programs to have a fabric you're seeing the

juxtaposetion once that happens they built the fabric one and one and one is way more than 3 but specifically as a thought leader we're working with both groups specifically to look at the various component and helping them to repurpose the dollars for additional dollars of investment to make sure that fabric is getting to goal it generally takes a 3 year goal for on a investment of hospital visits and health care visits and medical homes and you'll that stuff but they have to work together and if you have anyone separately richard and keri are right we are committed at a health plan as providers to

insure there's a fabric this year implemented as a totality of the integrated services that produce the challenges that has been done in other situations that really makes that work a what we can do is help keep you informed of the process on the building of a frafb that is predictability on the outcomes and has a track record and replicated that is something we'll stand behind and give you that predicted value you're looking for. >> we look forward to this and quarterly reporting would be my mark in the sand to go forward i'll open it up to the other commissioners are there other questions. >> you mentioned our emergency room costs went down. >> i specific mentioned the emergency room visit rate has

gone down. >> what do you attribute that to. >> the outpatient are chronic diseases so they don't destabilize they're managed and stable and successful at home co p best recollection that you recall marijuana patient heart failure patient through deities or other issues kind of fall off the wagon and have major health issues not only nurses but the behavorial interventions to help them stay on the path. >> what about urgent care. >> it's been up frankly of the city and county population not as much as the population overall so we're puzzled by that. >> how do you find them you a

in addition to our general marketing and have a good feedback that people are seeing we're excited and having the notes of assess that have's not think available since the looking at the numbers we haven't seen the volume hit enough to explain the e.r. impact we need to see more people using that note of as opposed to e.r.s and other sites. >> commissioner lim. >> i think the gentleman made a good point spoke about the value for about the value of health care and i think this is where i'd like us to go and i'm very much

commented to aco and much more than just increase in costs we're looking at the value and quality of patient care and that's i think everybody could go that way it would be helpful now i i understand we're it takes 3 years to be able to mulch on the aco but presuming some of the costs are maturing and now because of the coordination of care we are able to get more discover more of some of the patient that needs more care i'd like to know is because a lot of our members wouldn't know the value until we have metrics during the last year or two and

looking at the outcome how many visits have we provided and if you could tell the value we're getting about the aco and metrics on drugs and pharmaceutical visits so we know that e.r. visits went down we are looking at some hard facts we can say yes, it is working and this is the things you're the members and us the board it is to see how it's working and some kind of metrics. >> commissioner that would be some kind of trend within the aco environment to wherewith he started to where we are i know you cannot do it on every area but in some of the areas like the er admissions and the stay

especially drugs so we're able to do as commissioner lim said over time this is the rate of return. >> absolutely not only do you need it but deserve it and some of the data when you look at it maybe not hollering obviously for example, as you reduce admissions to add a certainly point your stay will be up not 4.8 but 3s and reduce admissions from thirty to 40 from 2.3 to 3.3 but you'll see the dynamics i know that richard has implemented a home care program tweaks i saw the data so we will bring that result that can show

you trends of each of the programs to our point karen and as far as e.r. visits it is way more than that it is the sees and more the preserved assess to the patients will somebody answer a phone or doctors have cell phones or call 9-1-1 to the complexities you're asking and demand. >> and we'll be able to start to produce data on each of the programs their implementing what is more interesting what brown and toll has a system of care rather than the pieces that's our obligation to give you a system of care. >> did that answer our question. >> any other points? >> so it might be related to this i'm saying a 5 percent increase how - and yes, sir.

that's absolutely correct thank you all for your questions we're back to the final stages every item 3 yes, sir. their estimate to go up by - >> so it is now addressed now to how much of this 5 percent patient and plus dr. >> wait, wait you're seeing to page 8 oh, and page 8 of the presentation. >> yes, sir. back to our question i got a little bit confused. >> you're saying 4.7 i think that is more but the pharmacies is 8 percent and i think some of those are attributable to the speciality jobs and

pharmaceuticals and 5 percent that's the reason i ask that when you go to the doctors their complaining and brown and toland they're saying there's an increase. >> the projected capitation rate for 2016 is 5 percentage higher than than the experienced capitation rate of january and 2014 - february 2014 and january 2015 so actually a 23 month trend number i'm getting a number it averages 2 and a half percent per year. >> i thought a visit to brown and toland doctors are complaining their increasing the premium but the fees are going

down so out of the 5 percent is there a flow it there an increase for those would go to the doctors to the physicians? >> the complication but certainly from a brown standpoint we were flat but our rates to the physicians are kind of complicated some are cap television stations and some are fee schedules no one have gone down. >> primary physicians has gone up as overall utilization the fee schedule to specialists or case rates has been flat for the last two years and some cases slightly up and the volumes are slightly up so the total dollars spent has gone down and enabled

us to put more money towards primary care that is part of our primary care doctors their struggling so we have put more there but better management on other spots. >> thank you any other questions please wrap this up. >> okay with all being said and the fact we've talked about the challenging the aco to hit the claims target when is a number they've agreed to for 2015 and 16 we got an agreement from all of them the number we set not the same numbers you discussed those numbers they'll hold for those for two years that's a strong commitment all of that i'd like to make a recommendation you approve the increase in the rates between

2015 to 2016 by 11 one half percent. >> the chair will entertain. >> this is not the final rate or sort of. >> it is very close to the finally. >> but you'll giving us give us a final. >> yes. i'll core share any changes yes. >> next month it has the full standard. >> the fluctuation piece. >> yes. >> the chair is willing to entertain a motion. >> i want to approve the motion for 2016 it is for the updates. >> second. >> is there a second. >> it's been improperly moved

and seconded any comment from the board any comment or observations from the public? >> good evening commissioners, i want to. >> and you are, sir and r0ishd rothman i want to talk about page 5 large claims that was not discussed on this 4 i think we you know i'd like to see more detail in how much those costs and whether i know there is high pressure 0 laws those claims have been reviewed by a on hewitt or the h ss staff and what manufacture to be prevented from causing those large claims awhile most the presentation was sort of abstract only one talking about actual cases those are for those are it out liars

that drive up the costs what can we do or what can the contractors do wluld and the others to prevent it out liars if it is confident information it should be shared with the staff or board in closed session so we know what is to prevent those large claims and how much was the total i don't think this is secret i want to know more information about the large claims that wouldn't violate the high pressure to rules thank you. >> claire representing the sciu retirees i'm sorry sciu explicit is have the necessarily 83 formula the

number of active employees can we have figures with regard to how those will fact the sciu members and, yes, i would direct you to wait before you accept those rates to see the rates overhead for each of the specific categories before you accept the rates being proposed thank you. >> all right. if i think i want to be sure claire if you would pause i understand you couldn't say i want to be sure i heard what you're requesting we do if indeed i was miss representing it your request we at least identify the demographics by active and retiree? yes >> yes. >> the component and the

different formula for sciu. >> yes. >> all right. all right. so i'll turn to the executive director and maybe she can assist with the classification. >> executive director sciu has one hundred and 93 i'm sorry 96. >> repeat that. >> the employer picks up 96 of the rate for sciu the rates are for the majority of our active members which are at 93 percent so the constitutional rate itself by paid by the employee will be lower at 11 and a half percent. >> for sciu. >> for sciu so 96 one hundred and 9683 so the employee plus one is 96 percent and employee plus 2 or more is 83 percent so

the employee is exactly the same but sciu gets a better deal on that the other pieces. >> all right. is this adequate. >> all right. thank you other members of the public please identify yourselves. >> i'm henry better wiener city retiree i have a provacative question and i think it's been explored how much process doesn't blue shield make how much do the ceo's and the chufs make as the profits have gone up this is a valid question to ask you may raise the rates but what you know you talk about costs either you know there's a question of the profit and i want to see their financial report as compensation that the choses get i don't know how

relevant that is. >> i'll ask you to defer the question we've asked the members of the blue shield to come to respond to specific events in the tax status and have an opportunity to discuss this later and i didn't mean to be tense. >> you said that was a provacative question i appreciate the fact you introduced it thank you. >> all right. are there any other public comment are we ready to vote i believe we are all opposed by the same sign. >> i. >> all opposed by the same sign and we'll it is so ordered we'll now move to item 4. >> the deltastabilization. >> as we're getting to this item i thank all the represented

we'll be in touch i can assure you. >> okay as a matter of policy we have claim stabilization for flex fund we have it for the city plan and now we have established as of the last vote on policy to do it for the adult dental e po plan that is self-insured. >> just for a context i'm harder sorry but one of our active citizens that focuses on dental issues is not here today iuoe i hope he will adapting to look at this portion of the discussion important future reference but broadly speaking we spent $45 million on dental benefits here in the city and county of san francisco it's not an urban important question so, please continue.

>> $45 million for the self-fund ppo which guess 27 thousand of those vast group of people we're talking about underneath this board and the trust okay. so what are we talking about - >> we're doing the same thing so this is a standard exercise we go through where this applies we review the data and turns out we generated $3 million on page $23 million $$23,800,000 plus we need to amortize this over 3 years if we do exactly as we're charged to do this amortization comes to one million dollars plus for 2016 for the self-funded program and to cut to the chase i'd like to make a recommendation that

you approve the additional reduction in the rates because of the requirements of the health services of reducing the rates by one million dollars plus in 2016. >> all right. you've heard the recommendation are there questions. >> so this is the firefighter through the chair it will be having the affordability utilization. >> yes, sir. >> we don't want to put the $3 million as a reduction in one year. >> is ample. ly appointment we've done the pay as you go and now decided to get back to the basics of our requirements doing this correctly. >> chair will taken a motion. >> i move that we accept actuaries recommendation. >> is there a second.

>> there is a second are there any questions or discussions any public comment. >> is there any. is there any public comment hearing none we're ready to go to a vote all opposed by the same sign all opposed by the same sign so it is approved >> fantastic. >> item. >> item 5 action item approval 2016 delta dental renewable for all plans. >> okay. i'm ready to go item 5 you have in your packet a nicely scripted document it outlines the 6 plans offered by the health services for