this population hert disease diabetes that would be something you want to incorporate into your design going forward >> it's a good point i would add that when they're paying 80% of the bill doing disease management when actually cms ends up getting the benefit of that work it's not cost effective for us with the active population in the aco work we do that doesn't apply here we have seen really good work er emissions down and length of

stays down to the point it's bleeding over to the plan we're getting the benefit of medicare reimbursement which is the lowest reimbursement payer they're the lowest cost payer we know or virtually the lowest if the units go up that's where the intersection will be in the future >> it's a point to be monitored i want to put a pin on it director dodd? >> that is sort of my question this could definitely change the rates in the future and the rates you presently have now are just a little bit under what your present mapd rate is in our past history has not been good with this field the only time you brought your rates down with rfp and the next time they went up double digits this could be lower with the intention of next

year skyrocketing that say big concern with me. i think it should be everybody here you don't have the long memory i have on the board. so we have a lot of ups and downs with the blue shield and double digits with pressure i don't see how that's going to change. which brings me to the point will there be more transparency in this >> director dodd? >> i will add this will greatly increase transparency because we won't be trying to eek out information suter will have to accept what medicare pays right now suter gets more than what medicare pays, that is one of

the places we will see our costs remain lower because we're not paying the high hospital costs and we will also get the bill and diagnosis that is something that is completely unavailable to us now it will increase transparency because we will be paying the bills >> that is a big plus for me otherwise i don't see anything with your history really going up high next year. >> yeah a couple of points. i think our initial renewal which is double dujts was a status quo renewal was us looking at again within the medicare advantage plan there is different revenue streams there is medicare star ratings revenue risk adjustment revenue egg whip revenue all of that is subject to change from any given year there is less transparency than

simply saying the paid claims data with the medicare cob program for the record when we went from our initial to revised renewal for the status quo option there is some -- there was contract negotiations which i'm not as liberty to share to get us to the lowest point we can cut our rate by 17%. so i just want to make that clear we take it back to the drawing board and back to the providers and look for an alternative arrangement >> this board will continue as you know to monitor premium rate increases formally and informally by you folks we took a very public position as you were undergoing your negotiations with suter you were kind enough to come and explain your positions to us we were

more than sympathetic i'm not talking about quid pro quo but i'm saying the fact that premium rates continue to be triple what the rate of medical inflation is is a worry som issues as commissioner breslin pointed out during my tenure here that that has happened we're not expecting that return of state of affairs >> yeah i speak frequently with aon hewitt we understand the ongoing rates and the liability we understand that is critically important >> thank you. >> one more thing i wanted to mention. with the same situation i brought up with unitedhealthcare. to do diligence we should have an rfp to see what else is

really out there of course then your rates would really come down that is my thought again. >> i thought we addressed last meeting that would be activity considered in the next cycle >> yes. >> all right. are there any more questions from the board? >> thank you. >> is there any public comment? oh, yes. all right. as you approach to make public comment we ask that you identify yourself and then confine yourself to the time a lotted which is three minutes. yes? >> good afternoon my name is stephanie moman the vice president of contracting care with brown and toll physicians here in san francisco 3800 of the san francisco medicare eligible retirees are enrolled

in the blue shield 65 medicare program each of these retirees has a relationship with a brown and toll doctor as a primary care physician the options presented to you all have advantages and disadvantages as you have seen. i would like to highlight one of the important advantages of remaining status quo with the current plan specifically the shield 65 option the slide pointed this out as care management delegated to the medical group this is a coordinated care to the activities of brown and toll medical group our care of social workers medical director and staff come together with one goal in mind to present the right care at the right time to the patients we serve we believe in the value of providing

coordination among all health care provisors doctors hospitals others health care providers in the city to make sure the patients gets right care at the right time. at the center is the physician who understand's his or her patient's needs and gets what he or she needs being referred to the right specialist. being enrolled in the right brown and toll management support this primary care doctor's role is to not only take care of the illness to help with medical errors drug interactions unnecessary tes tests and hospitalization when everybody works together like brown and toll hospitalized and improved quality of life with those with serious chronic

conditions we urge the health service board to consider how losing this care coordination will effect your retirees brown and toll physicians will still care for your enrollees through the alternative plans that were presents it's important to know that none of these care options have allows us to do what we have been doing for eligible care members so our doctors can receive the support that he need to continue to do what they do best for the medical care for their patients thank you. >> thank you. >> how many people did you were in your -- >> over 3800 >> thank you. >> dennis kkruger active and retired firefighters i'm dismaid

that a caveat of this plan there are no further plans to go to san mateo for medical care for blue shield if you take this plan you can use the other system but if you stay with the old plan we don't plan to go down there and do any more work. seeing how there is a number of people that live on the peninsula i find that discouraging second of all they're dealing with the same population the few people i talk to the first question that is asked is will i still be able to keep my silver sneakers with this plan even though it's the same population in the same area pretty much in the same demographics that portion is not provided for in this new plan. i think that would be one thing that would be an advantage to the plan if they did offer that. if we go that way.

but i'm still sad if we don't go that way they're not going to go any further into san mateo county seeking better care down there >> thank you very much for your comment is there other public comment? yes? >> hello good afternoon my name is fiona wilson a physician. and chained at usc f primary care physician my current role is a chief medical information at brown and toll and three patient medical home here in san francisco california i posted a question what was the city of san francisco want? three things a healthy retiree population you want to spent less taxpayer doctors and better

outcomes for the patients and member i suggest getting those outcomes does not include letters from hmo to ppo in order to leverage the services that are built and serving your retirees well the model of coordinated and dedicated care to support better patient outcomes does provide affordability provider over site and infrastructure social work tools for assisten physicians for the health care doctor which is it's from ancillary pricing and choice to genetic care and alternative all of these help serve the patient better in the community senior patients obviously there is a great range what it means to be a senior patient many have complex

clinical issues and coordinates planning for complex patients with a seemless hand off back to the primary care discharge -- this contributes to the length of stay and less bed days that you all are paying for i urge the health care board to consider to promote the blue shield 65 + program because it provides for a wide number of seniors and health care providers thank you. >> thank you very much for your comment is there other public comment? >> carin representing rccsf in looking at all of the materials it's difficult to make decisions i appreciate the questions brought up by commissioner

breslin and commissioner scott if you look at plane dollars and cents it looks like this is the way to look when you look at what is lost here the case management and prevention services i dismaid to hear that basically the comment was it's sort of -- what was it? it's not cost effective to not provide case management that is clearly a business decision and somehow it's cost effective for kaiser and it's clearly cost epektive for uhc to offer that in their plans i'm dismaid,this is why blue shield lost their nonprofit status because they're looking at the bottom line that is a slam at blue shield my apologies these are the ill things that irk a lot of us i think we have to look at what is best for the members overall i

like the idea that it's an expansive network i think a lot of our retirees do to allow for opportunity to access providers to move out of the basic service areas i they that say plus if you look at the bigger picture of what the services are ib colluding the loss of something like silver sneaker it sounds like a little thing but it impacts a lot of people. i think maybe this say little premature and look at it perhaps if blue shield will go back with their blue pencils and refigure this and think about what they want to come back with down the road there is a way we can see it for the fufrpture now we have the disadvantages outweighs the seemingly obvious advantages

it's right on the fine line it's a difficult decisions our members, he -- we will cope with it either way and the others have the same deal if you are talking about competition. thank you very much >> thank for your comment is there other public comment? >> i'm herbert winer i'm thoroughly confused by all of this i'm well med by it i think i will have to run out and see my primary physician after that one thing i do like if i'm correct i can cross over to any physician in the city like say if i have a primary care concern if i'm with brown and tollen right now i can see my former physician with the hill medical group i can see him i have that

portability that say good thing i will state that one problem with primary physicians is they do have their own networks they have their own networks of preferred physicians some of them don't work out as well i have had that experience with my recent problem of nerve pain hi to go through so many physicians to localize what was wrong with me. there are those advantages and disadvantages i like the idea of preventive care and i think that's very important because that is cost-effective all across the board. you don't want to have to wind up in surgery for something that could have been prevented early in the game i think that is extremely important i like the idea with brown and tollen right now i get a free medical exam a year where they can identify the problem that is all to the good

of everyone including brown and tollin they won't have to make an extraordinary surgical expense. if i'm correct right now i have enough portability where i can see any physician as long as they cake medicare that is throughout the country that works to my advantage the only disadvantage is i better go to the social security and get my medicare card and going through that bureau okayty is extremely traumatic thank you from your audience >> thank you is there other public comment? director dodd? >> i just wanted to make sure we read into the record the two e-mails that came to the commission secretary >> yes we have had e-mails that come to my attention not only from this most recent forum we conducted but the earlier one. for members for these two

explicitly supporting the national ppo for blue shield if you could approach again one more time paul i would like to ask a question about silver sneakers i caught your point on clinical management tell me about why silver sneakers is not included in this process? if it's not this year would it be in an ensuing year? >> possibly i would have to go back to talk to our product team. it is packaged with our medicare advantage program. it's packaged with our existing plan but the supplement to medicare we don't typically package that discount program but we can certainly take that back it is a discount program i don't know -- >> you got some aid coming >> thank you. just in the nick of time. >> yes, sir? would you please

reidentify your >> charles lee with medicare product one of the reasons silver sneakers was not packaged with this proposal due to the timeliness of the proposal and try to sharpen our pencil and be responsive to the needs of the city. technically silver sneakers is bundled with the medicare advantage project. ppd 65 + so it's beyond the traditional service model for the silver sneakers model product which is a free membership for the folks on the medicare advantage plan. >> well your specialization in framing these products according to your statements is to try to mitigate risk as much as possible? yes. so i think the people engaging

in gym might be ship and so forth would be in line with the product and medical outcome my great hope is you will take a second look at this in the next cycle >> i appreciate that that is definitely something we understand as well. so if this product is chosen certainly that would be under serious consideration for next year as well. >> thank you. is there further public comment? this is a discussion item. so we will move now to the next item. >> chair i'm going to extent a curtesy. >> sorry dennis cruger active and retiree firefighters to have

2-3 cards to present when you could easily put it all on one card i think is one more thing that should be considered >> all right. thank you. okay. we're now ready to move to the next item. >> you want the read? >> yes we were on aye time four which is a discussion item now we're going to item five. >> okay. item five action aye time approve blue shield fully-insured 65 plus group medicare advantage prescription drug plan and the blue shield access plus medicare coordination of benefits premiums and contributions for

the 2016 plan year or approve blue shield fully-insured national ppo for medicare retiree premiums and contribution for 2016 plan year aon hewitt >> just so we're clear we're going to see two sets of rate information i don't want anybody to be confused the action will be to move to adopt one of them we can't adopt them both it's one or the other if you make a clear demarcation as to when you are presenting one item or one set of rates or one plan versus the other so folks reviewing this in the future will know what we're doing so we're looking at both rates at the same time but we're going to vote on one or the other okay? >> okay aon hewitt actuary asc excuse me i have a bit of a

voice issue this presentation is blue shield fully ensured renewal for medicare retirees i will turn you to page three executive summary it starts on the second bullet point by saying the present gdp 65 plus combine rate it's two programs combined. is 37856. they have now quoted that rate for an e-only to be 36842 then we have another card which is the national ppo which will be the second set of rate cards their rate is 36512. with that being stated i ask you to turn to page four. page four is the present final rate offer by blue shield for the existing status quo program

discussed in the prior presentation. so if you look at it the rates are always inclusive of the vision rate in the stability fee these are the numbers on page four if you look at the bottom it shows you the number has gone down slightly from 2015 -- excuse me that being said here are the numbers with the footnotes you go to page five it giveses you standard comparison for the disht -- differentials for the employer, and employee this is the existing plans with the limited and networks that do not have the advantaged program there is nol going on for mills people that being said that is rate card number one. status quo. rate card number two is on page

six. it is slightly cheaper and as was brought to the attention of the board why do we have this in the first place? just as a matter of information only. when we received the first quote for the mapd it was much higher than the final quote which is provided here. and when they noticed what is going on as far as competition with the inclusion of the program for united health care they brought the number down so we don't have to discuss the lack there of of that i wanted you to know this is a process i did not -- they said can we offer you something else so they offered national ppo which is full access to full ppo doctors around the state and the country just as an actuary respect to the board why is this cheaper when you have something that is a smaller network and more

highly managed? that is usually not the case for the programs they're more expensive than advantage programs you have the optimum program that brought the highest level of management with the limited network with the limit of egg whip our drug benefit that has lowered the cost so much when you couple that with the piece the medicare pays and what you have to support medicare primary your secondary what that has does is lowered the structure where it's highly competitive in the marketplace that is the general reason why this is cheaper. with that being said on page seven is our standard comparison. this is compared you know actually against the national ppo versus the standard program that we now have. just a range for you that is slightly cheaper in the appendix

we have an example in the appendix if you don't mind turning to there we compare it to the existing program just to give you differentials on page nine >> in case board members desperately looking for the rates it's under four it should have been under five >> it's coupled to the back of the blue shield presentation. >> i understand now everybody has found their spot there is no desperation >> i don't know if you have time to review the rate cards as you can see this is an interesting decision because the numbers are similar one is slightly higher brought down as my colleague mr. brown shared through final negotiations the other one is price to market they're close one has it's virtues the others

is it's management it's the full discretion of the board to make a decision i have no recommendation but you have to vote for one or the other okay i'm done. >> thank you. are there questions or comments from the board at this point? >> my only interest in this new plan was the broader network for some people but our members now have the option of going to the unitedhealthcare national ppo plan so i don't find that a compelling reason to vote for this with all of the other issues i brought up and any of theish you ewes the members brought up. that is my comment >> that is your comment. all right. >> go ahead. >> commissior sass? >> number one it's an interesting situation we have to

make a choice between one plan and the other with the city plan continuing to be offered along with the ppo option it's a much easier decision to make everybody has a choice of which plan to stay with in the case of blue shield it's an either/or choice we go with case management and primary care physician and coordination of specialty referrals very suss a ppo plan that doesn't offer that kind of coordination. i don't think price is really the significant issue here they're so close i don't consider that to be particularly relevant the cost of the two are so similar. we need to think about the needs of the retirees. there are some retirees that are in good health travel a lot travel nationally travel internationally but certainly travel nationally they'r