a comment most plan passports about two-thirds have the x us tax in 2018 irrespective of public or private segment the real issue for the plan supports in general another huge area especially we feel it from the bay area around the venture capital and the health technology i think about impact not only health insurance but how the employers delivers the benefits and we as consumers use health care that is an area we can't ignore the other piece is around the changing would it be fair to say we think again 2020 we have 5 different generation in of the would it be fair to say that's across the board so the value proposition for the different generation is very

different we know the millennials is coming into our workforce the expectation of the employers and what they expect under the benefits package is different the employees are thinking about what that means for benefits and what their value is to the employees and the other changing would it be fair to say factors we need to consider about the benefits the fact that we'll be the majority in the workforce as well as much broader ethnicity within the population so right now 18 percent of our population of different ethnicity growing to 37 percent by 2020 how do side that impact our benefits to the organization and then we'll got the access to public exchanges and as large employers have ceasing access to say those vehicles it changes the values and proposition as now we talked to our clients from the public

and private segment they feel that is a core part of their proposition to the employees not a mass exodus at this point the next few pages a survey results of the survey we do every year and it is a huge database that includes public sector as well on page 5 we basically asked our clients and plan sponsors what are really the key challenges their faced with their benefits program and as you imagine it is around engagement and motivation and providing tools for employees to active understand how to use they're health care and make changes around that when we think about some of these challenges their faced with there is basically 5 key areas we see planned sponsors moving

towards not a silver bullet to fix the health care many of the 5 things i'll talk about things that the boards all right considering and often about as we work with our clients those are the areas they're focused the opportunities of wellness a much broader prospective of wellness not only the physical but social emotional and physical aspects of wellness something the employers are talking about the holistic and the engagement the board is talking about transparency so engagement and other is critical and as i think about the programs designed going forward they're really focused on customers and the other or shared accountability the other area we see significant opportunity from reducing the waste in the system

is around provider reform i'm talking about that in more detail the two key areas again seeing a lot of trespassed and energy around this the context consider management and serious to the quality providers for better outcomes in terms of the questionnaire you gave us the top 5 how many challengers were offered to all those you know government providers number one and what the regional difference some of the midwest see the challenges definitely than in the far west. >> no about 12 to 15 different answers i'll say there is similar responses across the board irrespective of geography and only in the industry as well size size it a little bit different smaller employers feel

the cost pressures more significant than our business but consistent. >> and i think to highlight those very quickly one of them in engaging employees with which one conditions and disease programs requester put a check and motivating people probation officer make behavorial changes scope and so on the government regulations and we've within grappling with that access to price and quality education weave been concerned about that and ceased with the unpredictability of costs it seems like on eternal condition with the trends i'm in lien with those concerns. >> yes.

>> the next page is how employers are responding to the challenges this is an area that seize detests between private employers and public employers so i also many of the private employers have been tweaking their plan design and cost-share strategy the course of last 4 to 10 years running out of room to manage their costs on the other hand, where public sector plan sponsors provide generous benefits and cost subsidies definitely more room to move in that direction so when the responses to the survey for the public sector was you know what are the 3 key things their looking at inc. co-pay changes they're doing that and expect to do that in the future they have room to move from a design

prospective the area around adult dependent coverage in the private sector an employer has treated that adult dependent category definitely maybe a lunch reduced subsidy for spouseal you, you want to cover your spouse other employers plans those things happening in the private sector and the the public sector thinking about 6 percent of the public sector that do does that day and today and the third piece in terms of health plan 15 hundred deindict before the plan pace anything has been popcorn in the private sector not the public but is that the direction

we want to go as you can see currently there folks that are doing that today and another 25 percent thinking about that in the fire chief what's been interesting on the survey weeping we've been doing this safer for 20 or thirty years asking what change when will you make over the last 10 to 15 years with the looming health care excise tax the changes that are disruptive to disruptive change so we're seeing a lot of incremental changes ways to create more druchgs in the marketplace and the health system to create better quality and outcomes and better placing so i on the several items i've

mentioned earlier around the disruptive change page 8 so this is around reducing waste and moving away from volume to values and this is really an initiative around provider payments there is basically provider payment reform it is around a hive qualify involving the paeshlt and prompting cost-efficientness as you can see this angle area we'll take an opportunity to increase coast efficiency and increase better outcomes and quality and innovate leave movement in this area for a number of arenas around the care organization and collateral care organization and patient in homes additional infrastructure

needs to make that happen as you can see based on the survey a third of planned sponsors are thinking this has to be part of overall strategy when is interesting about that particular area the fact that i think over the last 10 to 15 years move forward to one - one-size-fits-all even though we know that health care is local that's some of the dynamics it is coming back to where health care is local very different and variations in zip codes and geography and opportunities to leverage that localness of health providers asia health systems to deliver better benefits to the employees in terms of assess. >> could you speak into the microphone please. is this better. >> someone that did primary care i was impressed about the support for primary care go i

don't see that in many laundry lists of ways to improve some of the perimeters you're talking about. >> yeah. >> i don't know what that means support primary care to an employer or whatever but like to see it. >> there is direct implementation every research has shown a primary care physician you're more likely to engage in our primary care system so a lot of the plan designs focused on making it cost fiscal to the primary care through the prevent care is it is free a loose we can promote things that have positive impacts. >> so with provider network super change those are area we're hearing a lot about and the progressive things aco and

patient center homes aco tell are very public in the bay area as well as the northwest and groermz of the u.s. we have over seven hundred and 50 acu over the country that increased over the last couple of years and the accountable care organization will be pardon the program benefits as they go forward and the same with medical homes 7 thousand across the country and growing there is a lot of discussion around directing care so once we actually have the information that you know certain provides providers and certain paradises have better clinical outcomes how to get the employees to use those so there are benefit designs around degree of care the care to the right place and

right time so a lot of discussion i'll stop there and see if there is any questions. >> can you explain what a medical home is. >> a medical home is basically centered around the employees a primary care that are correspondence the quality of care and facilitates their access to a care it is a coordinated care model does that answer your question. >> yeah. >> this is a really busy slide but i wanted to make a few not as we think about benefits and benefit delivery in the next couple of years so if you look to the left side of the slide where the force that are

changing for employers again, he talked about the millennials and the generational defensive that is interesting based on the consumer research millennials care about career development and less worried about retirement and financial well-being and financial welfare you have the women that are of the majority of the workforce that point more allocation of benefit dollars to ppo or life balance and differences in either slarld population or union population for example, surveyed population valued with the financial well-being if you have those different would it be fair to say in your environment how this changes the way you offer benefits and deliver the benefits so again, it is more questions for us to you look at but some things that are

happening on a macro basis for the employees as we move into the next 56 years their out of pocket costs will increase sixth so they bear more costs at risk and more flexibility and chicago's choice and control over they are benefits program wear marrow empire centered and some dynamics in terms of the things you'll talk about a little bit further you'll skip the next page we talked about the force the next several pages around things that are happening in the market terms never mind of vendor consolidation and with some of the explosions that are happening with the signifying in a and others providers the

carriers expect their outcomes from the consolidation and certainly the market share will deliver the values and value from cost prospective and an ability to leverage it is going to be interesting that will refwharl ability to leverage with the provider and hospital systems so it is almost like they're back in the driver's seat i think that carriers will say that you know having bigger market share will create the ability to analyze the data a district 5 district 5 and consolidation will help with the products with the public and private exchanges within over carrier format so there is some hive expectations of consolidation will deliver but based on the history all the

consolidations that happened in 1990 and 2000 really has been not fruitful from the cost prospective. >> on that point. >> it's been about two months ago there was trevor involving the ceo's of etna and another company and a key kwae key questions from franklin from minnesota at the end of the day will 24 consolidation reduce costs for consumers. >> and i'm still waiting for an answer to that question two most later i have absolutely no belief that will happen all the description are self-serving for the company the cost-efficientcy and leveraging the market and

sfoefrth i don't here hearing to the care shares i'm waiting for the answer i'll pit everyone on 90s notice those companies with those planned relationships i'll be asking those questions as we go through renewal. >> history shows it hadn't and maybe comment on the role of government part of problem many of the carriers have for profit arms and not nonprofit arms i can't keep them straight is there movement ♪ direction and in terms of you know the amount of money going into delivering health care so the overhead is not 50 percent to investors is that factor into here >> there are differences

between you know for property organizations verse in time and certainly from a nonprofit several tasht what actually goes to expenses i see differences and more consolidation observing in the private sector the for profit. >> the for profit. >> organizations. >> right. >> the next couple pampers has kind of talk through the lens and impacts of those consolidations open planned sponsors and provider and customer service center consumers on page 15 what does it mean for you say a planned sponsor that will impact our choice and competition that's the biggest worry with the consolidations with the mega health organization from a constitutional 125u7b89 i'm hoping it goes back to the 80s

and 90s providers come together for example, aco and the teaches models from a product nomination will come into the market to critique that competition but this point i have big carriers coming together you lose a choice to leverage the market it you're a huge employer in terms of member count it is harder to have a leverage with those organizations. >> (inaudible). >> sorry. >> and then in terms of lower admin fees that will take a while before you see it come to fruition. >> on page 14 research shows that consolidation railway reduces costs and improves costs

efficiency are you trying to say reduced costs productive of proves the efficiency and right all the negatives. >> also moving on the provider back to the medical home a trend in the bay area for providers when we come forward come down to some of the issues the carriers are reducing their disbursement this? not reducing the medical car care and question see the fees imposed by or requested by provider of their patient say they have to you know, i know one set of providers is $17,000 a year to get with a medical home so those two providers actually accompany their patients to specialists

there is to hear with the specialists is saying and twitter that's with the medical consider doctors are joined at the hip that's not possible did that factor into this i mean shouldn't should be thinking about either ways to encourage members savings accountant. >> great question from the medical home prospective a whole gambit of reimbursement approaches that carriers have today and we are moving more towards pay for performance it not like they're cutting their fees to the medical homes they're providing ways to do the right thing and the population their severing they have enough few minutes we see a full gambit

not to take the services way away but pay for values we see that request carriers and the medical home in terms of connoisseur services we see that more in environments their offering a much higher deduct out of costs so they can kind of supplement the deduct i don't see that where but have robust plan designs with low costs. >> we're on page 16 in terms of the implementation to the providers again, i think that is impacting the providers from a leverage prospective with the carriers but i think that will accelerate them actually coming together so

hospitals and medical assistants coming together around developing those products we think there will be innovation in that regard and i think it will accelerate judge what we're talking about the drive to payment by insureers to manage their business about more appropriately. >> from a consumer prospective that will be diminished competition and choice for consumers and they will be feeling a lot more increased branding by provider with provider exchange offering in a consolidated manner. >> okay in terms of some key events market events and we're focusing on the ones happening in the be sure so sutter's is

their hmo with their product competition both the marketplace and a lot of affiliations and partnership with areas across the west providers are coming together and their desire to contract directly with the shoppers in certain groups where we come together and product innovation and competition in that marketplace. >> the bottom bullet their quite a few of the here in the bay area we continue to have not only provider groups but health insureers rolling out in the bay area in san francisco and the south bay and obviously have several aco through the benefits

program. >> i'll actually move- i'm going to move to page 21 we'll talked about the mergers in the investment. >> one quick question. >> and a at the aco you've been around long enough see it they're working a few of them pulled out one of the ormz. >> that's a great question and ask neil and page to add to that their relating now noting new not a lot of data yes or no definitely but rationally going in the right direction in terms of the potential cost savings and things that are related to clipal outcomes and quality care not around long enough to say that is working. >> my understanding there was some hope that the government

will help this transition and offering supplemental funding if their experienced in the year two or three or 4 was adverse that is not come to past organizations are facing financial challenges because of adverse selection or whatever when your small it becomes a big factor. >> you definite need the infrastructure to manage our risks. >> another comment please introduce yourselves and i'm hewitt i'll have to say success is it is still evaluated and somewhat of an impact of the utilization and still not impacted significantly costs yet but you know as the times going on they keep trying to fine-tune and some things are working but

still way good early to tell. >> yes. director dodd. >> blue shield has given american people analysis of the aco utilization and costs to our same population through the non-aco members in that small analysis aco we're making a difference and neil will attest to the fact when you what is key in the aco the hospital commitment we haven't had one particular hospital committed all right. >> would you, please continue. >> 41 fox ucsf the enrollment is commercial body most of

businesses are fully insured that is different in the mini market kaiser permanente has the market share by a.m. anthem and fwluld from the market share prospective in this area opportunities for the additional consolidation and certainly that dynamics is curving ♪ marketplace o >> ocurving ♪ marketplace >> curving ♪ marketplace >>curving ♪ marketplace >> ucurving ♪ marketplace >>curving ♪ marketplace >> icurving ♪ marketplace >> ncurving ♪ marketplace >>gcurving ♪ marketplace >> urving ♪ marketplace >>rving ♪ marketplace >>ving ♪ marketplace >>ing ♪ marketplace >>ng ♪ marketplace >>g ♪ marketplace >> ♪ marketplace >> ♪ marketplace >> marketplace >> marketplace >> ring marketplace >> the network are one of the largest go health and brown and outside the i've listed the aco activities here interesting related to the cost issue and not born by my any data but

significant savings i've heard numbers as high as 10 percent it had been interesting to see the data once we have that pertinent information. >> again for i think those are pretty consistent with a what we've talked about in terms of impacts to the san francisco eco system is consolidation will impact the market and some of the leverage will shift back to the providers hospital and to the carriers there maybe additional competition for kaiser permanente which obviously has the significant market share with the consolidation we do so continued decline of plan sponsors ability to leverage for the consolidation here in the marketplace.

>> and then in terms of just specific to san francisco and the two blue plans merging it is yet to be seen what that means from a math prospective. >> this is a very grim assessment but i thank you (laughter) for taking your castro oil i suppose one the will bring out spots we have for which we're falsified with the civic group on health katherine represents for large employers we know that will take that kind of collaboration to kind of and in any way be robust to the what the assessor is telling us all right. we're taking those in

order who is up next by the agenda? >> issues statement taxed and transparency katherine. >> thank you i'm handed out today, i had our cfo put together a list of federal taxed so you'll get a sense of the size and enormity it we review this when we review the actuary letters by the supervisors but the fee went up from $2.08 to $2 plus and granted that is on this 220th century 200 and 65 thousand dollars a fee on top of the premium the transitional insurance fee moves down in 2016 but that is constitutional close to 4 millions and the c tax 2 percent

of premium is nearly $15 million on top of our premiums hasten and then we'll hear about the expertise i started to say on top of this rule recall the lunch break of legislation when at the tried to agree on a budget a practice for sometime the state impose a tax on medi-cal managed care plans are the medicaid and medicare said you can't tax the medi-cal's provider you have to tax everyone many manages care we were looking at a managed care at the end of the last closed session and the way it was written in the governs budget they were increasing every year to cover the medi-cal shortfall no perimeters on this

and essentially it becomes a tax on a tax or it adds to our excise tax obligations so apparently that is tossed out for this year and their deciding it was mentioned across the street he saw this i've not been introduced but it will have to come to some conduct by april of next year and it would be tragedy if we interest have to pay tax on top of taxed and we will work to change that prop thirty was passed several years ago a move to extend that that is a ballot initiative we'll have they not to make that permanent that charges the tax on people individuals can make more than 200 and $30,000 a year

so hospitals and the units b will come together to put anything on the ballot for that whether or not that solves our problem being taxed on top of taxes is not clear people at the table are not employers their hospitals and units who want to solve the medi-cal problem but not necessarily worry about our cost of our premiums so that is what i have to say about takes and call on marina. >> before we do that i'm to declare a 10 minute hygiene break marina you'll beyou. >> okay. we're going to thank you for that recess we're going to now take up the question as

presented by madam secretary. >> yes. this is a issues h s f transparency marina. >> marine health services and data manager i was off to provide a quick transparency initiative you all know that it is our mission to certainly preserve and improve the sustainable quality benefits in being able to assess the value of the care we're ref and have it access to the quality information so to that end in our continuing efforts to, of course, have the database heretofore ap cd as part of strategy and we've just recently completed the implementation phase and have a

europe and looking at how to incorporate that into the tranlt strategies we had a meeting on october 1st here at city hall attend by supervisor farrell and in attendance commissioner scott and commissioner breslin joined us for part of meeting we had members from the cal reform and aon hewitt in terms of transparency, of course, and our executive director katherine dodd and other members of the team and some other experts we have off to attend a panelist members from pg h on health as well as policy individuals from usf that came and had several hours long conversations in

terms of reviewing where we were nationally around legislative initiatives as well as talking about specifically the landscape that h sf faces in our northern california market and the make up of our members and our plans and what we can do with that certainly one of the comments in the room that day was one of the tools that has been most helpful in moving forward transparency has been the databases and we certainly have a number of states with them we're operate active over 50 more like 20 states those days but we spent sometime delving both possible how to leverage our ap cd you

won't go into that update the other take away no uh-huh hazard we know we face in terms of what we are and not able to do here in our market subsequent to that i attended the center for health care transparency they have an innovator forum in san francisco and the focus of that meeting was really trying to identify regional and statewide entities in a goal for insuring meaningful information on a relative cost and quality of health care services available to 50 percent of the united states by 2020 and so in that room were members from many different states i think about new york and massachusetts and wisconsin and colorado and oregon and a number of states that already have mcds and

certainly legislation are reporting they're doing and it was a variety of other some people that focused on quality and some people that were focused on the providers side or the purposes or consumers there were technical people in the room the focus was in terms of 24 strategy around the 2020 goal trying to establish regional data in a intermediate to collect data for the people and work together to put into the public says that a national public reporting requirement information around costs and quality as well as clinic information and instead of you know trying to build top down

solutions looking at a grassroots integration bring people together and be able to by each regional and intermediatey vice chair a responsibility could we get to the 2020 goal certainly the health services system we continues to look at how ways to take our action and driving the goals we're in the process of evaluating for 24 meeting if we could apartment and looking for elements we don't track only a certain piece if this is a value and will that work to do that we explored that previously this goes back to late 2013 we looked at integrating the chip the california health care information system that is administered by dpw there are different teaches chips and at

this point we looked at that integration there i know we hit into some difficulties in terms of satisfying the business association agreement with the city attorney and the other party so we did moved in 2013 it is pursuant we visit that here especially with the ap cd up and running we look at again to deriving to that actionable. >> with that point marina. >> yeah. >> the business group on health and investment you say it maybe is that a signal we can expect to hear from you how you'll be doing this and what. >> my first step to go back to

our city attorney contact to revisit what we had pementdz and see if there are opportunities to move that going forward california is certainly one of the states that has been ragging with the statewide database and should it be closer it will continue to expand and certainly with our long-term strategies being able to interact you are data you'll start with a conversation it looks like we can pursue i'll bring back for details. >> you have a graphic at the october 1st meeting i think that would be useful to insert to the record of that hearing the cc investment this document you're not supposed to flash anything the public can't see if we could

get a copy of that to be integrated it shows with the transparency begins and so it is always at the health care providers door thank you. >> thank you very much. >> thank you. >> are they're questions if you would remain questions by any of the other commissioners august yeah, i'm new to the board can i begin transparency and is it transparency of outcomes to the transparency or interaction what exactly are we talking about. >> it's a great question. >> sorry to ask at the end of your - i think if i had the answer i wouldn't be here but on white house i wouldn't get around the cost or what is is

talking about i know that even like this health care center for health care transparency there they're looking to the regional intraerdz to help begin some of the terms what we're trying trying tee drive to to the cost of care and interact p segregate terms of patient experience not only our provider prospective or our health plan or perspire, you know, to get the full picture on this so what we know die that i think that will evolve over time we don't know what we're paying for not the the value can we sit here and tell you he assure the quality is what we expect i'm

pleased the ac d.c. gives information about the quality and preventive skewer and big deal to do other assessments our agency for health care research and quality i know is looking at creating a standard hopefully, will be released next year but lip into 2015 to create standard quality for the ac d.c. so there is no easy answer what we mean by transparency other than oh, the question what are we paying and getting for what we pay. >> other questions from the board. >> all right. thank you very much. >> next we're going to move to the 10 bay is that right. >> the bay area 9 county analysis and yes. >> marie murphy.

>> hello marie is this our first time. >> yes. it is good morning. >> (laughter). >> i'm the research assistant can everybody hear me in the back. >> apparently you'll hear otherwise. >> i don't diego dousht it so we created this survey of the 9 bay area communities to enlightenment the 10 county survey you're quite familiar to getting a sense of the neighboring counties in terms of their benefits to employees in order of most to at least populous the 9 areas a santa clara alameda contra costa pr san francisco san mateo. >> solano, marin and napa we collected data so all the health

plans for employees busing plus one and two the plan design so what they cover and at what percentage, etc. we collected data on the premiums with and without medicare for retirees plus one with or without medicare before we go further it came to my attention you received multiply copies of document we'll talk about in your folder so if you're looking at a few different things we'll clarify just now i'm providing overview we looked at vision and dental and voluntary benefits i know i'm forgetting things hospitals and county and whether or not counties provide coverage for adult disabled children that

was a bit more involved than the 10 county survey the document we'll talk about today fortunately is a summary of the data the key utilities heave post the awe pension fund peculiar online over one hundred 50 pages at final count we didn't make paper coops. >> so. >> just to reiterate then even with the data that is part of our board today, you'll saying a expand volume. >> that's correct. all it is posted online. >> that's correct and assessable to everyone. >> that's correct online as we speak. >> okay. thank you. >> so if you'll turn to page 2 of the document you should have i'll i'll scroll the way to

tell whether or not our looking at the correct version by looking want bar that represents marin county you should see the bottom number of $800.08 by he won hundred plus percent by one thousand $30.94 and zero percent he at the top of the bar and zero. >> zero not 100 percent. >> correct. correct as long as you have that in hand i'll precede yes good so what. >> looking at the averaged monthly medical costs for employees only for each county you're also looking at the average employer and employee contributions to be premiums by

county the percentages you see represent the percent contribution for employer and employees those averages are not evaluated for many factors it would be considered important like plan design and covered lives per plan the demographics is as with you know the rest of this document we've provided this effort represents the significant step forward in terms of gathering the population on gashthd tends other things we meet want to think about should we conduct that kind of study in the future take those numbers with a grain of salt the activey analysis by ann might yield things but with the caveats directing your attention to the fact that the

averaged employee costs with highest in alameda and contra costa and santa clara then napa then is a loan be then marin and san mateo and san francisco from marin 100 percent covered by the county not a typo every plan designs is absent different for marin the employees get a cash rebate speaks for itself in the planned premium museum it under one thousand dollars plus moving open to page 3. >> can i ask would be question and, of course, of course. >> a health coverage you know

my understanding started during world war ii when employers outside of military industries couldn't compensate the employees can those adjusted for what the employees average income if we look at guaranteeing this county looks at generous their average salary for the same you know - >> absolutely. >> is that a stupid. >> no a terrific question. >> do you have that data. >> no a preliminary effort by the way, as a pilot effort that provides a usable starting point we didn't previously know but looked at into the future. >> commissioner lim. >> just a clarification for

marin the contribution for employees is over one thousand the difference is is an incentive. >> up to one hundred dollars they give back to the employees. >> what we'll see as we go obtain on the employee plus one and plus 2 the county contribution is set at a certain amount i'd have to look at the appendix the way for employee only premiums if the employee choices a plan they'll receive a cash back rebate correct. >> moving on to page 3 and very similar representation here except this time we're looking employee plus one premiums so we've averaged by county and

averaged the county contributions, and again, we see that alameda county premiums were the most expensive and followed by contra costa and napa and is a last night and san mateo and then san francisco and is a not only. >> move on to page 4 that takes us to employee plus 2 premium costs and average county contributions to the county costs. >> same idea and caveats not adjusted so interest not question questions i'm sorry to

viewers at home. >> what page page 6. >> no page 5. >> page 5. >> 5. >> so, now the retiree premiums on page 5 the average monthly premium costs for retirees only that have mefshg parts ab so again those afternoons are not evaluated adjusted for the covered lives, etc. i'd like to point out those amounts are not adjusted for the variance in criteria for eligibility for retiree coverage mover over as you can see we don't have data for many of the

counties we don't have the employer contributions to the premium for san mateo and don't have any data for santa clara so i'll say more about the difficulties later but for now getting the retiree data was difficult one of the reasons for that the divisions within the county that administer the health benefits for active employees don't necessarily administer the retiree benefits sometimes the people we get data didn't have answers didn't get them in some cases no questions page 6. >> okay similar to page 5 we're looking at medical premium costs and county tricks with employees with medicare and dependents

that are medicare parts ab we're taking o take into account the fact those are not adjusted san francisco contributions are generous not the most generous of all itself counties but we stack up well against the others then we move on to page 7 we look at the premiums and retirees that don't have medicare we see the most difference for san francisco excuse me. >> so looking at page 7 we're talking about the average monthly medical costs and counties tricks for retirees 0 both don't have medicare and

even though we take into account go what your data didn't account for we see that san francisco contributions are the most generous. >> moving on to page 8 this is a continuation of explanation of premium costs and county tricks for retirees without medicare this is for the premiums for the employees plus one without medicare. >> so again just as i mentioned for retirees with medicare those averages don't account for eligibility criteria one of the big ones oh, there we go. >> one of the big things without medicare is years of service most counties had some sort of requirement of years of requirements to be eligible for

i retiree coverage some have complicated formulas that has to do with sick time remain and the number of years worked, variance things that weren't account to the difference we don't account for those this is a guide rather than an exact measure but again given this information in san francisco the benefits esteem to seem to be generous in this department and in terms of 9 counties that were surveyed can we assume no data those counties not one service system that administers or reviews plans like in san francisco how could monotony knowha