change in the economy. the mayors instructions we are to propose on going reductions equal to 3 percent in both years. this means that the 17/18 budget request need to be reduced by 97, 442 as compared to the base which is the current years budget and then the cuts must continue into 18/19 along with another additional 97, 442. we are suppose today implement a approach to the future fte approach. this does not mean that we have to do any layoffs, a hiring freeze or keep positions vacant but can't create new fte tfs. we can't request any additional positions. the idea is they don't want

togrowth in the number of positions in the ongoing expenses we scr when we have additional positions over the years. and then we are to adhere to the city wide strategic initiative. only some apply to us but there are residents and families that thrive, clean safe communities, diverse equitable inclusive city, excellent city servicess and a city and region prepared for the future. we will come to you on february 9 with both the general fund budget and the healthcare sustain nlt fund which is called the $3 budget instead of 205 and bring that to the finance and budget committee and then the full board for approval on the 9th. >> are there questions by the board regarding budget instructions?

i 34 profoundly impress said sth number of initiatives as we reduce the requirements while we reduce by 3 percent what we are trying to do. that is a remarkable feat but thank you for your commentary. any questions by the members of had board? any general comment from the public? seeing none, we will go to the next item. >> finance and budget committee matters. proposed helths system draft and recommended option. >> i will relinquish the char to commissioner sass. >> thank you. the finance committee of the health services fwored held

a meeting earlier today to review a presentation made by mu ketoa investment group. this is organization that the department contracted with to assist us in developing a investment policy statement for the health service trust fund. they have-they made a excellent presentation that identified the standards we must follow and statutory requirements associated with investment policy we might have. as it happens the health service board is responsible for approving invesmentpologist and to that end we conducted interviews with several members of the department as well as several board members, myself and commissioner scott. they worked with our department and through our department gained support from the city

attorneys office and they have come back with a draft invesmentpologist policy for the department. i think a couple key point in the presentation that people should be aware of, the first is that the purpose of the trust fund is important to people to understand and they made two comments on this. the first is we temporarily hold contributions to the end of the plan before dispersements are made. those are funds that are required to be managed by the health service board and department that are liquid in nature and maintained to meet ongoing requirements. in addition, the health service trust fund exists as a funding source to insure payments could be made if the dispersements that we are required to make exceed the contributions receivered. to that end, the department maintains a stabilization fund that is approvaled by the health services board

and maintains a contingency fund which is a calculated value that is based upon the obligations of the organization and the need that our actuary identified necessary to insure under new circumstances would be unable to discharge our obligations to the members and pay premiums as they come due. with that in mind, there is a opportunity to look at what remains of those funds and evaluate how those remaining funds should be invesced invested so those are funds we potentially have discretion over. currentsly all our cash and cash reserves are included in the citys treasury pool and those invested by the city and the city is under

the-required under i think it is section 15 -53600 of the california code, those regulations and those requirements limit very significantly what the treasure can invest in. as our consultants looked what investments we could consider should we move away for the treasury funds it was determined we also are subject to the the same code section sthof california code. as a consequences the constlation of investments we could consider are similar and the same as the treasurer can consider. they are short term in nature and fix td ed in naich ture. there is a structure in such a way the principle is guaranteed and

liquidity is assureed and return on investment the third in consideration and it is that order those considerations are made. as a result of research and work they did, their recommendation which we approved is that number one, the -their recommendation is that the-i'll read this specifically so i have the exact wording here. >> page 7. >> to continue to utilize the treasury pool of the trust fund assets which meets code and includes investment policy reviewed and monitors by the treasury oversight committee. if the assets are invesced in the pool the board receive upidates on perform ons thf funtd and number 2, the board get a annual update from the treasurer and

tax clecktder staff and number 3, at least every three years review and evaluate the appropriateness the treasurer investment portfolio and review alternative options. we basically voted in favor of the recommendations and make the recommend aizs to the health services board and we also recommend approval of a draft investment policy statement included in the package that is provided to the board and this investment policy statement essentially includes all of the recommendations and items included that i mentioned. i are recommending that the health service board approve the investment policy statement and approve the recommend ation made by mu ketoa investment group. if there are questions on the topic or public comment or anyone on the health service

board has question about the recommend aigds we have a representative from mu ketoa investment group here to answer any questions you may have. >> what are you going it do? >> i like to move for approval. >> there is a second. >> it is subject to legal review so we bring back the final draft next month if quee have changes. >> yes, the recommendation is included. >> just to be clear, the recommendation is that we approve the recommendation of the finance committee to the board >> accept the draft investment policy statement and to accept the recommendations for-utilize the treasury pool for the city and have quarterly and annual updates qu once every 3 years review the appropriateness of that decision and consider altnchatives. >> the investmentpologist is subject to legal review, correct?

>> subject to legal review. >> you want to call for comments from the board? >> i like to call for comments from the board. >> thank you for doing this, i know this is a long time coming, so thank you for your efforts. y i just like to commend the finance committee and also mucadey. a. finance isn't a strong suit. i thought the preparation at the last meeting or previous meeting for this report and then the report it self including sort of a example of a option using a hipthetical was helpful and made me able to understand it and evaluate the recommendations and i feel comfortable with the motion. >> i did have one comment. at no time was this effort in any way a reflection on the role of the staff or anyone else in the treasures office. i

restated that pretty consistently during the past year plus we have engaged in this work. we have a fiduciary responsibility as a trust fund, as a trust fund to have an invesment policy statement and we needed to provide a rational for developing that policy statement and we think we have done that work. the legal review will make determinations regarding what else or what constraints there are around that under the various charter provisions of the city, but it was our responsibilities as we took this over at a forum this is a fiduciary issue. we thank the treasurers office for the cooperation and information they provided the board in the interim

period and expect they will continue to do so as we go forward. >> at this point i think we could open the issue for public comment. and a vote. >> thank you. i also want to commend you on a incredible job because i remember we had the treasurers office in herea few times talking about their policies. um, i just want to be clear because i look at the draft and i see the following options that currently satisfy these factors under number 5 investment options on page 3, you talk about the treasurer pool and quarterly written up dates and then 6.0 review every 3 years but number 2 investing assets with external investment and

number 3, making direct puffins purchase are those two sections eliminating and looking at the treasury pool, quarterly written and 3 years? >> no. what the investment policy provides for it provides the broadest ability of the health services board to consider any of those three options, however, i think it is our current judgment and likely to be our judgment in the future that the treasury pool is the appropriate investment vehicle for us. should there be some event that will cause us to wix wish to make a change if that were to happen the large component the portion required for maintaining liquidity, whatever portion of that invested by the treasurer because they do a lot of overnight investment remains.

we will look at a small subset of the fund. those funds not required for liquidity and includes all the liabilities and all the reserves. i think at the curpt time that amount is around $15 million. that is an amoint we could theoretically make alternative decision if it is appropriate to do so but at the present time and in my estimation i can't imagine a time where that would be a decision we would make and i think it would be a very unusual set of circumstances and one that is a very carefully considered by there board. >> those 2 sections 2 and 3 remain, it is just isn't practical and realistic but they are there as part the policy? >> great. thank you very much. appreciate the clarification. >> i also call on the chair to identify the consultant that worked with us. . >> would you come to the podium and introduce yourself for the

minutes and- >> hairy whit from muceeda investment group. first i like to commend for a outstanding product. i think the presentation in particular is easy for me to understand as a finance person but it was presented in such a way it is very clear to anyone reading it regardless of the background. what the options are and opportunity would be dependent on the option we selected. i was very impressed by one schedule in particular that showed that comparing what the return we get from the treasury department with the other two options available to us if you looked at what those options have earned, the differential between those options and auchckzs we have the return the department would have received is $5 thousand per year on average.

we are not looking at any meaningful benefit going the additional expense sw work and risk of investing outside the treasurer. i thought that was a compelling slide and one that was very influential for everyones decision. >> ready to vote? >> yes. i think that you call for the vote if i'm not mistaken. >> i gave the chair but i'll do it. >> i will return the chair. >> can i just add that our chief financial officer pamela leaven worked hard on this over the last several months so they became a team and council weighed in and pamela deserves kudos as well nchlg >> i think i made her life difficult with all my concerns and questions and confusion about this. thank you very much pamela. >> thank you again and certainly to

director leaven working with you in a partnership way during the process. is there any public comment or comments from the board? if not we are ready to vote. all in favor accepting the recommendation as stated say aye. >> aye. and >> any opposed ? i like the vote recorded as unanimous. we are now moving from finance to governance. from finance to governance. this is my life this last two weeks. i will now turn the podium over to chair breslin. >> item number 8, please. >> item 8, action iletm. review and approve result of fishical fy 15, 16.

>> you all have the report in front of you. there is donna cutalky from dhr consultant and highlighted a cupm points of interest and a additional point that happened this year is the executive staff opinion was included in one section for the management section. just will highlight a couple things in the interest of time here. areas of possible concern, they were a little lower than last year but not still too low. the board received information reports that are necessary to careee out duties. that is between neutral and whatever the next one up is here. neutral and agree so it is not

negative either. board meetings agendas reflect policy matters consistent with board rules. these went down a little from last year and why they were pointed out. board accepts the decisions of the board even if they didn't vote in favor of them. that went down from last year. anything i think at 4 percent, i don't think is a concern. shouldn't be a concern even though they may have gone down some from last year. potential focus areas were board members interactions and meeting activities. board members are respectful of ideas and opinions, that went down somewhat but still above a 4. disagreement between board members handled professionally, that had gone

down too but still agree. the ones that are low would be board provides sound advise to management, that had gone below 4 percent. challenges management and constructive manner had gone down below 4 percent. board provides alternative points of view to management has gone down a couple points. nothing below 3 . the one that is low is feasible the board engage in effective management succession planning and this was a very low score in there but also the executive staffs report. we have a succession policy which we worked hard on for some time and it is in

the directors under terms of reference what the policy is. the director assessment of human resource needs and development of appropriate human resource programs and procedures including succession planning, coordinating with other city departments as necessary. it is also written in the boards terms of reference we see the succession planning was done. maybe no one was aware of this but we did spend time on this and in the governance rules there is a succession plan which the director will say who is in charge and she is out. even though that did-it made me think no one was aware we actually had one. even though we did respond a lot of time on it last year. those

are the highlights. the ones that went down and low from last year primarily. and i like the idea that we have input from the executive staff. i think it is nice to expand a little bit to the full management team maybe next year if possible. any questions? >> i like to make a comment on the succession planning and the score in that area. i think it is all most self evident that we did want do as well as that with the vacancy of the executive drether we are facing and succession planning and from my experience in nearly 40 years in human resources isn't about who is operationally leading a function, if indeed the executive is out of the office.

that is continuity planning in most organizations to insure the business options and administrative options continue to go on in the absence of the primary or principle officer. succession planning within the terms of reference is really talking about when there are vacancies. what is the process to find replacements and how low within the organization, at what level should this board be engaged working with the executive director to create a formal succession and development plans for the professional staff. so, my view in reading the question, it was not just about operational continuity, it was really about management, succession and professional development and those conversations we haven't had in

my view, but we will be having as we are getting ready to engage and finding a successor for executive dodd. >> that's pretty well laid out by dhr. right? any other qugzs? >> i have one question. i'm not in addition to be [inaudible] also statistics. there was one i guess commissioner unable to assess on every category and when you have such a few number anyway, 6 versus 7, i wonder if anyone recalls in 2015 was that the case across the board and was it just not unable to assess? to me raises some question if one feels that he or she can't the questions.

>> it is someone who didn't fill out the form. >> the prior time everyone did. >> i just pointed out it does impede the potency of drawing conclusions and the areas of development when changes look large but could be related to 6 versus 7 people making an assessment. >> someone didn't fill out the form. >> okay. >> can i make a suggestion for next year? that is that reminders go to commissioners either by dhr who is doing them or by our secretary. they all go to dhr so the secretary doesn't know who sent them and who hasn't but we could ask dhr to do a reminder and maybe a phone call. >> i would like to weigh in.

>> i was in contact with donna cutalky and knew who was participating and who was not and sent this commissioner 3 remindsers. >> thank you. do you want to call for a motion or public comment? >> yes. motion before public comment. >> i move we accept the board evaluation with the focus on the areas of potential improvement. >> second. >> any public comment? all in favor? >> aye. >> opposed? unanimous. >> that will be reflected as unanimous acceptance. we will defer the other action item on the educational-do you have it? >> yeah.

>> doesn't everyone have it? >> we didn't discuss it in the governance. >> not that governance but a prior one. if you have a report please render it. >> well, we have it here. i thought it wasn't passed out. >> it is in the bipeder binder on the i pad. >> has everybody seen it? it is about three pages. >> yeah. >> we went through all this not this last meeting but the meeting before and it was finalized. everyone from the committee. everyone from the committee had input so that's why i thought it won't going to be on today. >> i'll accept that and director dodd has a question or comment or- >> i apologize for not being on top of when the input was requested

but i think the point at the bottom of the first page, access pharmaceutical pricing practices is a emoore fs term and may want to say stay abreast of pharmaceutical pricing process. and then gain improved understanding of claims. i think we just need to gain a understanding of claims. lastly, i would like it if the board understands self funding fully funded flex funded mechanisms because it isn't just claims it is also the other funding mechanisms so those are three additions i suggest adding. >> could you say those again? >> under access pharmaceutical pricing change to stay abreast to pharmaceutical pricing practings. under gain improved undering

just say gain an understanding of claims data analysis. and then lastly add understand self funded fully funded flex funded mechanisms. >> those edits could be added by the secretary? >> sure. >> are there comments by the board? this is action iletm number 9. action item number 9. alright. any other questions or comments by the board? do i hear a motion to accept the education plan for 2016? >> with the editsfelt >> so moved. >> it is moved. >> second. >> properly seconded. any discussion? i just interject a observation. this board has a $10 thousand budget

in this years budget from the general fund for educational purposes and to date we haven't spent a dime. we do belong to the international foundation for employee benefits. the advanced trustee institute will be held in san hosay jose july in june and there is another institute training for certification in public employ er benefits that will be hosted nearbe as well. so whether through those programs or other efforts we need to actively use the funds for which we badgered and begged the city for for the last 3 years or they will come back with the 3 percent thing drether leaven talked about and take it away

from us. i ask you to give some thought that are consistent with our role as commission members to make yourself available for the educational opportunities. >> so the ones you just mentioned that are local, could we get a notice sent to the board about these? >> sure. >> so they know they are coming. >> yes, but they also come to you every day, your mail box is flooded with e-mails fwraum the foundation every day. >> i don't have that. >> i got a catalog mailing but we can send a reminder of the ones that are close day and dates. director leaven you look as if you wish to make a comment. if i misspoken with the source of funding i deeply apologize. >> pamly leaven chief financial officer. now you were correct but i like to urge the decision if you want to do these things to get me

the information now because i need to get the money incumbered so we will not lose it because we are not spending that training money and i want to make sure we still have the ability to have it the following year >> i ask the commissioner to communicate no later than the next board meeting to drether leben and be sure to include our secretary in your communication if you have a desire to attend any of the meetings and i'll send out a e-mail remeending reminding which are local. any other comments or questions? any public comment on the educational plan for 2016-19? >> [inaudible] congrat ylshzs on having a educational plan. i like clarification, is the $10 thousand just

for board education? okay. it was only when the budget crisis hit a number of years ago and all of training and traibl was removed from aevds budget across the city. did this board stop going to the [inaudible] conferences and trainings because everybody got that cut? we have often encourageed staff especially senior staff but a number of staff to attend those trainings especially when they are local or close by like in tahoe and maupt rea and having this in san jose sound exceptional and very very close by. i would like to strongly recommend to all of you that you take advantage. i realize that a lot changed with regard to the trainings and so there is a lot more available now through dvd and electronic sources so you don't have to go to as many conferences, but

what you learn by having some type of dialogue and interaction with other trustees from across the country and other public trustees is especially in the specific conferences and trainings that are just for the public sector, that is invaluable. it is a double training, it is not only what you get and gleam from the materials but what you get networking with others in similar situations and vauved involved with public plans so i strongly urge you to take advantage of this. $10 thousand isn't a lot of money but if you can go to san jose it is a trip down the road and mileage and if you want to stay a day or whatever it is worth it because these are invaluable trainings and missing from the board for a long time and think it will help you understand the fiduciary

responsibility and what we are up against with regard to other plans and gain a bigger picture of what is really going on in the public sector especially with rart to the benefits so that is from the perspective as a former member of the board i can't urge you strongly enough to participate in these trainings. thank you. >> thank you very much for public comment. any other comments? >> thank you for the education plan. comments by the former president [inaudible] i have been attends frg the last two years the helths care management conference accept it was paid for by [inaudible] and they didn't charge the health service board or health service system from the budget so it was paid for by our union. now since i'm retired i'll take advantage of it because it is [inaudible] >> any other public comment?

any other questions or comments from the board 1234 i thank commissioner breslin for bringing it back. >> i have a general question, if you don't spend the money wouldn't it be deleted? i think this is a very valuable expense and you don't want it knocked out of the budget so this think is a [inaudible] >> thank you very much for that comment. we are ready to vote. all in favor say of the motion to accept the education plan for 2016-19 say aye. >> aye. >> opposed? passes unanimously. we are now ready for action item or discussion item in rates and benefits. we are going into rates and benefits. for those who are members of the public this is a committee of the whole. it is all of the members of the board. we meet in the configuration to

hear any number of reports between now and the time our finl rates are approved and reviewed by the board in june. at this time i'll ask director dodd to share with us our calendar for this task. >> >> thank you, you have the calen deder before you. in february we will explain the black out notice. we will look at the city plan adminivateive fees and review claims experience and we will benchmark copays with other localities. in march, we will hear the 10 conte and approve it. we'll consider stop loss recommendations and review the claims experience on the blue shield flex funded plan. rereview the blue shield claims

stabilization reserve. it will also present as they do every year the helths value initiative in march. in april, we will look at risk scores. these are the scores produced on the payer claims data base. consider the dental and vision and etna renewal. we rill also consider city plan active and early retirees. only the seft insured portion of city plan and approve the benefits and premiums for 2018. that is april 13th. in may, we will consider kaiser active and early retirees who will have claims experience and approve premium cuntbutions. similarly look at the blue shield flex funded non medicare and approve their benefits and premium cuntbutions and the city plan self insured rate renewal for active and early retirees. we will

consider at the time a best doctors renewal. we didn't put in best doctors will present first 3 months of statistics. >> when will that be due? is that in march or february? >> january, february, manch. we could probably- >> april. >> april 13th, i guess they could pull it together in two weeks. >> if you could just put a note it is at the april or may meeting that we would be looking at that given the transition here we just need to make sure we don't forget. >> okay. >> i know i will be out for the april meeting and would like to hear this so maybe we could consider may. >> that's fine. >> without objection?

>> and then june you'll be voting on theu hc medicare advantage fully insured and kaiser senior advantage and hopefully it will be-sail sthrou all these. again, this is a reminder that all of our deadlines are governed by the board of supervisors budget process, so if things feel rushed, it's not that we can't-we just can't post pone things another month because the board of supervisors must vote on them in july. we don't have the exact dates but will fill those as we go along. >> thank you, directser. is there any public comment or any other comment on the calendar? pardon? please. please identify yourself. >> [inaudible] can we strike

the 5th bullet in the april because we are doing it in may? just want to take that off. >> that bullet should be in the may? >> it is already in the may. city plan- >> i see. >> we just need to get rid of that. just a point of clarification. go ahead and make that- >> so, the april 5th bullet should be deleted. >> it is the third bullet in the may. >> translates to that. alright, thank you for the clarification. any other public comment on the calendar? hearing none we move on to the next discussion item. >> item 11 review funds status for incured about not reported ibr, reserve

foru hc. >> you had before you in the packet this document titled county of san francisco health service board not reported reserves. each-year as we begin the cycle we state for public the amounts we are holding as a trust in your incured but not reported reserves for the self funded programs. the three programs we have reserves for for this category of reserves are your flex funded reserve under blue shield, the city plan reserve for self funded city plan which going forward is your active and early retirees because the medicare retirees are fully insured with medicare advanlage ppo and delta dental ppo plan. if you terminate the plan at any point in time you have funds on the books to pay the run out claims.

the amounts are stated as of june 15. your june 16 is kaited on page 3. the runchs have not change d and acknowledged and approved by the auditors at the december meeting. they are certified and audited and aprubled by a second set of acwaers. you operate with fully funded reserves and this is informational only. any questions? >> any questions for members? hearing none, any pubhook comment? seeing no public comment we are ready to move the next item j. >> iletm 12, discussion item rchlt review fund status for reserves. and, it is me still. commissioner sass so adeptly stated in the review a excellent disposition of

information on the approved investment policy, you- >> object to legal review. >> legal review that you do hold as a matter of practice, apologist approved contingency reserve for excess loss. this is a fantastic liability to cover. it is also fully funded and on your balance sheet. the amount allocated and approved by kpmg and here are the amounts that you hold for each the same three programs that you have your reserves because they are self funded you take the risk so if you have excess loss have you assess independent of what you think is good from a independent entity that is acwares an amounts we say under 99 percent chance we will have the money on the balance sheet that will allow to cover the risk if we were exposed to loss. the answer is yes. this is fully

disclosezed to the public not a mystical number and these are fully funded also so you have this money and it is allocated for this purpose. >> any questions from the commissioners? >> just one question going fwook had ibmr reserves. the $29 million in the reserve should the health service board decide to move away from the self insureed plan and go back to fully insured plan with blue shield or other insuring and replace it is the not true the $29 million is paid out over a 90 day period that would be our liability in addition to a premium on a occurrence based that fully insured plan- >> yep >> the claims made basis would-we have the premium on a new policy as

well as 90 pay down? that is why it is maintained, a liability that could be paid in 90 days if we terminate the flex plan? >> yes. just to add a comment. if you went back to-when you paid it out you write it off the books. this is self insured enterprise, you hold quite a few assets for the benefit of the people that you cover. these assets would be erased and on the balance sheet of fully insured enterprise if you go that direction. you built a substantial amount of plan assets and sit in very good solid position which every time i get a chance to say this, you are the most volvent policy approved public sector enterprise i work for so i always like to say that. >> we like hearing it. >> i get gooss bumps when i say that. >> any other questions from the

commissioners? is there any public comment? seeing none, hearing no public comment we thank you our actuary and move to discussion and possibly action item 13. >> presentation of infertility benefit and recommendationism director dodd. >> as director dodd is approaching the podium i want to acknowledge a letter from supervisor tang that was submitted to the board for its consideration as we are reviewing this item today and she is expressing her very strong support for this item. i wanted to acknowledge receipt of that letter. >> thank you. you had a presentation on infertility at the november educational forum so some is a

repeat. those that studied it and committed to memory, you can just close your eyes . for those who didn't i do want to go through the technical part of it. the goals for our infertility benefit are provide services that result in a healthy live birt >> is this presentation available for us to project on the screen? >> it is on the website so we can pull it up. >> that technicality is worked on, please proceed. >> to recognize cull charl diverse individuals have a need and desire to bear children and insure medical treatment reflects the curpt research on the best treatment and medication to insure a healthy live birth. page 4 you will see a comparison across the

three providers blue shields, kaiser and united healthcare of some the current requirements. blue shields requires a waiter period. kaiser has a year or more of attempts. united healthcare has a year or more of unproducted regular intercourse qu woman must be under 35. blue shield of california provides interest cyto plasmic sperm injection. it isn't mentioned in kaiser or united healthcare. preimplementation, genetic determination is covered by all three. this is a genetic test for members at high risk for having embryos with specific genetic diseases.

long term storage varies. blue shield of california has one retrieval and 12 months of storage per life time. kaiser has only associated with a gift ibf or zif and one retrieval and 6 months per storage life time. the gift and zif definitions are the same and the cost across the board is 50 percent with the exception of our selffunded plan, which is fifen 0 percent after the deductible is paid. one of the first recommendations that is being made is to change the title of this to infertility and assisted reproductive technology because the realty is that for same sex couples it is really assisted reproductive technology, not

necessarily infertility. on another one of the benefit enhancement-i will go through these and if you want to stop me as i go through them-the other benefit enhancement is a requirement for 12 months of frequent unprotected sex between partner thofz opposite sex and to require coverage to include the presence of a demonstrated condition recognized by a license physician and surgeon as a cause of infertility. this comes out of a state law so when the state defines infertility that is exactly how they define it. we recommend eliminating the requirement that remubs the barrier sfr persons of same sex and adding rerequirement with a definition of california health and safety code. in terms of the

age issue, we recommend that we eliminate the requirement of a woman to be under 44 years old to receive the infertility benefit. elimination removes the age barrier and again compalestines complies on state law with age discrimination. the next enhancement is assisted hatching. as a important part of the process in the furtization of the egg. the unlt of the sperm to pin trait the cell or [inaudible] >> sfgtv- >> assisted hatching is upgrading the benefit. it hasn't been looked at for 15 years. it was a new technique

embryos with a [inaudible] have a higher rate oof implementitation. with assisted hatching a embriaulgist uses micro manipulation to create a small hole and drops that sperm in. we recommend adding assisted hatching as a procedure. [inaudible] invitro fertilization procedure where a sperm is injected to the egg. the single most cause of infur tailty so the idea is to have a good sperm injected directly into that egg. this one is more controversial if you will. it is preimplementitation genetic

screening which allows the embryos screened for [inaudible] you recall from the november forum that [inaudible] is where there are not 23 sets of chromosomes contributed by the male and female. we want to make sure there are 46 sets of chromosomes and not all embryos are developed with a set of 46. [inaudible] recognizes a major cause of failed implementation these embryos were never meant to be a fetus because they don't have the right number of chromosomes. this prevent the need implanting multiple embryos and reducing the possibility of multiple e births. note that preimplementation genetic diagnosis is covered for

persons with high risk embryos. pgs a procedure that isn't necessarily approved at this time, but we would like to suggest we approve it when it becomes the standard of care. on the next page you see the single embryo transfer. the process. this is from the american society for reproductive medicine guidelines. research shows that 40 percent savings when patients rely on the right treatment paradigm and the idea is comprehensive chromosome screening, single embryo transfer and you end up with a healthy baby. on page 13 you can look at the numbers in general speak for themselves. when you implant with one embryo you have 61 percent of

live birts. when you implement with two you have 65 percent of live births. when you imlment with 1 embryo you have zero twins, 2, 46 will be twins. in terms of miscarriage, one embryo you look at 12 percent miscarriage rate but with 2 you have a 20 percent miscarriage rate. again, preterm delivery, 8 percent with one embryo, 28 percent with two embryos. total new born intensive care unit days, 80 with one, 373 with two. it is profound different rinse in terms of the outcomes. birth weight is 34 00 grams versus 2700 grams when you have

two embryos implanted and total cost are double when you have two embryos implanted. so, the risk of multiple births higher risk of prematurity and future helthd issues, potential learning challenges as a result as the prematurity. we are able to implant one and have a healthy outcome in 61 percent of those times. >> can you state again this for the record the source of this data? >> the source is from the american society for reproductive medicine guidelines. this sh it standard of care in reproductive medicine. >> can i ask one question. did the total cost sort of surprised me. neo natal and icu cost are high so $90 thousand must not include the

reproductive technology cost to do two embryos versus one. they can't include professional fees, costs of- >> i thought it was low too but we have bay area perspectives on cost and this is a national-who knows. you are right, it is probably higher. >> the only reason i ask because we approved a certain cap and the cap i thrink is going it be reached all most regardless of the kinds of technology because they are expensive. this is a interesting number but the nicu days are not capped. professional fees pr not capped and all these medicines are not capped. all these things are not capped and so if this is really the total that has one implication

for us as fwored members, but if it doesn't include the non cap services then we would need to know that. >> i wonder what you are referring to in terms of capped? >> when we suggested a one time benefit of 25 thousand or 50 thousand one time benefit for the services. >> [inaudible] >> that is the adoption and sur gaes benefit. >> sorry, this is not-they can do this any number of times. >> they can do it twice per life time and it isn't two live births they get to do this twice. currently, there is only in one of the offerings it is one shot at it.

>> my mistake. >> that's okay. so, 14. so, speaking to that, it is increased the benefit limit to two life time cycles. not two live birthess but get to try twice and these are the different cycles you look at. we also wanted to increase egg storage up to 12 months. make sure we have arrangement so if people want to store longer they can. the storage cost are between $300 and a thousand a year andologist have to pay for thawing and getting them to where ever you are implanting them. available to

members. the medical treatment will result in the member becoming infertile. we also wanted to extend that so if for example and this often happens, someone has cancer but they want to make sure they get the eggs out to be stored but will be in treatment for a year, we want to flexibility to make sure that was available. so, enhancements are all on page 16. i have some other data for you. we used the claims database and looked up how many infertility services. united healthcare had none in 2014. none in 2015 and none

in 2016. in 2015, blue shield had 15. kaiser had 57. 2016 blue shield had 35 and kaiser 10 8. between 15 and 16 the number of infertility treatments doubles. >> that is for our members. >> for our members. i want to say that for example assisted hatching cost $750. we are not talking double digit numbers. adding icsy is 1800 dollars. these are not expensive but they are what is current in terms of the standard of care and if we hadn't improved the

infertility benefit in a long time and there are a lot of questions about it and want to make sure it is up to date. it also is a recruitment issue because women are waiting longer till they are older to have children and it is benefit put in all the high tech benefit packages and we just want to make sure it is available to our members. if you went through we could go through them one at a time. >> please do not. >> or you could just look down them and say you approve all those listed on page 16. >> i will ask are there questions from members? >> there is no age limit anymore? >> the only one who has a age limit is united healthcare and haven't had any infur tillsy service. >> there isn't a attempt to make the plans uniform? >> that is what we are attempts to do now. >> if you approve this is this

part the plans? >> yes >> the listing of what they cover will change? >> yes. >> they respond and effect the premium structure but it will be incorporated into our aquil- >> effective 2018. >> i still had one question. we wanted to extend this and make it uniform, the storage to up to a year. you mentioned for some people they may want to store beyond so they would at risk for the fee but that is available to them but at risk for the cost. >> they are at risk for the cost and working with a medical provider to figure out if they keep it there or move it somewhere else. >> okay. >> but we only pay storage for a year. >> alright. so, i think that we are ready for a motion but like to also be

clear what we are moving on. we are going to for our reference turn to page 18 in the presentation. i will entertain a motion to accept all of the items on page 18 and/or page 16 and in doing so we will be adding or bringing uniformity to the benefit across all health plans and these changes would be incorporated into the 2018 benefit cycle; is that correct director dodd? >> yes i want to opponent out the first point is rename the-yeah. >> including renaming the benefit and expanding or enhancing these various features. i'm willing to entertain a motion to that effect. >> i move that we rename the benefit as

infertility and assisted reproductive technology and adopt benefit enhancements as recommended. >> is there a second? >> second. >> it is properly moved and seconded that we rename this benefit and accept the and abruv the benefit enhancements listed in the presentation. are there other questions from members of the board? hearing no other questions or comments is there any general public comment? we have public comment. please approach the podium. tell us your name and please proceed. >> good afternoon, diana cizon a legislative aitd with katy stangs

tangs. thank you for acknowledging and looking alt the enhanced benefits. spl visor tang is a champion for working families everything from paid parental leave to lactation accommodations and feel the benefits add to that helping our working families decide and provide choice of how they like to create those families. we really appreciate you taking the time and looking updating it and making sure our members have the highest standard of care when creating their families so thaupg thank you for the consideration. i also want to dmote note our letter listed recommendations but left off a couple recommend aigdss including the age maximum so we support all the recommendations on page 18 that were not included in our letter. >> page 16. &page 16. >> you caught it from me. >> thank you very much. >> thank you. any other public comment or board comment or questions?

yes? >> i like to acknowledge the work of director dodd and staff for inhanlsments and making sure it is within the guidelines. make sure we are complying and- >> thank you. i want to acknowledge aon hewitt put in tremendous work and vendors. this is how to get on the same page so improve things working together. >> with that, we are ready to vote. all in favor of accepting enhancement and renaming the benefits aye. >> aye. >> opposed? it is reflected it is unanimous. now, i am going do something very dangerous. i will call for recess for 10 minutes. at 3:20 we

>> thank you for being very timely with our recess and we will now move back to the regular board meeting. we have gone through finance, governance, rates and benefits and flow now back on regular agenda items for this board meeting and this is action item 14. >> thank you. item 14, approval of health services system 2016 annual report. director dodd. >> thank you. in the interest of being brief, i will call your attention to the info graphic on page 4 but i will tell you a lot of work going into putting into the annual report each year and i used it for a presentation yesterday in the adaptive

business and people were just in ah how much we do. if you look at page 4- >> sfgtv. >> if you look at page 4, you actually can see since just 2012 increase since member lives. it is steep curve. we are spending $11.1 million on administrative cost and that is to serve over-looking at medical plan enrollment. this is from january of 2016, those are the numbers, but it is to sunch over 114,000 people. there are a couple brokers and employers and they said you do all the benefits administration and that is your budget and i said yeah. most large employers and even small and mid-size

contract out the administration of benefits and we do it internally and do it very well. this tells you how much the employer contributes, how much the difference employers contradicted to the trust and how much employees contribute. we administer 28 plans from 10 different vendered and have over 10,000 annual enrollment transactions. 500 annual data inquiries. 28 public meetings. 72,000 open enrollment packets are mailed with 12, 600 unique visits to the officer during open enrollment. those are just by the numbers. i think you all because you get the mupthy report realize the wellness program blasmed

and ihighly regarded throughout the city and that we are really using our membership, we called it a activist payer committed to higher value, we use the fact that we are a big elfent elephant in the room when we get together with other employers we say we can demd better and for less and the issue of trance paerns continues until we convince sutter to make the claims transpaernt. we can only point to kaiser as the model for participating in transparency. as soon as sutter does it everyone else will do it. looking ahead, as you know it will be a bumpy course depending on what happens with the new secretary price assuming secretary price is confirmed.

i think we are likely to see the biggest changes in medicare, which will effect our budget greatly our members and will require very facile policy change to keep the programs running. where there any questions about the annual report? >> any commissioners have questions or wish to provide comments? >> i'm impressed with the detail and the breakdown and i think i feel as a commissioner that had preparation for some the issues that jump out and getting back to page 4, one of the issues it does-i just lost it- one of the issues that jumped out is

the medical cost for kaiser versus united healthcare versus blue shield i think. and that despite the difference in membership, that there is differential in terms how much money is spent in different places and your graph below that-i apologize i lost the page. page 4 but i am not in the presentation. it shows that it is not because of inpatient cost, it is outpatient and where is that. where are we spending the money in that sector. because the pharmacy is relatively similar across the plans. i'm impressed by this and it does show where the challenges are. >> the united healthcare 42 and

blue shield [inaudible] part is we are dwooing more things on a outpatient basis but you are right and pharmacy remained the same the last three years at about 30 percent but no less 30 percent is a lot. it is a page that tells a lot of stories. >> are there other comments or questions? >> i like to thank you dr. dodd and staff for the report. i am more than impressed and in ah with what you have done. i think it is a lot of hard work putting this through. it is exhaustive process with all the statistics and information and all the numbers that you have put in there considering with the limited number of staff and we have over 113,000 employees that is a lot of work but you [inaudible] i

commend you for all your hard work and thank you so much and it is hard- >> we increased by 7 thousand members, a 13 every year yee have been here. it is kind of ah inspiring. >> especially the wellness and done a excellent. service to all the members. >> i get to give the report, the staff dhuz work. >> thank you. >> commissioner sass. >> as alwayss, it is a very professional product and comprehensive and complete and wouldn't expect anything less from you. i wanted to just take a opportunity here to join in thanking you for not only for the service but over the 17 years i worked your service as a commission for

department of public health. your services for init mayor as the health cairb person. mayor nusem and then your service for the department. you are a great example of excellence and commitment and it is a pleasure of my life to know and work with you. >> thank you very much. >> thank you. any other comments from other commissioners? i would then generally on behalf of the board want to not only commend and thank director dodd for this outstanding report, but she continues to point back and put the finger behind her, it is sth staff, it is the staff and that is her coleaders are here today. deputy grigs and deputy leaven, but it is all of the staff that work very tirelessly through all the aspects och benefit

amadministration and open enrollment and things that go on to make the system what it is on behalf of our members and to each of them individually and collectively i say thank you on behalf of the board for what you do, day in and out for our members. with that, is there any public comment on the annual report? sorry i'll ask for a motion to accept the annual report. >> move to accept. >> it is properly moved is there a second. there is a second. any comments or from the commissioners? any public comment? >> i just wanted to add to the commendation to staff director and department head cathlen dodd and staff for all the incredible work. this is i think the best annual report i have seen and i have seen many over the years. this is really

outstanding. very comprehensive and again it points out the fact that we have a phenomenal number of members in our system and woe provide a remarkable number of services are very little staff and it is to really command all their dedication and thairb work and to say that we as members truly appreciate it and i know as going from a active member who truly appreciated this to retiree, our members are so grateful you can't imagine. when they know they can make a phone call to health service and get their problems resolved quickly it just speaks volumes because many others can't do that. i think we have one of the most efficient systems thampt is the argument we use with the mayor and everybody's else working here with very very few-increased staff somewhat over the years but not really

to keep up with the number of members. i remember when we had fewer than 50 thousand members and now we are 116,000. it is funominal but the staff has ncht increased and think we have to fight for that and also commend our finance director leaven for all the hard work she has done with the mayors office and efforts to sustain the budget and to get more of the funds that we need to deliver services at this level. the city does not appreciate us. i think some of the orelt employers do. i like to thank the school district and community college does but it is for employers and they don't knee the deal they are getting and we need to let them know but this is the most fantastic annual report. thank you very much. >> otherpublic comment? hearing none we are ready to vote. all in

favor of accepting the annual report as presented by cathlen dodd say aye. >> aye. >> opposed? noted it is unanimous. alright. now we are into >> discussion item 15. >> 15, thank you. >> report on network and health plan issues if any. >> any health plan issues? >> i like to ask a question. >> let's go-please identify yourself >> shannon hos united helths care and want to give a brief report on activities we have been involved in. last week and this week we have on site

at hss. we had two service account managers and my slf there for the benefits analyst to transfer live calls to help with resolutions as well as any call backs needed. the hss staff took a significant amount of calls while i fsh there and out of those took 85 escalations so that is a very small fraction of the calls they were handling. out of those escalations the majority of those were cards not rvd. so were able to order cards on the spot and should be received this week by those members. there were a few rx issues to provide the pharmacy instructions or contact the pharmacy to get the medications. we had a couple

benefit review, some provider education and very little in the realm and couple transition of care cases. the united healthcare call centered handled 820 calls the first 7 days of january. the average speed of answer is 11 seconds. we had a service level of 95 percent. average handle time is about 12 minutes. the call trends there, same thing we saw id cards. some benefits review, a lot of rx inquiries. some provider look up and then out of those calls we had 26 post call surveys completed and we had a 99 percent satisfactory rating there. finally, we have been in direct contact with brown and tol end people inpatient and they agreed to work with us as a

patient is discharged to help with a smooth transition. that is my report. >> would you please stay for a moment? >> sure. >> you are actively on site now. how long will you be? >> that will end tomorrow, hss agreed. we were open to extended through january but hss indicated they won't need us on site after tomorrow. >> thank you. any other questions from members of the board? >> some ongoing problems with outpatient psychotherapist. they have to be a medicare provider? >> yes, they do have a to be a medicare provider. >> these are not medicare providers. >> they talk about license marriage and family therapist. >> medicare does not recognize. >> so how do you pay them? >> they are not covered. >> not covered-they are not medicare

covered or conched at all? they were apparently covered before under the city plan. >> medicare does not recognize that license right now. >> you do cover acupuncture. and cairo practor. >> we have routine and non routine or non medicare covered. that is a additional benefit above and beyond what medicare covers. >> the non medicare are covered? >> [inaudible] >> and then there was a problem with the supervised nursing care facility. there is very limited facilities because you hadn't- >> i did receive that as a concern, so sth skilled nursing facility, the only requirement is it be medicare certified. i do did do a

search in our network and sthr 158 facilities in or around san francisco. >> if they go to-apparently this person was looking for 1. if they go there and as long as they are medicare- >> they have to be medicare certified. there is no- >> the patient sends the bill then to you? >> the facility should bill united healthcare. >> that's it. >> any other questions? >> you mentioned there were a couple of personal care transition issues. i think you were going to monitor your ongoing discussions to make sure providers were urged to participate and i don't know if you have any broader feeling about that in the first couple weeks. y i don't. we have gotten a couple request sfr provider outreach. we have been able to reach out

to them and they are willing to accept the plan. i just continue to urge members to contact customer service or health service system and we need to know who they are and can make the outreaches as necessary. >> again i think a concern was that a lot of the primary care providers probably do accept the plan, but the referral pattern may not know what they refer to a cardiologist or rheumtolgist so make sure the process is transparent. >> right. >> i want to take the moment to thank you on behalf of the board for the thoroughness of your commitments and your activity through open enrollment, through the process of bringing this plan into being and we look

forward to continued partnership and work wg you. >> thank you. >> any other public comment from any other plan representative? >> good afternoon paul brown direct r of accountmanagement for blue shield. i have two updates i like to make brief update. this board is taking interest over the last year in cal index and there was a announcement this week i want to make you aware of. as a reminor cal index is independent non-profit and not aa partf blue shield. earlier this week cal index will merge with the inland empire helths information exchange in the river side san bernardino area creating now what will be one of the nations largest information exchanges based on the number of patient reports. the combined organization also

announced a new ceo, claudia williams who is former white house technology senior advisor. she has deep experience in healthcare and information technology and previous served as director och health information exchange at the u.s. department of helths and human services. the merger accelerates the effort to provide hospitals and physicians with real-time health information to provide higher quality care for our patients. provide you with that update and separate unrelated update that blue shield last week closed a three year deal with sutter health without any member disruption ment two years ago the deal took several weeks and a lot of angst among members and able to close the deal a couple days after the last deal

ended and ret rote active to january 1 and a three year deal. >> thank you paul for updates on both of those items and i continue to be amazed at the changes in the cal index process. thank you. >> what is the name of the organization cal index merged with? >> inland empire health information exchange. >> inland. >> so, what is the new name? is cal index the new name or what is the new name of the organization? >> that is my next update because there will be a new name. it won't be inlend inempire or cal index. >> is inland also non -profit? >> yes, same status non-profit. >> let me launch into this or

hold off which i will do when you come back with the new name. >> thank you. >> thank you, paul. >> i think it makes a total 16 million lives. >> i think there is 16 million patient records and i think the next largest in the united states is something on the order of 12 million. if it isn't the largest is it one of the largest in the country now. >> thank you and are there any other representative updates? i would like to take the opportunity to thank kaiser for what they announced at the meet ing last month regarding the allowance for people to turn in outidated or unused prescription drugs in the city and quounty of san francisco. i'm anxiously awaiting that opportunity at my local kaiser facility. i did not see the blue box but i know

that it will be there soon and looking forward to getting rid of some och instuff. thank you for doing that and being responsive. i hope some other healthcare systems that are base d in northern california will follow your lead. any public comment on the item? >> dennis kruger active retired fire fighters spouses and widows. two questions if i direct dlou the chair to united helthd care. first question, have they made any kind of i guess provisions for people who have long term prescription care in other facility to transfer over to united healthcare? three month prescriptions? the second thing is, the fact that i know now can see any doctor who takes

medicare without going through my primary physician, are there steps in place so that where ever i travel all this information that is gathered by the new doctor or whatever who ever you see, will eventually get back to my primary physician? is that up to me to do? is that up to united heblth care to do or is that up to the doctor who you are visiting to do? those are two questions. &thank you for the questions. the united healthcare representative can answer those items please do. >> the first has to do with prescription drug transfers. we did take in a open refill transfer file from blue shield for the mail order and those are in our system now, so if there are refills left as of 12/31 we

will pick those up and the member needs to call to reestablish them. >> i think the question was long term. >> three months. at a retail pharmacy? >> i have one prescription i get every three months long term through mail. that is what i'm trying to find out. are there provisions united healthcare to assist people [inaudible] >> yes, we did transfer mail order refills. there are some drugs that cannot be transferred and require a new prescription. also, if you have a refill left at the retail pharmacy you should be able to continue to fill those, just need to show the new id card. the second question was, as you

are seeing doctors outside of your primary care, how do the medical records gets back to the your primary care physician. i make a guess here but i assume that is your responsibility to get those records to your primary care and that would not fall on united healthcare to do. >> since there is a implication that may be wider than the person who asked the question i ask that you research that question. >> i will research >> and bring it back next month to have clarity on that point. >> i will do so. >> thank you very much. any other public comment? hearing and seeing none we move to 16. >> iletm 16, discushz item. tupt to place items on future agendas. >> any public comment? hearing and seeing none we go to 17.

>> 17, discussion iletm. opportunity for the public to comment on matters within sth board jurisdiction. >> i just want to compliment the board and executive director on their good work. we are really facing stormy waters ahead and you guys really have a touch assignment and i don't want to see the board or executive director or the health service system donald trumped. thank you. >> thank you, any other public comment? hearing none-sorry. seeing none- >> dennis kruger active retired fire fighters and dependents. a talk i did earlier about catherine one thing i forgot to do is say thank you very much catherine from the fire fighters spouses and widows. thank you. >> thank you very much. any other public comment or on the item?

if not, we will move to a action iletm. >> item 18, vote on whether to hold closed session for member appeal and hss executive director performance evaluation. >> willing to entertain a motion. >> i like to make a statement before we go to closed session. >> this is regarding directors evaluation. this is a board of equals and no board member has the right to change anothers evaluation without their consent. unless all board members are heard there is no point of the evaluation and point of feedback for the director. without different opinions you will have group think and rubber stamping board so want to put this out there before we go into closed session. >> commissioners comment and noded. willing to entertain a motion to move into closed session. >> i move we go into cleezed session. >> secsd.

>> properly moved and seconded we go into close said session. any comments from the board? any public comment? >> did you want me to stay for the appeal? i wasn't hear at the first hearing. >> yes. >> we are ready to vote. all in favor going into closed session say aye. >> aye. >> opposed? we like to thank each of you for being here today as we go into closed session and again, happy new year.