does what they do so well that we won't have to change the benefits. so as you see some of these numbers, if you do a comparison to go back and say how did hss is due compared to the somerset at the 10 county which is the bottom percentile there, i want to make it clear that these increases for these summaries, italy's average of averages, also are impacted by the fact they were reduced benefits and if you go back and read all the devils in the details you will see that. there've a lot of ages eight to have a lot of high deductible, the programs change. so i will stop that explanation. i just want to let you know. so before my recommendation is you approve the number which technically is what we have to do. >> all right. recommendation from the action could any questions? >> i'm curious about the santa clara county keeps going up a lot of the time. i used to know some details about their benefits but i don't know. >> well, we looked into santa

clara county specifically when we did one of our peers and we had people at hss look at it again could correct me if i'm wrong but they want to the new period of collective bargaining adjustably increased with a offered. it stayed fairly stable for a while. our understanding is gone up in the hope it will continue to go up. so they're just being more right now. it was more of we need to is that correct? >> >> that is correct. but they also formalize the county plan could santa clara county employees could elect to be part of the santa clara county health plan. i think it's called valley health. >> yes. >> the county was subsidizing it. the county stop subsidizing it. >> yes sir >> i will make sure i'm clear. some counties like la offers an

account like 50 different plans and some are like five. these are not weighted. these are not weighted averages based on how many people actually elect what looks like a cadillac plan or something week it's just an average of 15 >> that is the algorithm until we go through the process. you are absolutely correct, sir. >> [cross-talking / off mic] in the charter to doing actual item we have some flexible the correct me if i'm wrong, eric that we can adjust this to a certain degree but the average of the averages is embedded in the charter language. >> okay. any other questions from the board? i'm ready to entertain a motion. >> so moved. >> second. >> properly moved and seconded that we adopt the recommendation contained in the 10 county survey.

>> can i say the amount? >> let me finish the motion. with an average amount of $649.17. okay thank you for that prompt for the action. so that is a motion. and a second. any other questions or comments from the board? any public comment? hearing none, and seeing none, no public comments, we are now ready to vote. all those in favor say, aye. [chorus of ayes.] opposed, say nay. the motion carries unanimously >>[gavel] >> thank you. we are now ready to move to action item before in the rates and benefits agenda >> item number four action item presentation on self-funded program the insurance stoploss recommendation mr. hewitt >> it's come to my attention this particular document again

mr. hewitt ashtray. this particular document may not be in the packets. so we need to flash that one up on the screen. then i'll talk about what it says. >> okay. we have it on the screen. it's the handout we were given prior to the meeting that's updated is that part of this presentation or another? >> no. it's different. >> all right. okay. >> okay. do you have on your ipads this presentation >> yes we do >> okay. what it basically says is that what we are talking about is that the as the board including myself for some reason the board looks at each year whether or not they have the proper risk abatement coverage the insurance to correctly cover any apparent risk the may attack the bounty of the trust. this is what you

request from the actuaries to bring to your attention and to we with our reserves are contingency reserves in any external the insurance recovering a risk exposure correctly? do we need to get more coverage for any new exposure has been created or do you feel--or is your professional judgment that we are in good shape as we sit right now? so where do you have exposure? that's where you take risk. you ship it off to the vendor and the vendor says, i got this. good to go. you don't have to worry about any additional calls on monday. what happens is where you have the self-funded dental, the self-funded ppo program, and you have your flex funding could love three areas where you have exposure to risk because you create a premium

equivalent. you charge that and collect the money from all the entities part of this trust and then you pay claims. if you bunch of excess cost he would say i need to be able to cover that cost. we share with you who these are on the very first page as i spoke to united healthcare and in this document we presented last year we discussed what the virtues of this which is kind of what i've already alluded to, and then we going to talk about but you presently have. would you presently have is a contingency reserve. we presented the contingency reserve amounts in january that were set as of june 30, 2016. we set them once a year, take [inaudible] reviews them put them in the audit statement. they say these are correct that the fiduciaries are doing a good job holding these amounts of money and if the proper exercise and taking care of your exposure. we go through this and say, yes, reassurance is a good thing but you technically have with your contingency reserve, quite a

bit of the insurance. so it is your own internal re-insurance. then you have a policy if exposure gets a little out of hand called a stabilization policy could you say, okay, we have a fully funded set about reserves for terminal liability >> that is what we >> incurred but not reported reserves which is reserved required to have-they take the response within risk in house and pays claims. what that is for the edification of the audience beyond me, you collect claims coming after a certain date and time you have the money on your books to pay those claims. so you are balance sheet is in order in terms of that amount of money. let your contingency reserve each we will share with you is in the document amounts vary vary by these programs and you also the stabilization reserve.

so with the stabilization reserved as if this things runs a little more expensive than we had taken in, then we go through and set that amount. we did that last time for united healthcare. will do that again for blue shield. we will do that next month for delta dental. you take that money and over a three years you amortize that money and it goes into a deficit of three years to bring it back. you are always trying to true up the pool and cover your exposure as it is based on your historical necessities to cover based on certain algorithms that actually slick to develop. with that being said, i want to go to the and and say, here is my recommendation here i am sorry. i just want to show you how much contingency reserves -contingency >> that can be found in the appendix is that correct? >> yes sir. you have as of june

30 5,000,006 and $49 united healthcare contingency reserve. that's the last posted amount. last month, when we did the united healthcare claims stabilization we highlighted the fact that some of that is not present necessary anymore because you have moved the medicare retirees over to the fully insured premium we give you the same schedule we give you enchanted. here is your dental delta dental amount and for who showed up $50 million in contingency reserve that the amount you have money up to cover excess exposure. under bead with the recommended it says given the funding policies in the reserve supplement stabilization and having all these programs. the [inaudible] we recommend >> who is weak we >> aion hewitt you're actually. >> thank you

>> okay. reference no additional being-insurance is required and any further insurance would be considered redundant i'm not change the position because you have all this money already on about balance sheet from last year. you basically restate what we said last year. it's very same march meeting. at this point i would want you to buy no further reinsurance and maintain all your great policies. that's it. >> any clear fine questions from the board? >> we've not had the stoploss for years we >> you have external to this we have stoploss with blue shield of $1 million. so embedded in the flex funding arrangement is a $1 million cap to your individual claims exposure to flex funding. you do not have the stoploss for united healthcare. you have the contingency reserve. you have not had stoploss united

healthcare since i've been your actuary. but you made have it in the basket i'm just unaware. >> all right. any of the questions? commissioner sass >> yes thanks. when i look at the visit she can get out here and i saw other sheets in the package that i actually do see stoploss, stoploss credits showing up on our total expenses for the flex funds claims four 2015. so it's recommend from a million-dollar built-in stoploss? >> yes sir >> our practice has been to not augment that? >> that is correct because the pool is so big you don't generally speaking though lower than our threshold because of the trade-off could you be a premium that has alone for expenses, margin etc. and since you have the cash resized with $300 million proposition for that piece alone is probably

not cost beneficial to lower that say $500,000 and push that money out. at this point in time. >> any other clear fine questions? if not i'm ready to entertain a motion. >> so moved. >> is there a second? >> second. this is been probably moved and second except the recordation of aion hewitt not to purchase any further re-insurance for the plan year 2018. is there any questions or comments from the board on the motion? is there any public comment on this item? hearing none, and seeing none, no public comment we are ready to vote. all those in favor say, aye. [chorus of ayes.] opposed, say nay. it passes unanimously

>>[gavel] next item we will go to discussion item number five. sec. >> item number five discussion and review blue shield 2016 flex funded non-medicare claims experience could aion hewitt. >> now is this where we have a extra piece of paper? >> yes circuit he was not asking you where i'm just asking >> yes a piece of paper. >> there's an extra display chart distributed and i assume available here in the room? >> yes is a stack of them on the desk. >> that updates one of the slides and you will highlight which one that is. >> i will definitely do that. as a matter practice before we present the claims stabilization for blue shield since visiting risk taking proposition we present the experience data to give you an idea of how this

program has run since you take the risk in house and you're exposed to these costs and the truss of course has to fund the claims. with that being said, please, turn to the summary and i'll go through and give you some highlights of what happened . there is an adjustment that was made that we will describe to you but overall, expenses with all adjustments made total sense is increased 3% on a member per month basis. decapitations actually because of changes in membership went down and pharmacy costs which we have shared with you in the past are very problematic increased 8% get some of these bolts are things you would expect to hear as we go on. we have a fairly substantial executive summary item i would like to explain to you and say we have the highest regard for the habits of blue shield for what they have done to benefit

the trust and what has happened is, >> is this board one? >> poet one >> micro-printed paragraph? >> yes i'm going to let you know what has happened >> page 3 of the presentation >> yes page 3 of the presentation all as all the dollars can we get all the claims we get all the decapitation administrative fees, blue shield in their quest for integrity doing the right thing for the right reasons, was working steadfastly the department of managed health care they were able to change the definition of what is considered an insured product when it comes to your flex funding program. so what does that mean to you? redesignated as insured in 15, in 16 you are no longer designated as insured. so the 9,000,009 or $34,000 estimate of your [inaudible] is no longer with blue shield it is

now in your balance sheet good they've given us one payment and they will eventually in the next month or so give us the second payment. what has it done? is changed the results of the experience for this program four 2016 and you will no longer be charged the tax regardless of the changes of what is going on in washington today, if it was to be maintained, he would not be under current definitions, assess the tax. that is a $10 million swing in cost.. when we first presented these materials and 13, when we went to the aco, to the flex funded we were in the aco but to the flex funding part,--you are not assessed a hit tax. as time has gone on abysses created a very large expenditure for this city and county. so this is-i knew

being a little dramatic but i'm very happiness happen on your behalf. i think this is great. this change the results of 2016. going from what would be a slight deficit of four-$5 million who are +4-$5 million. all driven by the hit tax. so that is what i want to share with you and then we can now look at >> russia was 90.64%? yes, sir. >> yes, sir with the hit tax you collected more money than you spend creating again. we need the bounces in the trust fund will be bigger. >> all right. >> yes, sir? >> this won't be too into thousands of the >> it will be true forever. you won't pay. >> one. forever but in terms of balance sheet, we see every december >> no. >> that's what i thought >> did i mistake that? >> no. i just want to make sure. when we get to page 4,

type a concern about the trends but i guess when we get to page 4 can talk about it >> absolutely. >> just to be clear this is a one-time event >> yes one-time event he paid the money and we got it that >> thank you commissioner sass >> isn't it the true the premium structure we built for 2017 assumed a hit tax? >> actually be hit tax was not requested for-or, for one year, go ahead >> congress waived the hit tax kind of an election everybody want to get reelected to the way the hit tax. >> okay. >> so when we did the renewal he did not include the hit tax. so we generated a lot of cash. that's $1 million they have been buried in there. it's not there. we took it out. with that being the case, but in 18 you are absolutely-we will not

be assessing that tax. we don't have to waste of tax rates >> undercurrents lockley >> under current law, yes, sir >> so for 2016 absences refundable would have shown a loss in actuarial loss for the year in actual loss compared to her estimated position as opposed to adding some dollars to our stabilization reserves would've been taking a significant amount of funding >> yes, sir that is correct. we'll outline that in our next presentation how that impacted our overall unanswered. so turn to page for this is a great discussion before i do that anymore questions or comments? >> please, proceed >> what you have on page 4 is a month by month experience in this it table that we presented in the past. this table is developed by our good friends at hss us-we actually use this

this is the cash accounting. this ties explicitly to the finances and experience the invoicing of the trust. we don't take an independent claims extract tried to back to the cash number should these are the trust cash numbers. the way i practice is and actually went to present this information i like the cash numbers good in that particular have been going to this particular exercise. so what is this? this is the top line is the premium annexes the admin, our run rate for admin is $2.4 million. then we adjusted 02 $9 million in december because that's when we found out this money was coming back to the trust. at the end of the day, the admin expense for the year is $18 million, 18,000,007 and $31,000. that number is quite a bit less than

the number was in 15 and we will see this in the next schedule. now decapitation is run at roughly $6 billion. radical claims, that being fee for service, said her health plan, hill physicians, we let you know what the previous meeting they did quite a good job so some of their stuff is sort of managing through the aco has improved good this is all of the expense for the non-capitated piece. capitation is physicians received a prepayment and they take care of the defined set of benefits on behalf of the patients were employed or early retirees from this program and the rest is a fee-for-service exercise. so we go through that. pharmacy as we know has caused everybody a lot of headaches because of the incredible exponential growth of specialty drugs. then the good thing about the pharmacies we get rebates. so we pay $52 million in the pharmacy claims

and we got $3.2 million in rebates. we pay $709,000 to the hill physician group for their heating a claims target. we had some stop loss and this year we had much more stoploss in the prior year with a beat thresholds and we change the monthly [inaudible] saw this been said when you look at the expenses and you look at but we took into the house adjusted for the hit tax, it created a 90.64% loss ratio. so good news is we brought in money. we paid everything we could got an adjustment and we have more money than we brought in so that will help us adjust the stabilization reserves which we

will present in our next presentation >> all right. >> that is the data >> this is a discussion item. any other questions we >> look at the line on capitation, the reason why capitation is going up is the number of subscribers is going down? >> yes you have professional groups who raise their capitation rates and you have the who raises their capitation rates for mental health services . so they come into the marketplace and they say we will take care of it for this and every so often they just raise the amount that they charge. then there's another thing that can happen is if you're a mix of people you have more older people then you end up paying more capitation because there age adjusted. so have we had increases in caps? yes. have they been extraordinary, no yes, they do increase.

>> i was looking at the number of subscribers going down and capitation goes up. >> yes sometimes it's the billions we comes when the customers coming. half of the month is paid. some these go up and down. anyway any other questions >> commissioner follansbee >> yes our make sure i'm clear. when i look at the monthly incurred loss ratio 90.64% for the year, with that's driven by december because before december if you just average 11 was about 102% but technically the reason was driven down is this refund from the shield which would normally that have appeared in the-that tax that we were dissipating, that have appeared in administration? it's a one-month hit but technically we had not paid at that administration cost within equal to that over the course of the year because 90.64 is

still valid even though it looks skewed? >> yes. per 17 usc much lower number. under administration. i think it's roughly 6 or $700,000 less a month. they could give you the [inaudible] >> right. questions from the board? any public comment on this item? public comments. there is no public comment. any other comments? pete >> well, well we have one more page. this a year over year comparison to dr. follansbee's comments you see what was

interesting for the administration. it was $28 million. that was $18 without adjustment. so what we hope to see and we expect to see your pretty sure we will see, is $89 with in the range or 2017. all these other numbers are numbers taken from previous presentations this presentation to give you the rate of change of these various pieces of the expense items for this program. >> all right. with that, this item is concluded. we will now move on to action item number six. >> item number six action item approval shield rate stabilization reserves. aion hewitt >> this presentation is also active in the packet and we hope we will see it on the screen momentarily. >> okay. good afternoon aion hewitt this is my final presentation for the gate this inaction really want to approve-approved by recordation if you choose to. i'm going to skip over to page 5. i will briefly remind everybody as we talked about we talked about the insurance the stabilization of reserves is a method by

which we take danger losses, put them into our running total and then amortize the data lost back into the rate. so if you're not loss of deficit position you technically are adding money to the rate. whether dean position, you are actually reducing rates. we giving the money back. while the rating done by this board to your direction and policies that before i begin your actuary, are to benefit the employees and members of the trust. there is no money that set aside for any reason except to bring it back to these people inappropriate and pragmatic financially responsible method. that's why this exists. it is to do that and follow that policy. so this a fairly standard exhibit we present every year. on page 5, the expected: is what we set out when we established the stabilization reserve in the fall apart your good we were in

a deficit position meaning that we had been losing money if you want to just be retaining monies were losing money-we were spending more than we were collecting so at that point in time when we set the rates for 16 be built into the rates 4 million dollars the we needed to put in each of the respective rates. the enacted by the three-member tears early retirees retirees could we put those amounts and can we spread it based on premium and headcounts and said this is $10 for this one etc. etc. bit it's an exercise we do every year for each of these individuals propositions where we take risk and so we were expecting to make a game because we wanted to collect more money to wipe out the deficit then, we were going to spend. so how did we do? well we actually created a

game and we know why we created the game. of 4,000,003 and $40,000. then we change the contingency reserve, the gain is in the actual column and just to be real clear for the board in any males whose following along, all these actual numbers are on that experience report. you take those summers and bring them over here. >> what did you omit? you never forget. with today amid saying or doing in the prior presentation? >> okay. this page 5 i forgot to share the bottom line i to change the numbers for the contingency reserve. it doesn't change anything were saying or asking you to approve. it just this line needed to be updated. change in the can change as a result >> that's what this extra sheet is about? >> yes >> the esther sheet is in our presentation and it's a correction page 5 >> yes thank you for pointing

that out to the public. >> okay. now we are back to page 5 in the current presentation be thank you for being so nice. thank you, circuit we have the contingency reserve. when we do all the adjustments to this amount of money and you look at what we said we were going to gain but we actually gained adjusted and then we go through the entire exercise and say what is the net effect of this exercise. we didn't gain as much with all adjustments as we needed to gain so we were short $327,000. if we haven't got the head tax so that we are perfectly clear, that amount of money would have been close to $10 million. to answer your question dr. follansbee. so we're $327,000 short. what do we do with that money? let's go over to page 7. we look at page 7 we had a

running balance of 10 million. $307,000 could be at our $327,000 to the balance. that creates 10,000,006 and $43,000 we have to divide that by three. so for rates in 2018 we will be adding 3.5 million dollars based upon the requirements in the algorithms that have an established for several years but the health services trust pain stabilization policy. so my recommendation is you approve the amount and we go forth and do this when we create the rate tables for 2018 for the blue shield excellent program. >> all right. questions by members of the board? if there's no questions, clarifying or otherwise, i'll

entertain a motion? >> emotion- >> which can be found on page 8. that's a summation of the recommendation. >> i moved to approve aion hewitt's recommendation >> which requires- >> which requires energization of $10 million over a three-year period. adding 3 million [inaudible] the 2018 blue shield plan. >> is there a second? >> second. >> is a motion a second that we accept the aion hewitt recommendation contained in the presentation. any clarifying questions on the is there a motion? were comments? any public comment? hearing none, and seeing none, no public comment? we are ready to vote

all those in favor say, aye. [chorus of ayes.] opposed, say nay. he had a miscarriage >>[gavel] >> thank you. we are now ready to move to action item seven. >> item seven action item addition of sperm freezing to infertility benefit. dir. dodd. >> commissioners, thank you kent catherine dodd director san francisco health system get you past a conference of infertility and be productive technology benefit at the last meeting, yes and was brought to

our attention that it focused on the female gender and that there are infertility issues related to the male gender and that contact oftentimes men and upping infertile after treatment for cancer or some other kinds of things. so we wanted to add sperm freezing for up to a year. after that they would have to pay for it themselves, just like we provide the gamete freezing. it expressly excludes sperm freezing just until you find the right person. it's really related to physical illness. >> it's one-time? >> yes. just like infertility benefit >> all right. >> what is the extra cost?

>> it's hard to predict. it's the same cost as it is to please the gametes and we don't know how many people will take it vantage of a. so, i am sorry i don't have had and i cannot predict that >> is this one would put a cap on the number, the authorized amount dollar amount or my confusion out with another? >> that was the surrogacy. >> set that aside. forget that i even asked that question. all right. so at this point there is no estimate of utilization. we have no experience in this area at this point. as we do not have >> we could probably go back and look at how many men have had prostate cancer we do know they want to freeze their sperm >> right. i understand. it's kind of hard to quantify at this point. but this would be the equalizing of a benefit for both genders, if you will and

might be covered in our plan. >> that's right because discriminatory >> i understand. but we be called discriminatory its equal benefits in that sense. so any of the clarifying questions from the board? i'm ready to entertain a motion. >> i moved that we approve the recommendation for a one-time benefit for leasing of sperm or one year. >> is there a second? >> second. >> is been properly moved and second. any clarifying questions on the is there a motion? members of the board? is there any public comment? any additional comment? hearing none, and seeing none,

no comments were now ready to go with. all those in favor say, aye. [chorus of ayes.] opposed, say nay. i wanted noted it passes unanimously. >>[gavel] >> it be easier for we went to discussion item 9 director dodd? [inaudible/off mic] yes. since you're standing at the microphone. i've asked the person that will be different to an discussion item 8, just to stand by since she is there who take this discussion item privilege of the chair discussion item 9 >> item nine discussion item on gender dysphoria benefits director dodd >> i think-first one to pay tribute to the haiti and william could not and michael this country who approached and

worked with our vendors to try and establish equity from vendor to vendor in terms of what we provide for gender dysphoria which includes transgender surgery and other transgender related treatments. we also met with having him looking for his name. the uh see director of transgender services. i don't have it at my fingertips. he was very helpful in terms of going through what the standards of care are. we have, in your packet, the world professional association for transgender health, which has updated their recommendations and i think that what is great

about this point in time is that there is a medical standard of care. when we pass this visionary and innovative benefit so many years ago we were kind of just venturing into it. we didn't look to see how the different benefits changed. so this will update our benefits so that meets the standard of care. i think that it is important to understand, as stated in the past doctrine that every patient will not have a medical need for identical procedures. every patient is different. clinically appropriate treatment must be determined on an individualized and contextual basis in the consultation the patient's medical providers. the medical procedures attendant to gender affirming-confirming surgeries

are not cosmetic or elective or for the your convenience of the patient. these reconstructive procedures are not only optional -are not optional in any meaningful sense but are understood to be medically necessary for the treatment of a diagnosed condition. in some cases, surgery is the only effective treatment for the condition and for some genital surgery is a centrally life saving. >> director dodd is that particular summary, our hosting is contained in the presentation? the slide presentation? >> no. they are not >> i asked they be inserted as part of the minutes if you will and materials for this meeting . so you can excerpt or summarize it however you want to but we need to post that information with this item on the website. >> okay. so if you look at the deck before you, the definition

of gender dysphoria for adolescents and adults is included on page 1. it says, marked incongruence between one owns expressed-or one's own experience of gender and assigned gender were at least six months duration of 26 months duration and manifested by at least two of the following. there are six items that are manifestations of gender dysphoria. i'm not going to go through them but this is from the sister sickle manual of mental disorders 50 addition dsm five. on page 2 gender dysphoria is defined for children and it's a marked incongruence between swans experience or express gender and assigned gender release

six-month duration is manifested by six of the following. so-but were separating children out. if you turn to page 3, this whole area of gender dysphoria and children and adolescents is kind of coming to the fore, 60 min. did a couple of episodes on it. in american society is increasingly recognizing the children and adolescents experienced gender dysphoria. the national geographic had a special issue on gender good boy scouts of america began to allow transgender boys to participate in the girl scouts of america. and except transgender members and there's a heightened awareness of gender dysphoria in children and adolescents which may lead to an interest in medical treatment and the options for the best practices. so what is the treatment? for adolescents and adults you must be at

least 18 years to receive gender reassignment surgery. for adolescents and young adults, you must be at least in stage ii of the scale physical development which is kind of like how you measure puberty. using the inanimate but releasing hormone [inaudible] and the analogues are listed in 4. treatment with families with adolescents experience gender distal dysphoria is important. we want to make sure that members and dependents receive information about the potential risk and benefits both short-term and long-term of treating gender dysphoria in adolescents. per dr. gavin was referenced earlier at uht long-term outcomes appear to be relatively stable and safe for people treated with cabana tropic hormone gnrh but

potentially long-term side effects may include premature osteoporosis. the fda's currently reviewing the nervous system and psychiatric events associate with these analogues in the accurate application. local experts are available to help. the child and adolescent gender clinic at ucsf guides parents, patients and six transition with without medical intervention and the gender pathway clinic at kaiser permanente is the same. let's just go back to 2001. that's when the city and county became the first local government of its kind in the first major employer in the united states to include gender dysphoria related care including reassignment surgery. as part of our benefit design. the quote at the time were this is very much a civil rights issue is about equal benefits for

equal work and when i told sen. leno we were revisiting this he said you wanted to come and testify. i said, i don't think we need you at this point. but i will let you know if we do. he was pleased that we are-it's been a long time since 2001 there were updating this for keeping the standard of care. so there are two quotes therefrom 2001. if you look at the next page, seven, the covered benefits in 2001 included genital reconstruction and chest reconstruction of e-mail to mail. was it to an $50 deductible the lifetime cap of $50,000 per person. the health service board implemented a surcharge of the dollar 70 per per for participants per month and limited the eligibility to people who have been held service matters for more than a year. in 2004 $4.3 million in

surcharges having collected to offset projected claims. and we only have 166 thousand dollars worth of claims spent on seven different claims should you we collected $4.3 million. so the lifetime cap was raised to $75,000 and the city ppo surcharge to $.50 per month. the one-year required analogy but he was removed. so you could seek treatment upon entry into the health services. in 2006 we collected $5.6 million in surcharges and had to enter and 10 claimants. we paid out a total of three earned $83,000 on just 37 claims. as a result, the participant surcharges were dropped entirely. a little historical notes along the

right side. in 2013 the california department of managed health care clarified the plan that plans are prohibited from discriminating against individuals because of gender identity, expression resulting kaiser and blue shield dropping the lifetime cap. this is also a federal crime and as part of the affordable care act. after that august 13 board meeting you a see also limited lifetime caps for active employees and early retirees. not related to us, but in 2012 san francisco became the first us city to cover gender the assignment surgery for an insured residents as part of the public health department. so in 2007 kaiser moved $75,000 lifetime cap on the medicare advantage plan to ensure consistency dr. devin estimates that across all the united healthcare business the per member per month cost is about $.10 for offering

gender dysphoria benefits. at the same time the rest of the world military permitted transgender people to serve and offers medically necessary therapies and into a texas judge issued a national injunction suspended the enforcement of the nondiscrimination ovation. so this is especially important now because that nondiscrimination provision has been suspended. so-sorry this is taking so long with the complex deck which is why you're the month to think about. currently we have a lack of consistency across plans. many plans exclude benefits. other plans include them. so the w-past issued a position statement on the medical necessity of treatment. sexual

reassignment and insurance coverage in us urging health insurers carriers to eliminate transgender transsexual exclusions from their policy documents in medical guidelines. every patient will not have the medical need for identical procedures about language is in the deck i apologize. let's look at what the benefits are. on page 10, all currently all three of our vendors cover mental health services and counseling. all three of our vendors cover nonsurgical gender confirming therapies services or [inaudible] and lab testing to make sure that ramon levels are connected all three of our vendors cover gnrh and that the trade name of one of the drugs. an analog for puberty suppression. and all three of our plans cover confirming lower butter surgery. body surgery. on page 11 the

skin servicing which are chemical skin treatments are excluded by all three >> these are services that according to that they recommend and we, parenthetically, it says no recommendations to change. is that your-and without the your staff recommendation coming to us that these items on this page would not be recommended for change? >> correct. those include sperm organic procurement for future infertility,. we essentially already do that at the beginning of 2018. so we don't need to add that to our gender dysphoria benefit. abdominal fasting which is cosmetic surgical procedure to improve the appearance of the abdomen. that would continue to be excluded and calf implants would be excluded.

>> i was just pointing that out to make it clear, we know it's included currently. these are things that are exquisite and we are saying that even with the recommended future changes these would continue to be excluded in across all three? >> correct. beers on to page 12 >> on to page 12. these are places where there was disagreement between the plans and we are recommending the first column which is from blue shield does that it would be considered as a benefit after it was reviewed for medical necessity and that includes a brow lift or brow reduction could change cheek and nose implants. and chin augmentation. again, this is reviewed for medical necessity. so we are

recommending that people language and you can see that kaiser excludes it excludes brow reductions. what qualifies as reconstructive surgery, they cover chin, cheek, and nose implants when it is reconstructive surgery and they covered chin augmentation when it qualifies as reconstructive surgery. united healthcare currently excludes all of these so this would be a big change for united healthcare. >> all right. again i want to be clear that the items as highlighted on page 12 and 13 are the services that you are recommending that the other plans offer that are currently either excluded or limited in some way? is that correct? >> correct. >> okay. just a graphite dr. follansbee >> i want to be clear of using the criterion of medical necessity? are they established? either zealous criteria outside of blue

shield, that blue shield adopted? bill does blue shield have its own criteria because medical necessity is a bit vague frankly. i'm curious to know how we we get all the plans on the scene-medical necessity criteria that would not be immersed when not be excluded by medical necessity on one perimeter accepted on another peer i want to know if there's criteria? b was to my knowledge we do not >> to my knowledge we do not ask for the critical we can do that before next month's meeting >> it would be helpful and i know there has been a be some preliminary feedback by some plans so once we get those criteria they may want to comment on whether those criteria are consistent with what they would consider to be medical necessity. you may want to share them if you ever see

them in sufficient time. >> we will attempt to do that. >> if you can >> i will back to the statement that we began with which is that every patient will not have a medical need for identical procedures. so clinically early achievements must be determined on an individualized and contextual basis. so i am not certain we will have criteria because-do we have to say you are brow with >> has to be we will ask the show for what their criteria if they have established criteria >> were, what a mighty broader not only the criteria, what process do they use to make a determination? even if it is

into the light individualized treatment are going to engage in some kind of process that is at a peer review panel looking at all the factors were said something else. i don't know but whatever they are doing, if we can make the other plans aware that so they can comment not only on the benefit but with this criterion might mean and i think that might give us a balanced assessed assessment >> i want to reiterate keyboards because i think it would be ideal to have fairly uniform criteria. so that members don't come back to us complaining that so-and-so got this through whatever doctor and whatever plan or whatever plan, and i didn't and i am worse. we would have no way to adjudicate that if we do know what the criteria are. >> it's a good point. we will do our best to find out. so page 13 we go through chest

reconstruction, [inaudible] breast implants, again when policy criteria are met and we will come to find out widows policy criteria are, and the facelift for his left were neck tightening is reviewed for medical necessity. this one is excluded by both kaiser and united healthcare. the facial bone remodeling for [inaudible] masculinization, again it's covered when it qualifies as reconstructive surgery by kaiser. excluded by united healthcare and we recommend the language that we attribute for medical necessity. similarly, on page 14 state facial hair removal. it's absolutely covered by kaiser. six goodbye united healthcare and the language is the same for you should have lost growth drugs is excluded. we recommend it be

reviewed for medical necessity again individual people respond differently to drugs have different amounts of hair hair transplantation, again excluded and we recommend that it be reviewed for medical necessity. i don't think we're talking not just hair implementation for mayor pattern baldness. i think would talk about your implementation that relates to a gender. [inaudible] reshaping of your adam's apple again we suggest it be reviewed for medical necessity up with augmentation lip reduction liposuction, like opacity and like fulfilling, we recommend the shield language. injection of fillers are neurotoxins: gender botox injections. those are both excluded. those are

excluded by blue shield and united healthcare. but included by kaiser and we are reckoning kaiser's language in this particular benefit. vasectomy with chest reduction. the services may be considered when medically necessary. pectoral implants for chest vascularized nation. baluchi shield language rhinoplasty excluded by kaiser and united healthcare we recommend that a be reviewed an apostate is nose surgery. thyroid and cartilage reduction and thyroid condo plastique which is tracheal shave and maybe you can help was that dr. follansbee the was just reducing the external appearance of the thyroid cartilage of the neck. particularly if males are

transitioning to fema. speak >> okay. voice modifications are big again recommending the blue shield language. voice therapy or lessons. kaiser covers it but we are recommending blue shield language. nipple tattooing again, we are recommending the language luteal and have augmentation,. these united healthcare does all of them. there excluded that mr. medically necessary. so there is an agreement to their and disagreement with kaiser shaw mandibular reduction augmentation covered when it qualifies as reconstructive surgery. the terms of kaiser and the last one is speed travel and lodging in both the shields and kaiser have benefits in this area that blue

shield says these arrangements must be preapproved in advance by the plan and are solely limited to the expenses for the member who is going to kaiser says it's covered if you [inaudible] provider outside your home region. and united healthcare doesn't cover it. so now you know about all the inclusion of the benefits. the goal of the recommendation is to ensure consistency across all plans to prevent adverse selection to highlight dr. phone speed might happen if we are not clear on what the criteria is and to retain the san francisco health services system progressive commitment to bringing the well-being of employees retirees and dependents. adopting these recommendations will align san francisco health services system the world professional association of transgender health recommendation to eliminate gender dysphoria services. so the first

recommendation to require all plans to adopt the approach taken by the shield. then they are listed additionally to ensure consistency to require all plans to review from the medical necessity the injection of fillers or neurotoxins. the second recommendation is to eliminate the $75,000 cap for gender dysphoria in the uht ma pd plan. the third is to acquire parity plans offering both transgender and trans fund services for the coverage of travel and lodging expenses. and the fourth is to adopt the san francisco health system draft gender dysphoria policy statement which is attached. i'm not going to read through. it clearly defines what gender dysphoria is in terms of children and then it talks

about-we reviewed some of this so this is just a detail what was in the deck. docs of adolescents and then it talks about consideration for families with children expensing gender dysphoria. and we go through the history which i just highlighted but this is more specific about the history. it talks about what reconstructive surgery is and it looks like on my deck this was stable twice about be the policy we asked the board to adopt and be on record as guiding our benefit choices in the future. are there other questions? >> yes i have one. we have a suggested policy and is a you are intent these suggested plan changes would be incremented by

all plans for plan year 2018 or, with a be phased in over a period of time, or what? >> well, ideally we have requested they be implemented by 2018. you can see that blue shield has them the much already. i understand there might be ministry the barriers within plans and would only hope that the plans would continue to work with us in being the first and the best in the nation. to make sure that there is access to the call quality gender dysphoria benefits. >> is there a process that you up in terms of discussions with the plans to kind of milestone if we don't-if we are looking at this benefit they're looking

at everything else are doing on the renewal and they're saying, okay, we can get 70% of this done this year. this may be regulatory changes my practitioners, whatever else they indicate a must do to align with whatever the plants are doing and weekend get the other 30% done. then >> we are not going to save you won't enroll people in your plan. but we will let members know which lands offer a full complement of gender dysphoria benefits and which don't. >> all right. but it would be a larger consideration of the delaying the large change recommends reconciliation to the following plan cycle? >> but if the board base i recommendation but that something that we included in our plan. we did that for infertility and reproductive technology benefits.

>> that's why i am part raised a question >> right. good we did that because of one specific vendor. the other vendors were are ready to step up and participate. so that meant they are members did not have access to that comprehensive infertility benefit for next year. so it's up to you to decide how much pressure you want to put on the vendors, whether it is this benefit or other benefits >> okay. when would we-the was that's true for the sperm freezing as well because when the vendors said they can't do sperm freezing. >> all right. so when would we know or do we know now? >> we don't know. well he was who can and who can't? >> hopefully we will know by next month. when you will have to vote on it and at that time you could get specific direction for what you expected in each quarter in terms of progress were given no

direction at all just to get this in place by 2019 >> all right. thank you those are my questions. commissioner lim >> to get the perspective of the services could you give for the next month the number of surgical [inaudible] number of surgical services in place year-over-year. the last one reporting it was 2006 we don't have a number of surgical services so i guess we would not know >> at your request we can do that [cross-talking / off mic] we were frequently asked for, you do you do and how much does it cost and we do not want to single out transgender surgical claims in particular anymore that we want to single out see section claims. these are medically necessary but we can do that if you want >> in 2006 there's a number in place

>> right. after that we stopped singling it out because it's part of conference of medical benefits rather than being-we didn't want to single it out for, look at what's happening. these are increasing. we are happy to do that. i'm pretty sure [inaudible] >> can i put in another-the benefit discusses discusses a range of services that go with this issue. so i would not want to just look at surgery and all its variations outlined in the benefit from looking at all of the services that might be provided. is there some broad associated cost with that? you said counseling. you said other kinds of services that might be attended jans just surgery good is a way to get at that? if

not that is complicating it, i would withdraw my inquiry. >> just a dollar amount of the services without the number of claims, surgical services. >> we can attempt to get that for you >> again [cross-talking / off mic] >> no. that's what i want to make very clear. i want to be very sensitive to this and i think commissioner tammy is saying the same thing. we're trying to get a high-level i'm not talking a 20-300 item with the level is high level of understanding the cost impact of the benefit in the current year. it given all these variations of the planted some excluding some including. i'm not interested-and i don't think-have [inaudible] i'm not interested more granular detail about what services are my

codes and all that. i don't think that's either appropriate or necessary estimate this larger decision. >> i understand. in order for us to give you the total cost of care, we will need to identify which diagnosis codes to look at to add together to give you that total. we won't go into how many of each code. we will give you the total >> i am asking that report when generated the restricted to your office and not be disclosed. if that all possible. you get what we are asking for is a summary data that would be made public, nothing else. that's up to the council to dive me on that, but i don't think anything is to be gained by that. council? >> i have to take a look at the i'm not there what exactly would be contained in this report. generally,-

>> if someone sunshine the [inaudible] on the cost of services associate with gender dysphoria. >> right. again off to take a look at the report and messrs. identifiable information for it identifiable internation or conceivable information we would need for negotiating a benefit it's going to be sunshine double. again i need to take a look at the report and take a look at. he buys leave there some way that this data is useful for negotiation and maybe we could hold off on producing. again without seeing the report- >> okay. all rely on the guidance of the council. other questions? >> just clarification of your question you want this information but it would only go to the director's office. you would not sit?

>> no. i said i'm not interested in finding out all the associated codes in details related to a summary number for the provision services. that is what i was i believe commissioner lim and i are requesting it were not looking for all the background detail that led up to this global number two we don't have that in this current presentation and i wouldn't expect it or not updated president i'm not interested in that. i think it could be disclosed to individuals circumstances and so forth i don't think that's appropriate. but i won't know that until the global numbers are produced. >> i still don't understand what you want to see >> i want to see a total number. total cost. to the whole thing that's being described here just like was done in 2006. >> we can do that for what we are currently doing we can projected. >> exactly. >> we don't know exactly what people want >> yes. i certainly concur with

all the goals of the recommendations. but it's very important mayo clinic) as an infectious disease doctor not a specialist in this area actually the majority of individuals which enter this gender dysphoria don't go to general reconstruction. they go to a lot of the other procedures that are more evident in their day-to-day living and so i think any number that you give us will only cover the actually, the end of the line and not necessarily what were being asked for not quite sure how the dollars will help us but i do support the goals and identity rates i think a lot of the services are buried in primary care visits and all kinds of things. i think any number you give us will be fraught with a lot of caveats for inaccuracy.

again i do think it's important that we look for consistency in whatever we come up with from health plan to help and again for my critical expense, doing with some of these issues in a different setting, i knew which providers when i was in fee-for-service practice and in hmo who to send patients to to get done what i thought was necessary. because the was individual even within medical systems differences of opinion on medical necessity. and so it would be nice to have if we were going to go to help brands and ask for extension of services, that we would know what were asking for that we can then get some accountability for consistency. >> any other board comments? >> just a comment this concept of medical necessity i would hope that any patient regardless of the reason for

seeking some of these services would be evaluated for medical necessity and it's not just this subset under the circumstances. i would think medical necessity would be not necessarily an easy thing to get. if i were to for example if i were to decide i didn't want to shade anymore, and i want all my facial hair permanently removed, i would suspect that that would not be considered medically necessary. i wouldn't occur to me to even request that. so i don't know there should be a separate set of criteria for anyone just in my view guided medical necessities medical necessity if you will publish it to be cancerous, then it's medically necessary to biopsy it and to do what's necessary but if you just have a birth mark of some kind then that would not be medically necessary i think they be cosmetic. i find the idea of medical necessity in my think it would be a broader

consideration that conducted in any event for any person who has coverage from our insurers. how would it-why would be a specific set of medical necessity criteria for just one group of individuals? i'm not sure i understand that >> let me posit an example. breast augmentation. if i made the case that my breasts were so small that it was causing me to have a nervous breakdown would that be medical necessity? >> i don't know. i'm not certain it would. >> so the idea is that in gender dysphoria services there are specific gender identified bodily parts that cause that

dysphoria that cause discomfort that cause disease and that's why was her specifics of this benefit package. >> i understand that but i still think medical necessity is a broader concept whether you like it or not and whether it is the outcome that you would choose but for blue shield to say, subject to medical necessity might think that is not an easy hurdle to overcome in any circumstance. medical necessity i think tends to be little more associate with , not that you're unhappy many people are unhappy that her breasts are too small or too large or whatever. that's not associate with anyone particular group of people could so i don't know whether there should be a different set of criteria necessarily were

whether there would be good for blue shield to say here's a separate set of criteria for one subset of the population. i don't know fellow dd-if that's what you are seeking to have i'm not certain it's likely to see very much change in the ultimate decision by the insurer. >> commissioner ferrigno >> i think the medical necessary is very important because people fall through the cracks. it's really hard for people to go about and get those resource. so i would see it entirely different way and i think it's important to clarify what you can and also for people embarking on this is pretty big deal to embark on this kind of procedure said to have everything laid out i think is pretty important. >> thank you. other commissioner comments on this item? >> i just have one question. under the recommendation number three, what is the recommendation for transportation and travel coverage because that one was a. there were three different ones

but you are not recommending which one of the three. >> that we'd expect parity in offering both transgender and transplant services coverage for travel and lodging. the difference between blue shield and kaiser is that blue shield provides it for members who are undergoing transgender surgery and kaiser provides it for transplant or transgender surgery. united healthcare doesn't only provided for transplant services. so we are asking for consistency across the board. >> which one of the three? they would not want the third of course >> probably the kaiser. i apologize we do not

>> [inaudible] [cross-talking / off mic] >> if you would when this comes back. >> will also see we can find someone to speak to the more nuanced issues that arise in making these decisions. >> right. that would be helpful. any other comments or observation from the board? any bart public comment, and public comments? on this item? we have public comments. please come identify yourself >> good afternoon commissions my name is theresa sparks. i'm

the special advisor senior advisor to the mayor of san francisco on transgender issues. first of all give you a little personal background. i'm very happy to be in front of this work actually appeared before this board first time in 2001. then in 2003 and in 2005 if you look at chronology offered by dir. dodd i've been here kind of part of this evolution of the transgender issue since its inception in the early 2000. a couple things i need to offer the first offer my specific comments. one is that the courage of this board in 2001-, 2003 height, 2000 but has led a revolution in this nationwide initiative wasn't 50% of fortune 500 countries offer all these benefits that dir. dodd outline. number one. number two is most of the tech companies in northern california and across the country offered us. you may be aware of the recent issue around the supreme court heard around whether or not transgender children can use bathrooms appropriate to gender identity. i want to just suggest that if you look at the

amicus briefs were not only offer by 59 cities across the country they were offered by every nondiscrimination group in the country. they were offered by 1500 religious and faith leaders across the country are offered by the pta. they were offered by school districts around the united states. the offer by a broad broad category of respondents and participants in support of gender identity in the property concern. in 2001, this board we had very spirited discussion, if you make, it about this issue and the board and most of the actuary said well if we adopt this everybody's point you want to do it. and this is going to bankrupt the city because with 20,000 employees and shirley a lot of them are going to want to do this. if you see the actual numbers over the 3-5 years you saw the city gained substantial benefits

financial benefit to offering this because very few people actually chose to do it. in fact, we had to have a very spirited discussion in 2000 but for this board to release the ability of health plans to cover this instead of having a city plan because they lost the benefit of the additional cash infusion. so this is been an interesting process but world governments, agencies, businesses, churches, school districts are using the guidance of this agency, this board, to craft policies around the world. you have been progressive. you lead the united states in this. now as far as a couple things. one there are criteria for medical necessity. world health organization for transgender care has specific criteria for medical necessity that is the criteria that the american medical association and american psychiatric association

prescribed and recommend. so that is not a fungible-that is not a very loose interpretation. there actually are standards for medical necessity so if in fact this is a medical necessity how does this differ than heart disease? how does this differ than any other medical necessity when treatment is required and treatment is requested? there is no difference. if in fact you look at justice [inaudible] look at organizations you look at the doctors you look. american medical association and others there is no difference. medical necessity as defined as a medical necessity. >> thank you >> let me give you one quick statement i support everything the director said. everything that she's asking for parity in the ones that you're talking about a referred to as facial feminization surgery is taking donnelley male face and make you look more like a female or vice versa. let me give you some facts. right now tsa are

providing ginger people going through machines and calling things like a facial features that are not consistent with the gender identity and certain bodily anomalies and pulling them out of line and not allowing them to travel. that is one of the absolute initial factors that this would address. it also addresses the ability of the transgender person to get employment. it addresses the ability of transgender people to live their lives on a day to day basis. i'm always available to the mayor's office if you would like any questions be happy to answer any questions you have today or in the future and i just want to thank you for your consideration >> thank you for your extended, so i'm sure we will see what your next month. >> good afternoon commissions. speaking as a former member of

this board sat through all those hearings and actually went through this several times as we start with this process in the early 90s. i'm actually -i think i understand the medical necessity includes any psychological benefits or mental health benefits that relate because it truly must. one of the things that a recall we did as we went out and looked for a way to have an overall contract that saved everybody money so that we could get all the hmos on board all of providers on board providing these benefits and keeping the cost of the minimum there's a lot of people in the plastic surgery business and a lot of these issues. i'm looking at him going okay you can go to all kinds of different providers. maybe it would be a good idea if united healthcare talk to blue shield and maybe even to kaiser to find out where some of these

services might be available and have some more consistent kinds of contracts. so that everybody recommends everyone to a certain kind of net work so that there is that consistency that we save money that's a way to start. >> a center of excellence >> a center of excellence, exacted what we found was it didn't cost the system much money. you saw the numbers should we collected a lot of money and people didn't move here by the droves across the country just to get the benefit. truly, that of all the city employees it wasn't like 50% said isn't this fun let me get a. that's not what happens. it's a very specific kind of situation and it needs to be them i think it can be addressed in a very cost-effective way they think we need to do it because we need to and the discrimination

truly across the board. so i am suggesting our agent does get a lot more creative little more communicative and see if there's some other way to work this out because i think there can be. i feel like it's been going on for over 20 years. i've worked with a number of transgender individuals over my 40 years with the city. i made some very good friends and i watch the process and watch the grief and what i know is that medical and mental health providers have become very creative in their choosing of the services and how to really get these kinds of services for the individuals who need them. we can and that creativity that's necessary because if we provide these benefits openly and understand what they're related to, then i think it would be actually easier for most of the providers as well. i don't think it's going to break the bank. thank you very much >> thank you for your comments. either other public comments?

on this discussion item? hearing none, we will conclude discussion on this item for this month is to be brought back to us as an action item in april for our consideration and discussion. knowing that the mind can only company with the and 10 and/or i'm going to call for a recess that baby indulgence-is that the created time problem for you? it is not. i would like to take a 5 >>[gavel]we are going to resume >> were going to resume our rates and benefits committee portion of our main for the san francisco health service system for directors meeting. we have one additional discussion item. sec.

>> item eight discussion item presentation of simple therapy personalized pain recovery for possible addition to benefits. helena-- >> just to be clear as a presenter comes to the podium, we did item 9 in the regular agenda first since director dodd was presenting another item and wondered all of her presentation together. i notice that any agenda that would've made a amendment or change when we were drafting. so again we apologize for taking this out of order. if you would tell us who you are and then we can move to this discussion item. >> thank you i am helena plater- ceo of simple therapy. >> i'm having trouble hearing you >> is that better? >> yes >> one of the things these microphones do if they're kind of like you've got to look like you're getting ready to eat the

microphone. >> there you go >> i'm helena-ceo of simple therapy. simple therapy is complete the online option for folks experiencing muscle joint and back pain.. in lieu of having to make appointments and needing to miss work to go to physical therapy. so in your information packets you've got a presentation which i'll be taking you through in just a moment and then in addition to the main presentation there's a marketing plan which is in draft form to poor discussions with hss now. the incredible opportunity to take feedback and buildout transfer how we would reach all the different segments of the employee retiree independent population. that user. there's also some utilization data: from the all things database which shows the current utilize nation of physical therapy and preponderance of my scope scrotal pain in your population.

>> director dodd >> when we get to that last page is from h our data analyticss among that cost of opioid use. so it's not just claims is up we argues >> all right. thank you. as part of your introduction can you give us a little bit about where you are located, how long you been doing what we've been doing that ever think we >> absolutely. simple therapy was founded in 2011 by group of orthopedic surgeons and physical therapist. our chief medical officer and cofounder is a practicing orthopedist in fremont california. simple therapy moved from new york city to fremont last year, april will be our one year anniversary. >> thank you. >> sure. what you see-yes yes?

>> you start in 2011 by who was at? >> orthopedic surgeons. >> the population that this aesthetics you have in your, where do they live? are they in california? >> yes the cofounder and chief medical officer was a practicing orthopedist isn't free but fremont california which is where we are the second cofounder reserves are chief research officer is just out of philadelphia and camden new jersey. he works for m.d. anderson center at cooper university. >> desisted six of the people you're talking about in this presentation we are they from? >> simple therapy has 4000 users today. their nationwide. we have contracts right now with two of the large five largest health insurance company in the united states so we pull user ship without geographic research

>> given and you are in california? >> i don't have an exact number i can get back to you with that. i was a lease upwards of 300 of those because we did have a pilot and tool thousand 15 with a large regional company of fortune 20 company and a great deal of the population was pulled from the san francisco bay area. >> any public agencies? >> no. we've not worked with public agencies. save for one actually smaller municipalities without was-we do not go through the process we have now as they were offered as part of piloting contract process through our topline which is edna today handles all of the logistical maneuvering to bring a pilot to fruition. >> okay. if you would go through the presentation and we will defer any additional questions until you're finished >> sure. what you are seeing here is some highlights from the population you serve and those comment forms of muscle joint and back pain that each of these populations segments experience. i like to call out

the retiree population because we will be noting him momentarily. in their case the pain may not be specific to the job responsibilities but is instead due to must risk out ot generation with age and impacts their mobility and independence. so to talk about simple therapy and how we address these issues, i mentioned that we are one of percent online. for those who wish they can access right now if you have internet access simple therapy.com. i can take you to the site as part of the presentation. i am not sure. but you will see that the site allows you to choose what part of your body is hurting and how much it hurts and we will start giving you a series of questions which part of lot personalizes the selection of exercises that you can follow and do from home or anywhere. we have 18 starting points from head to toe. of note, there is

no prescription or equipment required. so unlike what you may think about going to a clinic in using heavy equipment which is less safe that type of exercise is not included here. these are exercise that can be done with a pillow or a towel or chair and they have equal efficacy from what you see in the data. we offer the segments in exercises and 50 min. sessions. anyone can access them 24-7. we are very high usage of the website very early in the morning, very late at night and on weekends. so we talked a little about how this works. the questions have been designed by our team of orthopedist and physical therapists. they mimic the questions that someone would get in a clinical setting 25 first of all, if someone is an appropriate candidates for unsupervised care or not. so just under 20% of people come to our site are determined to have other comorbidities in

place which would warrant in person care we message to them carefully that's what's recommended. but about 80% of folks during that 2 min. q&a can actually perceive right into the first session of exercise therapy and we will be in personalizing the exercise selection based on what they tell us. from that point on every sale to make it an exercise on the screen and are able to watch it happen once, look at that point is given by the therapist about what to do, what not to do and then perform the exercise, it gives very simple feedback to the program about how the exercise felt to them that allows us to adapt and progress the next selection of exercises that each user is getting his--her own sequence personalized to their own needs. finally, each user then chooses their own times which are most convenient for them. they can elect to receive reminders by e-mail or text or phone call and they can pick the days and times they want to receive those reminders so we are not invasive in their

lives. we offer 24-7 online coaching available to them on the website. there's a little icon they can click and speak to our health coaches. at all times, or orthopedist are overseeing the entire care and we're getting data real-time feedback on usage and all the input to the users group in less than 2% of cases, we will notice that someone is not progressing towards complete pain recovery in the manner in which we expect we will refer them out of the system into in person care. swear costly marketing monitoring that for safety. now here you have kind of the overview of all the reasons why we consider this to be safe. not to mention that this again is ordered and approved by two of the five largest health insurance companies. you've gone through a rigorous process with over 15 different physical therapist attempting to debunk our logic and system, find flaws, and has not been uncovered. universally we received approval and not

only clinically but technologically security and privacy of all the data of our users. again we are screening out some users. so the most-the folks most likely to need in person physical therapy are still directed to that type of care we have removed the types of risky exercises that are known in a clinical setting to need supervision, to need assistance from our video library database. they're not even there to begin with. they won't be a factor. you're showing coaching in the videos every step of the way that enables people to feel comfortable knowing from different you points how they should be performing the exercises. finally we've had 4000 users to date without any claims of injury or negative affect but in the off chance that does become an occurrence someday, we are carried-we carry multimillion dollars worth of malpractice and liability insurance. now you

see here i won't read these. we got a great deal of testimony small range of age use. you will see your page third age 30-72 our oldest user right openly is 93. our meeting agent user is 56. you will see some of that data here. you we have 73% return rate people coming back at the first session on average, the number of sessions of simple therapy that people complete ranges between seven and 13 get that's on par with what you see in real life physical therapy from age access data. overall, just over 70% of people import significant pain recovery from the simple therapy experience which is higher than claims of efficacy in person physical therapist. and when asked by aetna to its membership whether they found simple therapy on par less effective or more effective than traditional physical therapy is 2%

responded they said was more effective and has a lot to do with the lower barrier to usage in the convenience it offers. finally this is unlimited >> i'm sorry but benefits appropriate dress question. a couple questions about the demographics. number one, do you have a sense of what percentage of your 4000 have actually used physical therapy first and then come to the second because this implies that a lot had tried physical therapy for the same condition it is that we were suggesting queen >> i don't have that exact numbers. they would be numbers that our insurer-the claims would come from the insurer partners and they have not released that data to us. so the data that i am able to lease year is information that's been shared with me by the likes of aetna and other payers. >> so is that data not available to you? you cannot come back without then is that what you're saying queen >> it's not been available to

me. it's unlikely you will be made payable however i could request that >> for us to be put value on this it would be interest on this is this a first apple we would encourage our members or a second step after they've got gone to physical therapy in terms of how we talk about this >> the manner in which we are clients use it which includes fortune 100, fortune 20 companies, is to offer simple therapy as that first line of defense. have it almost as a triaging mechanism. that is primarily because they're number one focus and priority is cost savings. so they've already been able to show cost savings of close to $2000 per person 1000 hundred $53 exactly. by routing folks into simple therapy in lieu of physical therapy. now for the population here, in the city of san francisco i think that there is a warrant and

considering whether this making this available to all and not as a triage mechanism actually will supplement usage of these types of treatments and will offer more convenience and accessibility. make that a priority. because in labor-intensive job populations, muscle skeletal plane is the number one cause leading to disability so if you're able to offer a convenient solution to folks which enables them to self treat and dy i themselves back to typical levels of mobility and job performance, then there are other wider benefits. >> everything also days of lost work. to go to a physical therapist requires time off, etc.

>> exactly. one of the real benefits. this is something you can do on-the-fly after your shift, before your shift, whenever the need arises. >> these, continue >> sure. one of the things that we offer is part of our package is both quarterly and annual outcomes reporting. so we are basically recording every keystroke of the users. we know exactly real-time when they come back to our site if their pain is decreasing because we're catching a data point that each and every visit. and we will be able to show all manner of aggregate usage and results. now what's on the table for discussion? we would like to offer simple therapy as a covered benefit starting in january of 2018. what i've described up until now is sort of the basic program could easily team starting points of body pain recovery. we are also going to offer some additional programs. so for every single employee of

the city of san francisco will be a five-minute stretching program which would be changing the dynamic every day that they could log in and use. the tyree population you be offering a fall and fracture prevention specific program. for folks who have deskbound jobs we will be offering an office ergonomics program. we would allow for language options and cantonese and spanish to address the populations it there and we would cover all the marketing and communications while the populations to generate utilize issue. now on top of that, you discussed with hhs to opportunity to offer a free pilot of the fall and fracture vegan program for that retiree population starting in september of this year. there'll be actually no cost involved for the city of san francisco and we would benefit as well because we would be able to get real-time feedback

on the program from your 65+ population to make enhancements and tweaks before the formal rollout in january. you get pricing information here get you can see the screen made available to all 103,000+ numbers of your population for under $30,000 a month and just less than three and $60,000 a year. yes? >> director dodd >> we are lucky enough to have a data analytics department they ran the numbers and you have before you the pain frequency and utilize asian >> where is that? - i'm is the la >> sorry is the last page >> just we can keep everyone abreast of where we are. [cross-talking / off mic] there is a page at the end looks at page 87 according to the ipad but we will see what it is but at the very end of this presentation there is information on utilization and that is hss. he was that as our

utilization so that of all of our patients, the eight patients with pain were 21% of our total lies and that was 1% increase over the previous year. the average number of visits for patients was 4.77 which increased over 4.64 in 2005 and patients of multiple diagnoses of pain were 3% of our total lives and 14 percent. now when i sing, paint a pain definition is limited to a narrow diagnosis of back, lower back pain joint or carpal tunnel syndrome. we are really speaking specific to the pain that this program addresses. the average number of visits per patients with multiple diagnoses was 10.57 this last year. so the physical therapy utilization patients of pain is 6% of our total lives and makes

up 27% of the of that 21% of total lies. so 27% out of 20% of our total lives have pain. their average number [inaudible] 4.27 and you can see the other additions. now we are lucky enough to have actually run dollars related to opioid use which is a hot issue. last year, that this is an understated data point because we don't have all the unintrusive scituate medicare. you may have the financials associated with [inaudible] retirees. 12% of those were identified with pain use opioids. remember, that was 21% of our total population. so last year the cost was 926 for

opioid prescriptions associate with those identified with this narrow definition of pain. so it's almost $1 million. clearly worth experimenting with birth trying to see we can actually reduce those pains scored. i actually need right right now because my neck is still stiff. that's our data for us. to enter into a conversation. i know that commissioner breslin is a great believer in physical therapy and often simply don't need to do that back surgery. we need to do physical therapy so here is a way that's very accessible way 12 people start and obviously they get screened out but they do need to see a doctor or a physical therapist or potentially have surgery.

>> thank you. i will ask-i know there's more marketing based of the presentation that follows you may have to forgo that today. you put across the major points regarding the proposal for this discussion now ask other other questions of the commissioners at this point? ps i'm going to i'm interested in how you are approaching both payers, in other words insurance companies queen we don't provide medical care directly and now this is sort of the contact almost do that. not really do it because when not licensed to do it and then but also coming to the public sector. so can you maybe talk a little bit about that? are we duplicating this? are you going to be going to kaiser or two blue shield for united healthcare also as part of their rates packages?

>> so when i mentioned that we are currently talking with two of the largest insurers, none of those three are included currently in the population that we are partnered with. of course it would be i think the great benefits to millions of folks if we were and so we are proceeding with those types of conversations. we are very happy of them this alternate it. in this case specifically. so if and when civil therapy did become a covered benefit under those plans, we would then phase out of this direct relationship. this is not a situation where one day we would find ourselves in an overlap. this is something we can implement now for 2018 event have it flipped over to be insured and covered in the future. >> other questions? >> yes would be doing the our reach like the business to the

sites? >> yes that would be members of our community care team. they are employees of simple therapy who are well-versed in answering questions from folks. they are the same people take turns staffing our calls and the e-mails and customer service. they will be the ones as part of the marketing plan which we will not cover would visit the police re-syncs, the fire stations, >> i just wanted sure was not our staff >> there's no requirement from your staff. [laughing] unless anyone wishes to come along for fun. >> so to me there so substitute for the human contact and a lot of older people don't like doing a lot of things online either. i've done a lot of physical therapy so sometimes there's just a little tweak to think you get online. we go to physical therapy, it's two-way street. person this posted,

home and do the excess music to give you written exercises when you go home which, to me, i didn't so i am quite skeptical if this really is working for a lot of people. but i could see it as an agent but certainly not a substitute for physical therapy. physical therapy benefits could use a little straining out as far as i'm concerned. the hmos, a lot of really what i consider good physical therapist would not take hmos because they pay so poorly. so i can understand people maybe figure they get as much online as they would from some of these hmo physical therapists could not talk about all them but some of them. because that's a big problem though we've never looked into this benefits you make sure they're getting paid adequately and then we provide like 30 visits or whatever it is per person and when i go it's a couple visits and check through

and that's it. but it's not getting paid well extend this therapy to the 30 visits of course. so they can make their balance sheet and i don't blame them but these are the things i consider that are wrong with our physical therapy right now and the united healthcare that came in, i've been getting reports of the pain what they said so they're cutting the time for some of the patients. so we have a lot of underlying problems besides this which i know are not your palms >> i was a year not alone in that. you have identified a host of problems all of which i consider to be completely valid. >> second, physical therapists co-pay, i don't see why it's any more than a chiropractor or a acupuncture is a physical therapist is a strengthening

therapy than the other two. to me it should not be any more of the notion of via $25 co-pay compared to a 15. i think people are saying, i've heard people also say can afford to go to this couple times a week. so i suggest that we make our co-pay in line with acupuncture for the present physical therapy that we have. and chiropractic. to me that would make more sense. >> i think that makes a lot of sense and i want to clearly state that our goal is simple therapy is not to take physical therapy as a benefit away from anyone would choose that as their preferred course of treatment. there are a lot of quality high-quality, low-cost physical therapists out there to be found and your population deserves access to that. when i note from your numbers, though

if they utilize asian physical therapy currently is much lower than what we have seen in other labor-intensive workforces across the populations that we have worked with them to be the means of the accessibility problem. the reason that simple therapy was founded, the idea came to be was because the orthopedist writing prescriptions to physical therapy kept hearing from their patients come i just cannot get there. i can't get off work that many times per week and i've transportation issues. have child care issue could simple therapy was created to address those issues and i think with experimentation, if you will, after looking at a years worth of data which you would find is that we are reaching folks in your population would not normally be able to get to physical therapy that is going to impact things like lost, missed days of jobs and productivity and

the impact on surgery down the road. because the folks you're not going right now we need it and become disability workers comp and surgical candidates. >> i agree but motivation will be an issue. it's easier to go in and have a beer than two [inaudible] spews a lot of our exercises are done on the couch so that's what we are going for. [laughing] that's exactly it. get on the couch. >> okay. commissioner lim >> in one of your slides it says in there [inaudible] in person care instead. what you mean in person who is that in person care? >> that depends on the level of integration that is chosen. right now, we would have a basic level integration at this proposed pricing level where we would refer folks back to their existing provider directories for their existing health plan them to find and schedule an

appointment. the deeper levels of integration that could be possible. it could be much more specific. if we try to an actual ea chart electronic health records or provider bases to have that recognition be more one-on-one. >> this means a person has to read [inaudible] has to call the provider >> correct.. i'll give you an example. someone comes in with lower back pain of and bay area aqmd one of the questions they would get is is that i've been shooting all the way down your leg is another question to be have you had a fall within the past two months. with series of combinations of yes, no answers you make a determination of where we believe it is in the user's best interest to actually go and see that counsel of a clinician and then that would be the type of case that we would say we recommend that you go to in person care. here is the link to your directory to make an appointment. >> one of the things that

might be interest also as we consider this is where does this type of an approach overlap existing services in our health plans. some have more active online services than others. might be useful also as we get further into this discussion to see where there are parallels or overlaps. is it your intent to have conversations with our three health plans? >> i think of those conversations are encouraged then absolutely, yes. you pursued independently from this relationship he conversations with at least one of those three which are progressing so, yes, it seems as though that is warranted and we could do so >> all right. other questions of the presenter from the board? any public comment?

hearing none, and seeing none, no further public comment we thank you for coming today and i'm sure will come back to this issue in due course. >> thank you >> we are now ready to move to the regular board meeting. we are no longer here as rates and benefits. we may look the same, sound the same, but we are now the regular board, not the rates and benefits committee. so we will now move to discussion item number 10. >> item number 10 discussion item presidents report. pres. scott >> yes there's a couple things i want to cover. we have a couple action items coming up in this board meeting that required my substantive involvement and since the last board meeting and by substantive i i need our some minutes in terms of activity. i don't begrudge any of that if the results are affirmative. i say to my fellow board members.

however, [inaudible/off mic] no, not at all. we have had some positive input from board members on both of these items in any investment policy statement as well as the executive director job description and rfp and i think the members of the board for the time they took to review the materials and provide suggestions to get these documents to their current state. that's not to say there won't be a tweak or two as we get to the items. it has been a very active month from that standpoint. i also had the opportunity the other day online just at random the california healthcare foundation sent out an item about what could happen if the club were pulled on the affordable care act and how we would impact the economy for the state of california. i

found it profoundly surprising-i've not thought about in this context but if indeed the acts were completely repealed nothing replaced it what would happen to how many jobs would we lose in the state of california, they estimate and again this is the california healthcare foundation, 334,000 jobs would be lost and that it would impact or have a revenue impact of about 6.7 billion-with a b-billion-dollar. if nothing was done to replace it. well as i sobered up after reading that documentation online, lo and behold, we had two bills introduced into congress by the ways and means committee and by the commerce committee of the

house. they been actively debated over the past 24 hours or so. both have passed. those committees are due to head to the budget committee in the house in the next week or so. so i'm asking my good friends at it on you at jan hewitt we had a presentation back in early january which highlighted major trends and issues and there was some slides there about the aca could i would like to have you take a quick look. i'm not talking about a year and $1 million luck but i high-level look of the implications of this bill, of these bills as they might evolve over the next week or two and how they might impact some of our issues here at the health plan. whenever it happens to be that would be of interest but that might have

some bearing on us as a health system may be broader issues for individuals as well it would be of interest but i'm saying a summary level view of these bills as contrasted to the material that you provided to us january. so that's a request if you will at this time. so that in summary my report for this month. the resulting work will be discussed and i hope considered by this board as we go through the rest of our regular vet meeting. at this time, i will call on the secretary or discussion item number 11. is there any public comment on what i said? just as an aside as i press on here. okay we will now move to item 11. >> item 11 discussion item directors report director dodd >> thank you secretary scott. i

will start from the back of my report and go forward because it builds up to what you just asked about. you should've got today and update them by [inaudible] on the status of the aca replacement. it's a one pager. this is an update since the information i included in my reports. but let me say, that in my reports, it is clear that the appointment of tom price the separate of health and human services, he has vowed to scale back much of the many of the regulations that exist in the affordable care act and he believes in a market framework built on privatization with more flexibility with the states. tax code changes including a cap on the tax exclusion for employer coverage health care

coverage. we then saw the appointment of ms.-who had been the medicaid consultant in indiana under gov. pence. was a governor plans? >> yes he was governor >> thank you she-her firm was founded and consults with states on medicaid including an approach that emphasizes high deductible health plans. with account similar to health savings accounts. many many articles have been published about the ineffectiveness of high deductible plans and the riskiness of them. so that's where you're starting with who is in charge and you move to repeal and replace where you

start with president from speaking at the speed state of the union address where he promises to expand choice increased to access lower costs and at the same time provide better care. however among his party there is profound dismay about how to get there because freedom caucus were the more conservative part of the party doesn't want any tax credits were any tax anything. >> entitlement, they call it >> yes entitlements that he's having trouble aligning with his party. when we last spoke about all this we talked with the budget reconciliation act as being the vehicle for making and that is certainly one of the ways they're moving in from a leaked version of the reconciliation that one of the key pieces was this cap on the

tax ability of employer benefits. they are starting it will be 90% but it would be progressively lowered and again that doesn't have an amendment unanimity among the public and party was believed in the policy circles to be a the nose under the tent the camel's nose under the tent or a foot in the door for ultimate elimination of employer-based health insurance is something you so need to be conscious of is we listen to these debates. the last thing that were important were the cadillac tax repeal but replacement by tax-by this employer tax. but the numbers don't add up. you just don't get to the same amount of

funding within an employer insurance-based tax. lastly,, which we heard just in our rate presentation today, that farmer continues to go up. while trump met with pharma and is calling upon congress to reduce the artificially high cost of drugs, immediately, it appointed as secretary who opposed price vigorish asians. so we are really in a state of chaos in terms of what might or might not happen and i'll take a lot of work to get people to agree. the mayor has called a stakeholder meeting for what would happen in san francisco were they to implement their appeal with or without her placements. i was invited to that meeting good i think the public health department has her hands full in these next

four years all start with the and and then if you look at the one pager, it's clear that and again references the freedom caucus but might have on the back of it thing you are interested in. is the comparison for the ryan bill ryan repeal bill out of a affordable care act bill. more to come i think >> i don't think we have that. no, we do not have copies of that. >> well, we will get you copies. >> i knew this and that after the meeting can alter follansbee >> just one question and part of the platform is that in order to improve the market-based economy they would allow insurance companies to market across state lines bikini maybe talk about maybe just mentor the impact of that would be the way we handle our

bargaining, it said? >> there actually are states that do have insurance products across state lines united healthcare has our insurance across state lines. but i think the issue is what is the bench? what is the bench what is the lowest level of regulation? we have very high rate relations for insurance, etc. put in place to protect consumers. so i think the minute you say let's all-let's spread california's lines to delaware or iowa, you are really looking at disintegration. job other ideas? >> no. i think the point i guess i'm listening for is we would not be in a position as a board to start looking for health plans that are only may be licensed in the state

whether our consumer protections as a way to cut a doing and run if they were to pass such regulations. or allow such. >> right. it would limit your jurisdiction. so then i do want to highlight some of the parts of my report could this be my last report. because we really reflect just how much, how far we've come and how much we do. so if you just typing this is a moment in time when almost all of our positions are filled, although the be a big vacancy next tuesday, but other than that, we have filled our positions. if you look at operations the inbound calls increased by 11% and the speed to answer increased by 6.7% but we were still under the

industry standard. we still faster than what the industry expects. operations hired another 1210 and 10 three 1210 and 1209 is being held open so hopefully things will come up to speed its very complex set of rules and regulations to learn and to administer. our call volume in february went up because of the weather. people called us and said i'm coming in and talking to us. so a decrease office visits. all of our open enrollment applications were scanned into the enterprise content management system. so this is a three years in the making of proposing it, getting it funded getting people trained in doing it. so of those 11,000 open enrollment applications they've all been scanned in and linked to the individual person. which

makes finding information much easier. in terms of data analytics, we once again to fill the requirements of the affordable care act and generated 53,281 1095-c forms. we have couple member complaints that they had not arrived but the federal government did allow for additional time to produce them. the forms that we produce don't need to be turned in to the irs. except for the self-funded forms but the funds that you have to be able to prove that you had coverage. so that's kind of like your receipt. for all those donations you give. [inaudible] declaration insured the sitting county forms which were 36,122 were all delivered without having to mail them to three

saved a significant amount of money doing that. so kudos to data analytics department, to operations and to administration. again on the enterprise content management system, 5% of members files of all those hundreds of thousands of files we have had now been digitized and imported into the system. and we hope to-we were continued uploads over the next three months. we continue to have difficulty with the split carriers. some blue shield and united healthcare but we are hoping that all problems will go away. we will solve them. in terms of financing and accounting i do know pamela brought the word that the department got but they recognize to the contribution to the financial replacement

system and there's an award that goes from department to department they proactively gave suggestions. they also submitted the general fund budget that you approve the last month and in contacting in vendor management some of the things that you see don required that context be executed and we are on top of the contracts so that work can be done quickly. communications assistant with the release of the new well-being campaign which is the better every day feel a little bit better every day. sleep better every day. exercise better every day. do it incrementally but if you do it incrementally will ultimately ward off those chronic conditions and be better every day. we are participating with the department of human

resources of pregnancy and lactation information. we've expanded the healthy weight program 24 departments and the web statistics last month were that were than 18,000 visitors and 18,000 e-mails were delivered and we had 13,700 visited that's incredible electronic statistic. 14,000 those were opened so as we continue to improve our website i hope we continue to see that kind of open data. well-being will well-being was given an award by ibi was to the integrated benefits institute. was one of the finalists for the 2017 healthy enterprise health management performance award. next year will get the award we won't be a runner-up

but it does allow us to have a few people go for free to that conference which is coming up in march if there's any members of the board who want to attend. it's a lot about health and productivity and i think i want went once. but it's available to the board as was to our senior staff. we launched the new well-being webpages and reuse out for icons. now we have forget live healthy, feel good, and get care. we have combined our online calendars that we had 79 champions which is very high engagement attend 10 trainings and that's also a lot of work for the staff. our champions hosted 11 on-site events at the roof place in the launch of new to new healthy weight programs. eap saw 25% increase in number of hours of individual

counseling and they provided 31 organization whelping services. in terms of the directors report them i just like to point out into a shout out to you [inaudible] who contacted far 52 retirees who lives in the flood area to make sure -attempted to contact and reached them if they could to make sure that all the resources they needed to be saved should the dam break. we met with simple therapy bit we went over statistics. i presented testimony the joint planning and health commission meeting this is going to be an ongoing issue because you will recall we put language in the development agreement the new setter cmpc hospital that they cannot raise our rates more than 5% the initial three years and more than medical cost inflation +1.5 for the last four years. so currently, data analytics has worked with our

different vendors to get that data to an independent actuary to determine whether or not they did in fact increase it over 5% and i will be meeting with to update mitchell and to include the development staff next to make sure that we stay on top of this. you will recall we did engagement survey and we all met and came up with ideas of how we could work on different areas of weakness. one of the things that i will miss is as a member i represented [inaudible] california quality collaborative and abroad a lot of those ideas i got back to our land and to our vendors and the reason they picked me because at a clinical background because i try to squeeze mitchell in there and they said well you really rather have something there's a lot of physicians they can pick from. so we will hopefully get

results and reports from those that we can implement. health affairs, which is a preeminent policy journal in the integrated benefits institute presented a free workshop on healthier employees productivity and return to work which i attended. we met with supervisor farrell legislative aide to undoing legislation and healthy workplaces sort of permanent real estate when they look for a new building to rent though make sure there's an accessible stairwell. they will make sure there's healthy vending machines that they will make sure there's room for exercise. they will make sure the refrigerator fresh water so that we really walked out talk in terms of having a healthy workplace. so you all will be working on that in my absence i will come back and lobby for it.

along with lee, we prepared to bills for consideration by the state legislative committee which are in the packets it turns out one of them is a spot built the pharmacy bill and retain up next week. but we supported bills like that before. the champion celebration was incredibly successful and mickey callahan attended it. i think i said before that william michael and the worked on that gender dysphoria presentation. i have also for the last three years been trying to work with the department of public health about having our vendors contract with the san francisco health network zuckerberg san francisco general hospital for care. it just happens that only the receptacle care is apartment where there's any room to provide services but the up of surgical care that's provided at the general the finest in all of california. they have the best infant outcomes and mother outcomes.

so we are still cranking through negotiations with shield could ill physicians is gung ho on it. and hopefully we will follow up with united healthcare undoing that. there will be a real good to san francisco general but it would also be us paying ourselves for the care we give and they would get great care. stephanie did a presentation in department head meetings of will miss this week which had everyone in engagement other potheads. it was really it was great. i have here that i met with the controller that was this morning and i didn't because some you may or may not know my mother died this morning. so mitchell went all by himself to the controller's office and offered up a proposal for dependent verification. it looks like we'll be moving forward with that. i'm leaving after this meeting to present at a national conference on

[inaudible] care organizations and san diego at the request of blue shield and health physicians. i received a commendation from the commission on the status of women and i think the staff who attended. i received a commendation from the civil service commission and thank the commissioners were tended. not to say how many of them there were. i will turn 61 next week and retire on march 14. it's been a privilege to serve the board numbers and i just want to say coming to each of you. i will start out with commissioner scott your hr experience is invaluable i think to this body and your patient guides and robert rules of order therethrough scary situation that i learned a lot watching you and relied on your wise counsel. commissioner lim

you so closely examine the budget and find innovative ways to make changes and save money. it's a tribute to your service on this commission and it's always nice when you don't feel like you're just a rubber stamp for what's being proposed but that you actually added. there's value added that it similarly, commissioner sass you all this to our principles in terms of budgeting which is really important and you're on top of every one of those members. commissioner ferrigno (i can depend on her like [inaudible] commissioner ferrigno always talked about [inaudible] and the service area that doesn't have a lot of resources has access to care. commissioner follansbee, you

not only understand health system could you bring medical expertise and it's been great having you sit next to me and i learned from what you've added. commissioner breslin i appreciate your diligence and i've done my best my seven years to focus on things that are important to you while being activities healthy weight nutrition and diabetes progression and move meant. you will have [inaudible] and nutrition in our contact contracts this year that something that you've asked for. the simple therapy may not be the physical therapy program that suits your desire but it is one that has been very successful and i hope that you will consider it because i go home from the physical therapist without piece of paper that sits on my counter for months at a time. an opportunity to plug in and see someone show me how to do it reminded me how to do it, i

hope will begin to satisfy some of that desire for physical therapy. i think your priorities in member services, i look back in our peels much lower than they were under the previous director in terms of appeals that are brought to the board which means for solving palms at the operations of all and that's attributable to the staff. i would just like to request that i've not felt terribly respected by you as a commissioner and i hope you will treat the next director with more respect because that's part of why i'm leaving. but beyond that, learned a lot from everyone and i am not necessarily going to miss it it on going to come back and sit next to [inaudible] and we will take turns, up to the microphone. to the vendors, sometimes we disagree but sometimes we create really innovative for grams, the

diabetic prevention program is an example that good i'm hoping that [inaudible] program is as successful as it starts that your point out that there were members were seeing marriage family therapist in this [inaudible] and those not reimbursable by matt wac has managed to include them all. so no more members are being displaced in terms of mental benefits. again i shut up to you hc. delta dental, can't look at raymond without remembered that i can floss my teeth today but i think you'll see our utilization down in dental and so we will be saving some money i hope then representatives of the different organizations. united educators, are dependable and here and always representing that group and our csf and her, is here and anyway, their

people are not here but it's been an honor to serve you and i'm thrilled about becoming a retiree. thank you. >> catherine i know i speak on behalf of myself and the majority of the members of this board and thanking you for your consistent professional and dedicated leadership for this past decade. it is my hope that we will have a tangible way of recognizing your service at the next meeting. i was not-i was remiss and could not figure out how not to do it without a serial meeting or public discussion work sometime. so i'm going to figure that out the next 30 days and see if we can call you back. for the public acclamation from this board that think you deserve. so thank you again for all you've done and i asked board members to join with me given

arise and vote of thanks for your service. [applause] >> i did not do it alone. staff, staff, staff >> all right. idea the commons were observations for members of the board great >> i just want one thing i would say is in reading the job description for the new position i think it benefited from including the comprehensive breath and scope of all the things that you created and provided and delivered in your time here and i think it is probably now one of the most comprehensive job descriptions that probably exist in the city at this point. it's a reflection i think you have defined in my opinion what a an excellent

director candidate needs to aspire to. it's going to be a real challenge to try to get there but thank you very much catherine. >> any other comments from members of the board? commissioner lim >> thank you catherine for all your services. i think i came in a year or two after you came in. you brought vision, excellence to this board and especially providing san francisco the members. thank you very much. >> anyone else? any public comment on the directors report? please, identify yourself her. [laughing] >> herb weiner. i want to thank you for your service. i also want to express my appreciation that we were able to establish and i believe

workshop on your watch it i would hope the criteria for the new director would be that they continue this, have a very strong, and [inaudible] at the attitude and also enable legislation with civil service that prevents bowling at the worksite throughout the city. it's taken a real toll on workers with depression, nightmares, bankruptcy, divorces, even suicide. so this is very important and i think they should be one of your legacies. thank you. >> thank you for your comments. other public comment? >> claire-our csf thank you, herb i support what herb said. catherine come i think you're the most incredible hires we ever did. i remember hiring i

think 4-5 other directors during my tenure on the board and you raise the bar as i said before you totally did. you were usually happy with was our hires because we grew each time that we move to someone else but me got you that was unbelievable and i also was thinking about the other day and remembered the back of those days where he looked at the board of supervisors in the 80s so it's been a long time. welcome to the early retirees. that's a higher premium. so there will be some issues. i spent to hear from you. definitely. but welcome and realize they did not bring that application middle sunday application over to you to make sure that you join our organization and have some become active in the group. we can only thank you very much. i know i speak for their tyree's dennis cooper is not here today

but i know the firefighters are greatly greatly appreciative of all of your assistance as members of the poa and other miscellaneous employees and activists. we don't see them here today but i know they're grateful for all you've done over these years but there's no question that retirees are incredibly grateful and i think this last move with regard to this new uht plan and how that has worked, i think has benefited retirees greater than anything was done for a very very long time. because we are able to provide national service which we've never been able to do. there's a long list of accomplishments and all the information that you brought us both national and statewide so that we could be much better informed i know when i was on the board having that information was very vital and we have not really had that prior to your service. so there are many things we can-it's a

huge on this but we can't thank you enough and i hope it's a great party on monday and i look forward to seeing you a lot in the future. thank you. >> thank you. any other public comment? hearing none, and seeing none, we will now go to the next discussion item. >> item number 12 discussion item hss financial reporting as a generally first 2017. pam 11. >> pamela levin chief financial officer. the report in front of you is actual through january 2017. and we are looking at projection through june 30, 2017. the changes in the projected balance is 8.1 million. this is

greater than the amount reported in february. the primary reason is because of the refund of the hit tax the ashtray talked about but we are seeing a continuing unfavorable claims expense for city plan and the dental self-funded plan. there's been no additional pharmacy rebates in january and are your and projection remains the same.we one application for the surrogacy adoption benefit that is still under review. in terms of the general fund we are projecting that we will end the year on budget. >> thank you very much. is there any board inquiry or comments? any public comments?

hearing none, as he would we want to item action item 13 >> item 13 action item group san francisco health service system trust fund investment policy statement. president scott >> yes i'm going to relinquish the chair, the gavel to chair of the finance and budget committee commissioner sass for this item. >> thank you. but we have included in a package is a updated revised investment policy that is now open to legal review and will be brought forward shortly with a motion to approve but i want to walk through how we got here and what our process has been a kind of changes have been made in this revision. it began really that the-it began long before this but the health services board meeting of january 12 the finance committee eating at first and reviewed a

three-page seven section investment policy that had been drafted by the desmond group. it was a consulting hired to help us with this. we brought forward a recommendation to approve that policy subject to legal review. we also brought forward a recognition to and continue investing with the treasurer's office. that recognition was approved at the time and will not be considered again as i understand it. following that meeting, the city attorney engaged outside counsel to perform the legal review and included in this package is a copy of an updated seven page 10 section policy. which has extensive revisions to the original positive i think in arriving at those revisions i want to express my appreciation to pamela 11, kathryn dodd are commissioners,

and pauline marks for all the input they often treated to really improving what i think now is a good policy. i think without those i think without that active participation of all the parties involved would've been very difficult to put something together. it was really the right kind of a policy for this kind of department. but to walk through what's happened here come i will say that although there's extensive revisions the court almonds of the policy are largely unchanged. just quickly to walk through the seven sections of the first policy and tell you what's happened with each of those, section 1 of the original draft which is the background and policy objectives is now in session 1 of the new draft and its the text is although the text is a bit longer the main differences that includes some citations exact wording citations in several sections of the charter. other than that there are no substantive ages to that

section. section 2 of the original draft those were the fiduciary standards. those are now we stated in section 4 of the new policy and again the really no substantive changes to that section on fiduciary policy. section 3 and five of the original draft those of the statutory requirements and the investment options. again these are now included in section 7 of the new draft and virtually the same objectives in large part the same statutory requirements it imagines the charter mentions the california code and so on. in section 4 investment goals. as stated we stated in section 3 in the draft there are now four but i think the material he really said much difference here is nothing substantive in change in that section. in section 6, the

section on review, is a most identical to the review section in the new draft which is in section 3. section 6 in the original draft is i've met the review session at section 7 the effective date is the information on effective date is the same in both drafts. that's now in section 10. again no material changes. so if you look for what the additions the policy are, i think there are two new sections. one is a section to which revised definitions of many of the terms used in the policy if you had a chance to look at it there are several-there's a lot of terminology that did not exist in the prior draft that totaled out the definitions for those. then finally in section 6 there is a new section that is basically a listing of responsibilities of various parties to our investment

activity that would be their sponsor the lease of the board, our board, the comptroller, the custodian, as defined in the draft, and advisor should we choose to engage one, and the treasurer. so the responsibilities we chose archive and numerate it in the new section 6 and then finally the one thing i think is an important addition and i feel like it came somewhat from pauline marks is a section that states that in the decision to hire an outside investment manager the funds that would be invested with that outside manager and i quote would equal apply to the self fund owns less obligations which are funds required for daily cash flow and also reserves. as i think we reported first time around, of the 70,000,000+ that sits in our trust fund, it's

about sleep $10 million plus or minus. it may move a little bit year-to-year that's my that's not committed to either reserves were obligations required for liquidity. so in the event that change were made, with this policy century says is the portion of funds that would be invested with someone else would be limited to that component, that component that's not needed for liquidity or reserve. so i think-i guess would be appropriate perhaps for someone to propose make a motion to accept the policy >> i move the investment policy draft as it should be adopted in full. >> second. >> wheeler motion and a second. any other comments from the other commissioners? >> thank you i know you did a lot of work on this and thank you all for doing that. it's been a long time coming. >> thank you i guess we also need to open this for public comment if there's any public comment?

>> hearing none, and seeing none, i guess of the common is close. >> you cannot take about >> exactly right all those in favor say, aye. [chorus of ayes.] opposed, say nay. >> i request this be a bp to vote just for the record given the significance of the policy. >> let's begin with >> of the secretary >> scott aye lim aye breslin aye follansbee aye sass aye spears lead be reflected as unanimous >> yes. >> thank you spears overturn the gavel to our esteemed president >> thank you. thank you commissioners for your diligence and input on this policy. with good luck we won't have to review it for another

three years. we will see what happens. we will now move to action item 14. >> item 14 action item discussion and bullets to prove executive director job description request for proposals and authorize city department of human resources to start executive director job search selection and recommendation process. president scott >> yes as we all know on march 14 there will be a vacancy in the executive director role for the health service system. as a result, we had at last months meeting a brief presentation of an apartment human resources about process and general steps it in their intervening four weeks we've spent time with solicitation by myself from the board members to react to an existing job description that it didn't provided. the god of the

archives. i don't know where. [laughing] commissioner breslin seem to be going the person in living memory that have a copy of it. also, we put together a draft that we circulated to the board and input and so forth to get to the document that is before the board today. in addition, we ask that the board of review the request for proposal documents that would be used as the announcement of the vacancy by the department of human resources and christina, where are you? christina-i forgot the ladies last name. help me. when you come for, please and identify yourself? >> christina-department of

human resources >> she is going to be be able and operational arm of this process from the department of human resources. to be joined by our counsel eric rapoport and i have advised both of them individually-i don't think i've reached the brown act in this regard counsel, that my expectation of both of them is that they are to keep this board including myself clearly within the bounds of what are the public reporting requirements and discussions and all the rest of the things that were supposed to be committed to. as we go through this process. that anyone of us as a commissioner or a me as president of the board gets out of line my clear expectation is that you will exercise your authority as our counselors and get us back on track. if you don't to that, i will call you out for it. okay? that the public threat. in any event we know to be give very able advice and counsel and guidance

as we go through this and i thank them for their willingness to partner with us in this process. so christina is there anything we need to know about the rfp process at this point that might be helpful as were considering adopting the documents today? >> no. once the board adopts these doctrines i can issue the solicitation to our list of preapproved recruiters. >> okay. very good. so i would like to take the executive director job description first and there's a couple of edits that come to me to my attention that i would like to add to the document. one i will ask the advice of counsel on but the other i would like to just to insert. there is a suggestion that we have some reference to quote fiduciary capacity of the

executive director. so counsel, can you give me some guidance on that? spews i can take a look at that but at this point i would suggest that not be added to i think the word fiduciary is a term of art that applies largely to trustees and beneficiaries and create certain legal obligations and i don't think necessarily applies here. >> okay. but you're going to review it >> yes i'll take a look and let you know >> you'll take a look to see if it in fact [inaudible] [cross-talking / off mic] >> obviously everyone at city employee has the power authority to spend money is going to get in trouble if they don't do it correctly or if eight-we've conflict of interest laws but in terms of using the word fiduciary, that's a term of art and i'll get back to to see whether it would apply here. i think it's pretty clear the board members are fiduciaries but i'm not too sure and i don't think the director is

>> all right. okay. i would like them to go to the bottom of the first page on the executive director job description and it begins in the area of resource management and governance and it goes on down to the third line could it says in a manner consistent with-i'd like to insert the words, the city and county of san francisco charter provisions.. charter provisions, and sf hss mission. that was be an additional and wish to be added. then, on the section that says a successful applicant will have , i would like to add a bullet. will have working knowledge and overtime and acquired expertise

in the city and county of san francisco charter provisions as applicable to san francisco health service system. as has been pointed out, this role is really the guardian, if you will to help us to be sure we are kind of adhering to both requirements of the charter as well as the mission of the system itself. so i want to insert those two changes in the is brought to me by one of the commissioners to this document. we will look at the fiduciary consideration. in the request for proposal i would like to insert in the background

paragraph, in the last sentence, this position is appointed by, and reports to, a seven-member health service board where both elected and appointed which meets monthly basis. we have that language in the job description. it might be useful to include it here. at this point, i would ask that there's also i think in edit and i: commissioner breslin to point out where that one change was >> under the executive director the position is the key executive and leadership of sf hss and again appointed by and reports to the hss us board of

seven members. were both elected and appointed. i don't think you change that >> no. we did not. so that one is correct >> is clear were appointed by and report to the right we've added onto the request for proposal section. okay. those are the suggested edits or changes unless there's others that other board members have at this point. to both of the documents. if there's not i'm going >> i just one question. the current health certificate in other words may be substituted for a ba degree and i'm not so sure that person should have a ba degree as well. >> well, in the job description on page 4, minimum qualifications question of a baccalaureate degree from accredited college or university and human resources, business health administration or, other related disciplines and

increasing levels of responsibility in employee health benefits policy design administration with five years of management level experience impairments that is been administrative expense in a minimum of three years of senior enrichment executive level health plan benefits or health plan administrative experience. i suspect-i would suggest that those are comments from the job description need to be reflected in the rfp language if they are not and then word says substitution that's the one we need to look at. it says applicants may substitute up to two years of requirement education the current cbs certification, plus additional qualifying experiences.. i'm reading from the job description. so the job

description substitutes needs to be consistent >> match bullet number one on part b >> right. so not substituting or taking out the requirement to have a baccalaureate degree. >> correct. duly noted. >> i know but it is the consistent with the job description. if we use the job description substitution language as well as the minimum qualification language in the rfp, i think we'll be okay. that's their quest structural change >> yes we can do that >> okay. now just so we're all clear, all of this stuff-first of all the first person be confident people of questions about this rfp is to? >> me christina-in my e-mail

will be listed in the rfp soak all questions should be directed to me. >> okay. window they have to cement those questions on the proposal? >> i believe it is friday, march 31. >> friday, march 31 >> by noon. >> by noon. >> pacific standard time. and then proposals are due when? it's going to be daylight savings time. on 31 march assuming want to change that. daylight savings time. >> okay. >> then went to have to have their proposals and? >> friday, april 28. >> by? >> by noon. >> so we put that on the record as part of the proposal. so we will know where the questions go to and they do not come to commissioners. >> correct. >> they do not go to the legal counsel. >> correct. >> they won't go to the former executive director at that time

>> correct. >> all right. big 02 who? >> of april 2 christina at dhr. >> thank you good i just one make that abundantly killer. other other questions from the board? >> i like to make sure i'm clear on the language. that first bullet says an applicant in this is in the job description can substitute two years of required education with a certified employee benefit specialist certification that would mean they would not be required to update that's alert to agree because you can have a bachelor degree with two years less educational expense would occur to me that maybe with that should say is you can substitute up to two years of the experience employee health plan administration as opposed to education i could see being >> do i make that change? >> i would suggest we not

reduce the education requirement below the baccalaureate degree substitution under any circumstance >> okay. >> at all like a substitution for a ba degree >> i think that would mean someone with an aa degree and certificate will be technically qualified to be the director and i think even a bachelor degree i can say that to be a minimum level of education. i certainly-august of bachelor degrees on not dissing it on any level but this job requires for the special person. >> all right. you want this to substitution today about the work, education and substitute, >> management-that experience all fine expense in employee benefits health planning administration at the senior management executive level. same as it is with the other substitutions >> all right. christina did you get that change? >> yes >> thank you. any other edits or substitutions? comments?

observations? i'm ready to entertain a motion for adoption. >> so moved. >> second. >> there is a second. is been properly moved and seconded any other clarifying russians or remarks from the board? council? for the public? >> herbert wonders who suggestions. one is, if somehow one of the paul's obligations could be with a masters degree in social work with a background in medical social

work. that might be a good pub qualification for the executive director and the second thing to reinforce what i said earlier, the director would develop an anti-bullying policy at the worksite to be instituted for policies in the agency and also a charter amendment.. now anti-bullying legislation has been introduced in other countries. massachusetts is in the process of introducing it. it's become a matter of national concern in this board should be able to execute it. it should be able to institute it through the departments human resources. so these are my suggestions for one of the qualifications for the executive director. they should be various [inaudible] we want place the city on the map and addressing that >> thank you for your comment. any other public, green

hearing none, and seeing none, you're ready to vote. all those in favor say, aye. [chorus of ayes.] opposed, say nay.the motion carries. we are now ready to move to >>[gavel] >> we are now ready to move to agenda item 15 april looks on whether to go into closed session regarding the appointment of the health system acting executive director. the recommendation is to hold a closed session before folks move, there may be news after the session so i just advise you of that but glad. >> there's going to their quest after the session >> request a valid plan bs with a valve plan ue