supervisors, and i just thought that the responses that were stated today were unacceptable. department of public health should be fighting on behalf of our residents. we should be demand be accountability. we cannot be colluding and collaborating with them. i just think given what we've heard today, we have to be committed to the position of retesting, and i look forward to working with our current mayor and board of supervisors to ensure that happens. we need to be the community advocate, not the advocate for the federal contractor. i think overall, i'm just going to express my dismay and utter disgust at what is happening. i cannot believe that tetratech

is getting any additional dollars from government or federal agencies. i'm speaking right now as a citizen and as an elected representative, but i strongly believe that any contract should be ended with tetratech. this is just not especially isabl isable -- acceptable. i think it would behoove us, on our own reputation, that we stop contracting with this agency. it makes us look bad, and i -- i'm -- i just have to say i'm utterly confused as to why that has not happened yet. i'm glad that all the agencies are working as quickly as possible. by the way, i've heard many good things about region nine of e.p.a., and i know that, you know, you continue to ensure that we do regress testing and work, but i think we have to go above and beyond our

bureaucratic response and the scientific response and actually respond to the understandable concerns of our residents. (a), there is evidence of falsification of data that impacts the health and safety and well-being of our residents. and two, this neighborhood experiences disproportionate instances of asthma and other health related concerns. we have an additional responsibility to our residents to ensure that we really are doing everything that we can and we're doing it as quickly as possible. i hope we have a hearing before september. we said as quickly as possible, and even before this hearing, i hope that we get a response on what the next steps are in terms of the proper course of action, and that we get to fixing this problem as soon as possible. thank you so much, supervisor, cohen, again. >> thank you, supervisors, and so i think i heard a potential request to continue this

hearing to the call of the chair. [inaudible] >> okay. and so colleague dos, we'll do that without objection. and so madam clerk, is there any other items before us today? >> there's no other items of business. >> thank you. then we're adjourned.

>> president chow: we will please come to order. the secretary will call the roll. >> [roll call]

>> the second item on the agenda is the approval of the minutes of the meeting of may 1st, 2018. >> president chow: the minutes are before you for approval. a motion is in order. there's a second. are there corrections to the minutes? seeing no comments al those in favor of the minutes please say aye. all those opposed. the minutes have been approved. thank you. >> the director's report. >> president chow: director garcia, please. >> good afternoon, commissioners. i wanted to have our compliance director talk to all of you today regarding the recent breach that we had from a third party. i thought we have to send out letters that was delayed by the department of justice. they were investigating the third party. i just thought it would be good

for you to hear directly from our compliance officer regarding that and the work to be done to ensure our patients are informed well. >> good afternoon, commissioners. i'll give you a brief summary. december 22nd of 2017 we received -- okay. we received preliminary notification of a security incident from north communications which is a third-party contractor that provides medical transcription services for us. the incident involved patients from z sfg and laguna. once notified the fbi and the department of homeland security also worked with a cyber security firm to assist in their forensic investigation. we received a request from the department of justice to delay any notification. they explained that notifying any effected individuals could impede or interfere with their

investigation. federal law enforcement determined that a former nuaince employee was responsible from getting the data from one of their data platform. the employee downloaded data to an external hard drive from his home computer. the hard drive was recovered by federal law enforcement in a secure storage area which was secured by three locks. the individual has been arrested. the u.s. attorney's office has state that had the government has no indication that this former employee either used, sold or other wise transferred the data. tests concluded that there's a low probability that the effected protected health information was compromised. there were 893d ph employees effected and the patients have been notified on friday. we also made notification to the california department of public health and because it involved over 500 patients we also

notified the attorney general's office and the media. the information that was effected on the patient information was the patient name, date of birth, medical record number, date of transcription and the transcribe notes. if you have any questions. >> president chow: surely. do we know the motive in which this happened or that we now have protection against whatever allowed this to happen? >> yes. they said that there was a vulnerability in their platform that -- when the individual did the unauthorized access. all of that data has been transferred to a secure -- a new secure web-based application. they have assured us this data

is now secure. >> president chow: so our i.t. people, do we have oversight to see that our venders including nuiance have protected sites? >> right. during this investigation our i.t. director was involved with looking over forensic reports and we were in communication with them. we had extensive -- throughout the month extensive communication. >> including the president of the company. >> yes. >> president chow: so are there other venders in which we might need to be sure that they have the right types of information security that our i.t. director then should be also using this as kind of a wake up call to make sure that they also are protecting the information?

>> that's a long-term responsibility that we've been engaged with, assuring that we have business agreements with each of our subcontractors and reviewing their security system. that's an on going process that we've been doing for several years now. >> president chow: commissioners, questions on this? excellent. all right. thank you for the information. >> thank you. >> president chow: we'll take that. >> thank you, commissioner. since that became public i wanted to make sure that you heard it directly from our compliance director. as you know, the governor jerry brown released the may revision of the state budget. this revision reflects about an $8.8 billion in higher state revenue through 2018. compared to $6.1 billion projected in january. i wanted to make some highlights that we are still working on in terms of its impact and the biggest one that you would see there is the maintaining of the administration's proposal to

prohibit the use of schedule 340b, drug pricing program reimbursements effective july 1st of 2019. this also has supporting mental health. the may revision including one-time funding to help county support, identify and treat services in the mental health system and also one-time 50 million augmentation to target funding for multidisciplinary teams to support services for homeless individuals who have mental illness. a one-time fund increase to support graduation for mental health professionals. $6.7 billion for staff to support county mental health programs and review expenditures. placing the $2 billion no place like home bond on the november ballot to accelerate the delivery of housing projects to serve the mentally ill. also in that may revision was the expanded hepatitis c clinical guide lin -- lines

with an increase of $70.4 million to treatment all patients 13 and above of hepatitis c regardless of the stage except for patients with a life expectancy of less than 12 months. just wanted to make sure you have some of the highlights. we will be bringing you some information regarding the 340b as we learn how that impacts us financially. i'm going to leave our report to that because if there's any questions regarding other items i'll be happy to respond to them. >> president chow: commissioner loyce, you had a question? any questions to the director on her report? if not we will thank you for the report and move onto our next item. >> thank you, commissioners. item 4, general public comment and we have three requests. just to all of those commenting, you will have three minutes and

i will have a timer when the buzzer goes off please know that's when your time is up. so i'll call the names. >> good afternoon, commissioners and president chow. i'm gale ceo of housing communication proprietorsh communication partnership. i'm hear to talk about a failure for case management and other services at richardson apartments. first i want to acknowledge the fellow commissioner on the port, how this situation might be difficult for all of you. you are here to ensure the public trust of the health commission and to ensure its add voluntary -- advocacy of the people here in san francisco as well as supporting the staff and

director with their tireless work they do. we own operate these two physical locations. they are apartment complexes. for the last six years we have struggled to work in collaboration with ucsf city wide to currently with hold those services contracts. we even engage in year long mediation in 2013 and '14 at the request of the director. at the time of the submission for this rfp, they refused to provide services city wide, a right which we have under our operating agreement with the city and county of san francisco, section 4.9.c. we also have been allows ucf city wide to operate without a current valid mou between ourselves and the city. chs terminated for cause the mou in september of last year.

no one reached out to us in september to resolve this issue. it was radio silence. it stated that any agency applying for funds under rfp8 had to demonstrate site control to be considered. it was a threshold criteria. city wide does not have site control, mou, pay rent or a lease and they remain on site providing services at the generosity in service to our residents. i'm asking the commission today to instruct director garcia to not to enter into this new contract with city wide at this time. since chp does not consent to service which again is a right we have under the operating agreement with the city and county of san francisco we are asking that the award be

reviewed and if necessary only to ensure that our residents have no disruption in services. we would entertain a one-year contract for working in collaboration with this suspect and ucsf to resolve these on going issues. thank you. >> president chow: thank you. next, please. >> good afternoon, commissioners. thank you for taking the time to listen to our comments today. my name is christie saxton and i'm the chief programs officers at community housing partnership. i oversee the embedded services, case management, employment, clinical services at 14 of the 17 buildings. i wanted to take the time today to highlight a few of the reasons why we terminated the mou with city wide. we have attempted to collaborate and partner with them for 6 years and it has been challenging. in fact it became so difficult that the department of public health brought in a mediator to

work with us for approximately a year to come up with shared working agreements and out comes. unfortunately that process did not yield the results that we had hoped for. rather there continues to be a strong lack of communication and partnership with their team. we have data from our residents, from our on site property management staff and our administration staff all supporting this difficult relationship. our property management teams continue to lean into myself and my teams who are not on site around how to best support the residents there, specifically around their mental health and wellness needs. residents called me to highlight their strong dissatisfaction and they additionally voiced these concerns at our annual town hall meetings. all chp staff continued to feel unwelcomed when they are there on site. an for example of city wide's refusal to partner with us is around the city's initiative to convert of the units to bro

jekt-bas jekjekt -- project-based vouchers. it was to obtain space for our residents but we systemically received refusal to support this process.

>> president chow: anymore public comments? >> no. >> president chow: we will take this up with the director spatially and get information back to the commission. thank you very much for your testimony. we'll move on to our next item, please. >> item 5 is the report back from today's community public health committee. >> the committee met at 2:30 this afternoon and we had three items on our agenda. the first item was a presentation by the community consortum to give us a historical over view, who they are as an organization and introduction of the new ceo -- somewhere i had her name. that's all right. we have her name for the record. so mark will -- >> i'm sorry.

yes. >> he will put it in these minutes. one of the things that we found particularly interesting was that it has created what they call a sos van, which stands for service out reach within the community and it's particularly interesting because it has a piece associated with it. so the people who are homeless on the community in order to get them into care one of the ways that you can do that is by offering pet care services. so they are able to provide vet services and with that provision some people from the community have been engaged in healthcare. i thought that was a really interesting and important point to share with us. they also are award winners from the federal government in areas

-- oh, dear. api received four category awards for ehr, ski and enhancing cares to neighborhood centers, ehr quality, ehr reporting health center quality leaders for their recognition. ehr reporting clinical quality improvements and the quality improves for san francisco. so commissioners who were present, do you have any additional comments you want to make with regard to this? or questions. >> president chow: seeing none, you can continue. >> the second item was the syringe access disposal services

which was a presentation by the community health equity and promotion branch of the department. they shared with us a strategy for addressing syringe disposal and also the fact that there will be a new contract which i will talk about in a moment that allows for an approach to 24/7/365 -- 12 hours a day, excuse me, go out and collect needles on the street. they will be contacted by the 311 system and actually be available to collect syringes on the street. they will have a van to do that boric. they are not and i place emphasis, not to engage people in treatment services. they are out there to do one thing and one thing only, collect used needles. they will do that job successfully i hope.

there will be a staff of ten that will be working to ensure that we as well as the department of public health and our other partners in city government are able to remove as many needles as possible from the streets of san francisco. commissioners, comments or questions about this syringe disposal? >> president chow: commissioners? any questions on that presentation? it was quite extensive and certainly demonstrated that our city is committed to syringe access and disposal. it was a health commission initiative a number of years ago. subsequently the department has continued to work very effectively within this community. so we will be hearing an expansion of the efforts to

collect needles that we have been able distribute needles. that i think is your next topic. >> that's my next item. the next item is the community moved approval for the full commission to accept -- approve a contract with the san francisco aids foundation in the amount of $916,907 which they will hire staff to go out -- there's a start portion to that. they will hire the staff to go out and collect the needles of those on the streets. we agreed unanimously that this is something that's critical to the first part of the discussion we had just a moment ago. so with that commissioner chow? >> president chow: yes, will take this topic up as a separate item. unless somebody has a comment

for clarification we will then have that agenda as our next item. >> yes, item 6 is request for approval of the san francisco aids foundation which to provide syringe clean up program services. >> okay. so the department will present the contract at this time. >> and approval is requested, commissioners. >> yes. >> good afternoon, commissioners. i'm tracy packer, the director of community health equity and promotion. i'm here with john milacar who oversees all of our contracts. i wanted to point out that the ceo of the san francisco aids foundation, jill, and the senior vice president of programs, laura brooks is also here to answer questions that you have. john is here. he's the expert on the contract so i'll turn it over to him. >> thank you. >> i'm not sure what to add after that excellent introduction, commissioners. pretty much said what the extent of the contract is.

just to expand a little bit on the start-up piece, which is for the remainder of this fiscal year, san francisco will be hiring ten people and the efforts behind hiring ten people is job description, hiring the right step, all the hr piece does take some time there. the other piece that was mentioned was the use -- was the purchase of a van. so that van will be helpful because it will be able to transport the staff to different areas oh -- of the city requested by 311 or neighbors. it will also be able to take back. this is something we don't want to use private vehicles for. also the van will be branded with the san francisco aids foundation logo on it but it will clearly indicate that this is a syringe clean up program. so it also offers the

neighborhood -- offers us some visibility for this effort. it will take -- there will be sort of an armed guarding at the beginning starting july but by the end -- actually, by the end of august they expect to be fully staffed and fully operational. >> president chow: commissioners, any contractors before you on a recommendation from the community and public health committee. so just require a motion to place it before us. discussion on the contract is in order. there was no public comment on this item? >> i have not received any requests. >> president chow: okay. so commissioners proceed with your comments if any. other wise we can be prepared for the vote. so commissioners, comments? there being no comments and the presentations were quite clear therefore and the city will move

forward as you approve this contract i hope. all those in favor of the contract? all those opposed. >> [roll called] >> the contract has been unanimously approved. >> thank you very much. >> thank you, commissioner. >> item 8 -- i'm sorry, item 7 is a dth policy on the procurement and use of gift cards. >> good afternoon, commissioners. the item before you is for approval. it's the dph policy on the procurement and use of gift cards. dph has always used gift cards as incentives for patient and clients to meet their health needs and some of the examples are on tv they use the gift cards as an incentive for the patients to take their meds because it's a pretty argerous regime. it's also used for behavior health, health clients meet

their goals. it's just maternal child and add -- health and family planning activities. while this policy is new the use of gift cards is something that we've always done. the reason why i'm coming to you today is that the city's office of contract administration and the controllers offices requesting the departments actually have a written policy. this is a good thing and we wrote our policy based on the guidelines from the controller's office. so as you can see, the policy directs that only patients and clients are eligible for gift cards so city employees, contractors and other staff working on behalf of dph are not eligible for gift cards and that there's provisions in the policy but kind of one of the -- i'll just go through them very quickly. the purchase of gift cards must be approved by the cfo or a

designate. gift cards must be purr -- purchased with department funds. the value may not exceed $50. we are going to be controlling the supply of gift cards. programs can purchase 12 months of gift cards but we'll only distribute one month at a time. the rest we'll keep in a safe. so there are other features of the policy that are -- that is attached. so i will stop now and let you ask questions. i don't want to bore you with all the bureaucracy. >> president chow: questions? no questions on the gift cards. then a motion for approval of the policies in order. >> so moved. >> second. >> president chow: there's a second. no further discussion. then we'll proceed with the vote. >> [roll call]

>> president chow: policy has been approved. thank you. >> there were no public comments for that item. we move on to item 8, the san francisco foundation lease and this is an item for approval. >> president chow: thank you. mr. primo. >> good afternoon, commissioners. mark primo, capital advisers to the director's office. this item is a request to approve a lease before you as you have two packets, a brief power point and then the actual lease. it's a request to approve the lease between the san francisco general foundation and the city. it's for space at 2789 25th street which is the community health network building. let me bring this up.

so 27 years ago what started out as a volunteer organization has blossomed into a foundation that's generated over $200 to zuckerberg san francisco general hospital for initiative in research, education and health services. during the rebuild part of the $200 million, 141 million was generated for the purposes of focusing in on the new acute care hospital which you guys are all familiar with. so the lease is basically since we did the ucsf lease for the research facility we are now going through all the leases on campus to make sure they are up to date and has all the provisions that the city has in

them. this is a lease to create that base and then we are going to come back probably in about three months to do a longer term lease, probably a 10 or 20 year lease for the foundation. these are some of the terms that are contained on page 1 of the lease that go into more detail. so the 2300 square feet, it's on the second floor, there's improvements that the foundation is going to make and that's why there's adjustments to the base rent. the city is also receiving money, received $350,000 last year and is hoping to receive about $1.8 million next year to make improvements to the building for all the occupants. that's pretty much it in a nutshell unless there's questions. the ceo of the foundation is here if you have questions of her.

>> president chow: commissioners, a commissioner has brought up the question of the titling because the titling on the notice says san francisco foundation lease. well, we realize that the topic is san francisco general but will this be a problem? the notice to the public actually reads it as san francisco foundation. >> it's a clerical error and the materials were all posted online. it should not interfere with it. >> president chow: the materials were posted online. >> i apologize. that's a human error on my part. >> president chow: as long as the public understanding it's in regards to san francisco general foundation. the material is posted. is that okay then? okay. commissioner sanchez. >> commissioner sanchez: i would just asked a quick note to this just to state that initially this was part of the volunteers program in the ere --

early 90s and then it was brought together with the director at that time, dr. sandy hernandez and george gronova and george klein who wanted to work together with their friends and volunteers at general to focus on patient needs because they were so concerned about a crisis going on and the nature of our patients and so forth. they signed off on that. it was to provide quality services as much as we could volunteer to give at that point. it's astounding that there's now been 10 or 15 revisions as the foundation has grown. initially we were given free space in the hospital along with some other research units at ucsf in the hospital have grown or whatever. i just want to state that it has really been a significant part of the san francisco general hospital. it remains the san francisco

general hospital foundation. it impacts and works collaboratively with our director of public health, our public health programs, our community clinic et cetera. it's astounding the amount of trustees we have who are new, some are three and four generations, five generations. all are committed to the quality and the excellent directors we've had to really make sure that the focus is on patient care, research and as so defined. we needed a home port and this is a home port. that was the only plan for others. i had some cousins who worked there years and years ago. they were the finest cabinet makers in the city at that point. anyway. so it's really grown and this is really a demonstration of the fact that the city and general hospital is committed to continue the providing resources and services and philanthropy to our unique patient population

and unique outstanding staff and faculty at the general. so i would move that this be accepted by the commission. >> president chow: thank you. is there a second to that? okay. so questions in regards to -- there's no question of the value of san francisco general hospital foundation to our mission for all these years and our thanks to that. so i understood that we need the lease in order for them to proceed with the renovations in order to be able to contract with the contractors, et cetera, right, because other wise they can't do that. it then says and that sounds like a matter of good faith, that after this later we are going to create a longer lease? >> correct. >> president chow: rather than having it added as this or is there a reason that we are, you know, not providing a longer

lease at this time? >> so, yeah, there's a reason. in order to do the construction and to abate some of the hazardous materials the fastest way to do this without going across the street to the board of supervisors and spending another six to eight months, the fastest way administratively is to do the one year, get it fixed and then come back and do the longer term year. that would allow us to do all the work that we need to do, temporarily relocate the foundation and bring them back after they do their work. >> president chow: okay. that was a question of mine because i would think that we had wanted like commissioner sanchez said to be able to be sure the foundation feels comfortable that we want them here and that we want to assist them in the work that they do so valuably for our hospital.

commissioner guillermo. >> commissioner guillermo: if the lease is not sufficient to have everything done, what's plan b? >> so there's a plan b and a plan c. plan b it can be extended on a month to month basis and we can do that with a letter that's atta attached to the base lease. so there's a way to extend the time if we need to. >> president chow: commissioner guillermo, you want to follow up a question to that i can see. >> commissioner guillermo: well, i think i'm still trying to understand, you know, how business gets conducted sometimes in terms of the things coming to this commission and things going to the board of supervisors i guess. that to me was the question. >> okay. so basically it's the lease of one year or less. it can be approved by anybody such as a commission.

when it gets over a year certainly when it gets to five or ten the charter has to go over to the board of supervisors for their approval. part of the problem over the past 30 years, space was allocated perhaps without leases and maybe with handshakes and so what director garcia is trying to do with greg wagner is to go through systemically and make sure that the city as well as the tenants are adequately covered for any kind of liability. >> commissioner guillermo: i just -- >> i just wanted to emphasize this is the first of many leases that may come there. it's just as stated. in working with the city attorney we found lots of decisions on space and we really needed to make those official. at the parallel process we will continue to prepare for the longer term lease as well. so we'll be working on that.

>> thank you. >> i wanted to see if our ceo of the -- wanted to come and make a few comments. >> please do. >> first of all, thank you to all of the commissioners for your incredible support. it's wonderful to know that we are going to have a former permanent home. we are dedicated to the next many years of supporting the hospital in all of its endeavors but particularly to help advance its primary strategic initiative to be the most excellent public hospital in our nation. that is our goal. so we sincerely appreciate your support. >> president chow: thank you. >> any questions? >> president chow: any questions to our -- >> i wondered if amanda if you could talk a little bit about your renovation. >> absolutely. so we our grown, our staff over the last several years so we

don't have adequate enough meeting space. the board of committee and board at large is bidding out -- building out additional meeting space and making sure we have enough cubicle and private office space for our team and have a space to clab r -- collaborate with our colleagues. >> vice president loyce: could you state your full name and title. >> amanda hire, ceo. >> vice president loyce: thank you very much. >> president chow: how many are on the staff that you are going to house at the new facility? >> we currently have 17 staff. t majority of whom are fundraisers, raising funds for the hospital. >> president chow: sure. further questions? thank you very much. i'm sorry, commissioner guillermo. >> commissioner guillermo: may i ask where are the funds coming from, funds from the existing

general fund of the foundation or are they being raised specifically for the -- >> they are funds that we have raised and saved over a course of many years. so they are unrestricted dollars that we have set aside for this particular project. we feel like we are at a point where we can execute on the plan. >> president chow: further questions? if not we are prepared for the vote. all those in favor of the lease? all those opposed? >> [roll call] >> president chow: the lease has been approved. thank you. >> item 9 is the fiscal year 2016 charity care report.

>> good afternoon commissioners. kristen pa tel here at dph and i'll be presenting our charity report. this will be presented to the finance and planning committee on april 3rd and we finalized this report using the commissioner's comment. so thank you for those. for this presentation today i'm going to provide some important background information related to the charity care ordnance and charity care landscape here in san francisco and then i'll go into our annual report in particular focusing on our city wide trends for charity care and

then provide a little more information on the hospital specific data section that we have in our report. there are more sections in the report in the long appendix and i'm going to try to focus on those go. -- on those two. so our charity care ordnance in san francis san francisco was passed by the board of supervisors in 2001 and at the time this law was the first of its kind in the nation and it supported a spirit of of public disclosure to increase transparency, accountability around charity hospital care. the ordnance requires hospitals to report on charity care data to dph annually and notify their patients of free and discounted services. there are eight hospitals that report their data to dph annually, required by ordnance. these are saint mary's, saint francis, children's hospital, cpmc and saint luke's and three hospitals report voluntarily, keizer foundation hospital san

francisco, ecss and zuckerberg san francisco general. with these eight hospitals together dph is more accurately able to capture city wide trends and charity care. so before i start on the report i wanted to give you a little bit of a timeline for charity care because there's some important factors to take into account. this timeline here on your slide provides some significant events that have occurred since the passing of the charity care ordnance and these have had an impact on charity care in san francisco. starting with the creation of healthy san francisco in 2007 this was our health access program here in san francisco that have allowed uninjured residents access to health care services and we are able to capture healthy san francisco patients cost services in our annual report separately from traditional charity care. with the aca becoming law in 2010 and then our preparation period here in san francisco

from 2011 to 2013 we have seen an increase in health insurance coverage through medical expansion and covered california efforts. these are highlighted in this fiscal year 2016 report as well. so we are now moving into 2017/2018. it's important to note that there is uncertainty in the federal level around healthcare and the aca. currently with the repeal of the individual mandate, elimination of cost sharing reduction we think we will be able to capture these or other impacts that might happen in future annual reports for charity care. so moving into the report itself, this charity care annual report helping us compile, analyze and prevent trends and data across our eight hospitals. it captures, again, both healthy san francisco and traditional charity care patients separately. we do want to note about this report that it captures one year of data either on a july to june

or january to december timeline based on the hospital's fiscal years. over all this report will give you a high level over view of charity care in the era of health for our city and also showcases how trends are experienced differently by hospitals. so this report we engaged representatives from the hospitals, so all eight and then we present is draft and the report to the hospital annually. this year you'll notice that our report is designed in a more concised streamline format and we still provide all the useful information for charity care in the city. so on the slide are the three major city wide trends that we found this year. this is for hospital charity care. these are mainly related to the acc. these trends have remained relatively consistent from the report presented last year when

we first saw the implementation of the aca. so first i'll go through each one and provide data and graphs for them. since fiscal year 2015 and now in fiscal year 2016 charity care in san francisco has declined with the continued implementation of the aca. the first figure, the one on the left, provides unduplicated patients for the last five years and you'll notice from starting in fiscal year 2014 into 2015 and now again into 2016 we are seeing significant declines in charity care patients for the city. in fiscal year 2015 we had about 60,671 and now in fiscal year 2016 we reported 51,569 or 15% decline. the next rate provides an over view of charity care service utilization by type, so emergency services, out patient and in patient services. you'll notice the inpatient, out patient services have declined

from fiscal year 2014, 2015 and now 2016. emergency services from fiscal 2015 to 2016 have remained stable. there's a slight increase in about 3% and i'll get into that later when we talk about traditional charity care as well. so continuing with the first city wide trend charity care expenditures have also began to decline significantly in fiscal year 2015 and now stabilized around 85 million in fiscal year 2016. there is a slight increase and we don't really think that is significant and it could result from different factors such as patient rate, cost to charge ratio and others. over all there's a shift from charity care to medical shortfall that you can see. med-cal being the difference

between med-cal expenditures for services and hospital reimbursements for those services and hospitals typically absorb that cost. with the expansion under the aca this metric has become important and we started to include it in our report to capture all the uncompensated cost care that's provided in the city. if you look at that top line you will see taken together the med-cal shortfall was a total of $661 million in uncompensated care for san francisco in 2016. so if we dive deeper into types of charity care for healthy san francisco and traditional there's differences to note. healthy san francisco craters to uninsured from the model. healthy san francisco as a population has a greater access

to an organized system of care, stronger connections to primary and preventive care and has had support and out reach through the programs to transition onto acc initiated coverage if it was applicable. for these reasons you'll notice that the most significant decline that we see in charity care, patients on the left in your expenditures on the right are mainly for the healthy san francisco population. this started basically from fiscal year 2014 has continued into fiscal year 2016. you won't see the similar declines in the traditional charity care population. i think that brings us to this third and probably really important trend as well. even when this era of health reform we are seeing that traditional charity care continues to be necessary, especially for these populations that might be harder to reach or may not be able to access health insurance for reasons that may be homelessness, immigration

status, for example. in this slide you'll see a proportion of all services by types. so emergency, inpatient, out patient and these are separated on the left by healthy san francisco and on the right by tradition traditional charity care. most absorbed increasing dependence on emergency care from 2014 to 2015 and then from 2015 into 2016, particularly for the traditional charity care population. in 2016 one in three services that was provided to traditional charity care was emergency care. this trend you won't see in the healthy san francisco population which has been about the same in proportion for each of the services. we think it's important that this population may be harder to reach and only accessing the system when absolutely necessary may not have access to that

primary and preventive care that healthy san francisco population might. so continuing with this trend around traditional charity care, these are residents of the traditional charity care patients in san francisco and elsewhere. san francisco residents have and continue to be the majority of hospital charity care recipie s recipients. we saw a large number of homeless and unknown addresses, around 16%. we also see about 9% bay area residents outside of san francisco, 3% california residents and 1% out of state. these were relatively consistent over the past five years though. as we dive deeper into san francisco residents for traditional charity care, a figure to the right has a break down by supervisor district. consistently we see the largest number of charity care patients

are from districts that have lower average household incomes, particularly district 6, district 10, district 9 and district 11. we also provide a complete zip code analysis in the report. so that concludes the city wide trends. i do want to focus a little bit on the hospital specific data section that provides charity care patients, service utilization, expenditures and med-cal shortfall as they experienced by hospitals. the trend that we focus on, i think this section provides you a little more descriptive information about each hospital itself. it was important to note that there are reasons, various factors that can influence charity care across hospitals, patient preference, others.

to give you examples from the report from this section, the first one on the slide is charity care across hospitals for the past five years. over all the san francisco trend is that charity care patients are declining. we do see it may not be the case for all hospitals and they may not be declining at the same rate. so with that gives you another hospital for hospital specific data related to charity care expenditures. we are preventing a lot more descriptive information with the section so you'll see that the trend that we saw in san francisco may not again be experienced in the same way per hospital. some hospitals even saw slight increases in their expenditures such as ucsf. on the left you will see the break down, the percent of total charity care expenditures to provide a general summary