minutes? seeing none, we will proceed with the vote. all those in favor of the minutes, please say aye. all those opposed? the minutes have been approved. >> clerk: and on that item, there was no public comment request for that item. item three is a director's report. >> since the meeting is long today, i'm expecting dr. omagon to come and talk about the i see of camp mather and just for your edification, it's open now. but i think i'll start, if you don't mind, until he gets here regarding the issue of anything on the report -- on my report. >> okay. and you want dr. aragon to present at this point? >> he should be here shortly. he just stepped out for a second. >> okay. commissioners, we have before you the director's report. are there any questions in

regards to it? the director has also provided us an overview of the epic install. >> as you know, kent mather is part of our hetch hetchy property near yosemite. we run a camp with almost 500 people that come at any given time. i was contacted by the parks and recs director regarding some sicknesses that were flu like and because it's in tuolomne county, and i had a question for one of the commissioners about this, there's an m.o.u. by our county that any communicable disease would be managed by tuolomne county.

i did ask dr. aragon to attend and go to the camp because of the concern of the number of staff members that were getting sick, and so with that, i will contact -- have dr. aragon come and explain the background to the sicknesses and also the resolution. i think it's a great example, multicounty work, and also, the incredible footprint that san francisco has throughout northern and southern california. >> good afternoon, commissioners. so actually, i was to start out with a comment. the last time i was at camp mather was when i was a little boy, so i had these positive memories of camp mather. i don't know how many of you have been there, but it's almost a four hour drive from

sonoma. but i went there to get an assessment of what was happening. at that point, we new that at least four staff had come down with what looked like noro virus, gastroenteritis. the young staff that works there with between 18 and 23 years old, so they're really young, and one was actually transported by ambulance to sonora. we were concerned about the number of medical cases, we didn't know what was going on. in approximate combination with the tuolomne county folks, we recommended to camp mather that they close down for a week, give an opportunity to disrupt

transmission, figure out what's going on, do an investigation, let everybody recover, educate, disinfect the camp, it gets to sort of do a reboot, and we did that. we decided to do that. i met with the staff on saturday, and we did do a survey with the staff of 77. so 33 staff up to that point had become ill, and so it was more than the initial 11, so it was at least 31. and it doesn't look like it really penetrated into the campers. it's hard to tell because they always leave on saturday. they're only there for one week, so there's some that may have already been exposed, but they had gone already more than a week ago. so everybody mobilized very quickly. the camp mather management was fantastic. and every place was cleaned twice. we consulted with the california deputy of public health, and staff cleaned, and then, we actually had professional cleaners come in.

they have these things where they cloud the rooms, and they cleaned everything really well. to date, there are no additional cases. we've got two incubation cases with no out breaks, so we're fine. for me, it was great just to get up to camp mather and see how beautiful everything was. >> and i did call dr. aragon on the 4th to get him over, and we are doing debriefing with the park and rec department because they do have volunteer doctors and nurses, so there's a question to that volunteerism that happens, and what do we do with the future? we'll be having a conversation with them. >> at least one more comment. >> please. >> is so we've had the opportunity to work on two

other large norovirus out breaks, and in 2012, we had a high school where over 900 students became ill, where they had projectile vomiting in the hallway. so we have a tremendous respect for gastroenteritis or norovirus. >> thank you. commissioners, do you have any questions? you see dr. aragon is retreating quickly, but do you have any questions? >> question. campers that have departed the camp, what is the level of risk of them perhaps infecting family, co-workers, etcetera? >> yeah. there's always a risk. it didn't look like a large number of campers. we know that about six had become ill, and what we notice

is that probably the number of people that have been affected is twice that number, so it's not a large number. we notified everybody when they left -- i was there friday. when people left on saturday, everybody left with a notice, is that there was an outbreak here. if you get sick, here's what you need to do, see your doctor, etcetera. and then, for the incoming, after the week, everybody had signs every, hand washing stations, and people had a plan, letting them know what happened because the plan was to do ongoing surveillance with the new group to make sure now new cases occurred. >> commissioner green? >> it's remarkable what you did. i have two questions, and i wonder if there's any differences in the decontamination protocols from the first out break years ago, and what about precautions in general? is there any set precautions

where outbreak is rare but it's possible? >> so one thing when i first started looking at norovirus, you had to use electromagnetic copy to get a diagnosis. the challenge with norovirus is that hand sanitizers do not work with it. that's sort of the key thing to know, is that hand sanitizers are not a substitute for hand washing. and then, the other thing is it is just so incredibly infe infectious. even when you vomit, that vomit has become -- is infectious, as

well. >> yes, director garcia? >> yes, again, thank you, dr. aragon. we did a short, quick update through my director's report regarding our epic update, and there was a question from the commissioners on that, and i did want someone to come and speak on that. >> okay. please. >> let me take you through this. >> could you speak more into the microphone. >> i surely will. >> thank you. >> so i was going to take you through a little guide of our epic phases. i'm currently the acting director positiof d.p.h. and we for the original implementation of envision c.p.r. next month will mark my 20th anniversary with d.p.h. so epic is however much larger

than any of our previous implementations, and -- let me get the presentation up for you. should be seeing that on your screen. it's much larger, like i said, than anything else that we've done in the past. but we are ready for it. we've been preparing for quite sometime, and i want to take you through a few things that we're doing to prepare for it. we are continuing to update the equipment in the network for the infrastructure. we are continuing to hire staff at a quick pace, and done with great help from h.r. i certainly appreciated that, so that was a fast timeline. we established a build team. we established governance and project communication for the staff and the itch willmentation team, as well. we have established a robust

informatics and team, and we are hiring a staff to lead the end user training, which is managed by eric schafer. i'll outline a few more things as i taking through the phases of the project. there are five phases to the first wave of the implementation. these phases have been defined by epic, and they're refined every time epic rolls something out, and epic has done hundreds of implementations, including right here in the bay area. d.p.h., as you can see from the timeline, is currently in phase two. and on august 3, 2019, we will go live with the initial wave. the first wave includes zuckerberg san francisco general hospital and emergency trauma center, laguna honda hospital and rehabilitation center as well as primary care and specialty care. the remainder of our network will go live in subsequent

waves of the implementation, but that is just the first wave that we're in right now with those five phases. phase zero, which was from january and ended in march of this year, included on boarding the team and epic training, it is also the start of third party systems, which are necessary to have a fully functional epic system. d.p.h. identified 85 contracts required to make epic fully functional. while some of these were for simple licensing, such as billing codes, others were for actually software applications. to date, 50 contracts have been completed, and the team continues to meet deadlines required for epic build. as you can imagine, it's very rapid for 50 contracts. phase one focused on the

completion of the project plan as well as training and certification of the epic build team. this phase of the project involved holding 230 demonstration and work sessions with clinical and business staff who made over 1700 decisions that determined how the epic team would build and configure the system. d.p.h. staff also attended epic training during this i see if a. the epic training was a rigorous process. it involved completing a project and having to take a test, in addition to a week-long training, and this had to happen before any of these staff would be allowed to build on the system, and i'm very proud to say that 100% of the d.p.h. staff who went through that process actually passed and got their certification. so we're well positioned now in our build phase. phase two, the phase that we're currently in, started in may and goes through november . in this phase, d.p.h. plans to

complete the billing implementation of front line staff, such as specialties, clinics, clinic schedules, order sets, and many of the other details that will allow the system to be fully ready for testing and use. during this phrase, we're preparing staff by closing work gaps against the epic foundation. that is what they delivered to us. it is built off of, again, every one of their implementations. they've improved the system to what they consider it to be a very functional foundation system. and they improve it with each install. we've now seen a couple -- a least a couple installs have been built off of the foundation model and they're very successful. the work flow gap is led by dr. albert yu. during this phase, d.p.h. will less setup integration with all

third party systems. right now, we're establishing communications during this phase. d.p.h. continues to establish quality control channels to ensure communication and coordination. we have cross team work groups, and these teams are tightly coordinated. we have a dedicated communications expert to guide the communication. we continue to prepare the sites with work stations that meet epic specifications, and also add any devices and peripherals that are needed at that time. this includes the deployment of single sign on and wireless where it's needed to make sure that it's adequate for use. so phase three, which will be from november to may will include integrated testing. this includes testion the patient flows from beginning to end using different scenarios. these are based on typical flows such as submitting a patient for typical diagnosis, following the data flow as the

patient is assessed on the floor, orders are placed, diagnostic test results come in, the patient is discharged and then scheduled for a follow up through a clip ib. we track all that data through the system and make sure that it's flowing property. also in this phase, we're making sure that the third party systems are doing and receiving the data, along with any physiological device monitors are functional and have the data flow in. phase four involves completing training for the d.p.h. staff who will be using epic as well as the technical dress rehearsal and tracking the go live. and then, on august 3 of 2019, we will go live on epic. after we go live, we enter into the fifth phase which involved post live support and user surveys, ongoing training, installing the system upgrades and preparing for the next wave. so i want to highlight a few areas that we're closely

monitoring. third party contracts, we still have contracts to finish up, and while we're making deadlines, there are many variables involved in contract completion, and the team is -- this is a daily call to monitor this. completing the clinic work station roll out, building out test printing and connectivity to epic, this is what i.t. does well, but it still means we have to closely monitor it because there are thousands of devices. making sure d.p.h. is completed which includes over 21,000 build configurations inside the epic system. epic has the tools to monitor it but again we need to make sure we're staying current with where we need to be. testing of 125 interfaces, another thing that i.t. does very well, but it involves third party vendors, different departments. managing the logistics and content fore the training, this is our end user training.

d.p.h. anticipates training 9200 end users, so a large group that we've got to run through within a two-month time period, so huge lodge stick effort as well as go live planning, another large logistical effort. the team is and i am very, very excited to have it go live and be in full use. i'm scheduled to come back and give you a full i.t. update in september, and so today was just to kind of take you through where we were with the epic project. do you have questions -- and that date was september 18 for the full update. >> okay. first, we'll start with commissioner guillermo. >> thank you for the full update. also appreciate the information that you provided for us, and also appreciate the excitement that seems to be pervasive across the department. regarding -- i have a couple

questions. the first one is regarding phase two, if you were to do a stop light sort of dashboard on this, would you say that beginning in may and up to the present time, we are green, yellow? >> we are green for most things. i had i'd say a little bit of yellow. we're close on the contracts. we've got a couple that we're making the deadlines. >> and will any of those impact the cost? >> no, it won't impact the cost of it. i'll also say that we will work with epic on some of those because there's usually a way if there's one or two, that we can figure out how to manipulate the timeline and still get them in there. we just can't have this happening with many of them. >> so you would say that there aren't any red flags. >> i don't have any red flags. >> great. thank you. >> and i hope to not have red flags. we will address them as they

turn yellow. >> okay. great. the other question i had is regarding these third party contracts and issues of cyber security. and so -- because it's not mentioned anywhere here in the update, so questions about how the implementation is going to address issues of cyber security, particularly with third party contractors, and then the training of internal staff with regard to cyber -- >> we are in the process of hiring, and i think training is one of the things we need to address and make sure it's, you know, very robust for our staff, ongoing. in terms of access to the system, that's one point we will monitor. in terms of third parties, they have business associate agreements with us whenever there's ph i. involved. so there is a look at and a security agreement with them

about how they're going to do that. >> just -- just a caution. the third -- oftentimes, with issues of cyber security, it's the third-party contractors where there is an infiltration that actually occurs because of the inability to control on that end, and so i just raise it as an issue that's something -- >> i agree with you. >> -- it could be red as opposed to red going to green. >> thank you. >> commissioner green? >> i just want to understand, the hospital needs are different than the clinic needs. who's really involved in that, and if when it's really kind of test driven by the end users, is it in phase three that some of their input or comments will be incorporated? how will that work? >> dr. yu is anxious to get up

here, but let me just say that as we are part of this process of build. in august that we're starting to go back and meet with our input -- our subject matter experts and run things by them as we built. so it's an iterative process. there's been a very complex number of subject matter experts and domain groups that have been setup so that folks can get answers to their questions, and we can have those open lines of team communications, and they're seeing what they get before they get it. >> thank you. commissioner bernal? >> thank you again for the presentation. first of all, congratulations and thank you in advance for your 20 years of service with d.p.h. >> thank you. thanks. >> i was wondering, could you share an example of a work flow gap that could emerge or perhaps has already emerged and how that gap is filled? >> there are going to be things that today we may not do in the system or there are instances where things may be combined in the system and they're more

automated, and so that what people do today and what they're going to have to do when they get on epic, to the extent we can close that gap, we will change their work flow to meet that. i'm not giving you a specific, but it could be during checking in patients, it could be something we're doing # when they're actually documenting on a patient, it might be slightly differences than what they're doing today, or it may be large differences than what we're doing today. >> and it could also be what they're doing in a test drive. >> and it also begs uniformity across the system. we can't be doing it differently at different locations. >> thank you. >> thank you. i have a -- a question that as you're getting into the phase in which you're beginning to look at the user starting to use the system for -- as you

described, have we found that one of the advantages presumably of epic is that many of the users are acquainted with it at ucsf? has that been with systems or does that cause a conflict because we have a little bit different system? >> you know, i don't know. i haven't had any comments back about that, and the difference, with one exception. some folks have asked to have this uscf build installed, and of course we can't do that. we're going with best practice, and we're going with the content. so things that make it unique with how we're practicing, we build that. we don't change the entire system. >> so i guess we'll see as it goes along. in emergency room its of the coming reports -- in terms of the coming reports, we have, in the past, received a timeline, right, with different points

for completion. i think commissioner guillermo has raised the potential of using a dashboard. i don't know which is the better way or way you wish to convert it, but i think as we get our reports it would be helpful to understand some of the areas that you're addressing in a fashion which -- >> so i can give you a dashboard with some of the detail here, like, whether it's red, yellow, or green? that works in a timeline? >> right. i think we had both as we were going through both of the actual rebuilds, and this is an actually rebuilding or sort of a building process. i think that could be helpful now as we're moving into some critical areas. >> okay. >> okay. thank you. >> thank you. >> thank you very much. we'll look forward to your report in september. next item, please.

>> clerk: sure. i'll note there is no public request comment for that item. item four is general comment, and there's been one request. >> yes, i believe we have one- >> clerk: actually, it's one for this item. >> one for this item, and the other is item six. that would be evan mclaughlin, please. >> and i have an egg timer. when the egg timer beeps, please know your time is up. >> thank you very much. thank you, commissioners. my name is evan mclaughlin. i am a representative of ifpte local 21. we represent employees throughout the city and d.p.h. i'm here to talk about an issue that involves understaffing of a particular team within d.p.h. this team is the procurement team for information technology. i moy wynona is aware of what i'm talking about here, and the commissioners should have received a letter detailing

what is actually going on, but i wanted to emphasize the importance and urgency of this. since the implementation of the f.s.p. program, this team of employees has identified their workload has increased significantly, a 440% increase in the minimum time required for data entry perrequest. at the same time, the size of their team has been reduced. while just for comparison, the materials management team at san francisco general, which does a similar type of work, their staff was increased by 19% at the same time. some of the consequences of this has been increased amounts of staff sick leave. there's been an increase of reports of stress. there's been an increase of human error. most seriously, there was an employee that suffered a physical injury on the job while performing something that was an extra duty without

assistance. so like i said, we already are in conversation about this. there's been some talk about trying to address the structural issues about why this team has consistently not been staffed adequately, but i will say that employees have consistently brought this up to i.t. leadership. they feel that no movement has happened. so we both have an interest in making sure that these people are able to do their job as well as possible. we both have an interest in shen you are that the health of the city and county of san francisco workforce. so again, i'm sure here to urge this commission to help this process go along, making sure that these critical vacancies are filled -- >> time. >> -- and that we address this issue as quickly and effectively as possible. thank you. >> thank you, mr. mclaughlin. as you know, in public comment, we do receive the comments, and then, we will ask in this case,

our staff and the director to give us a report back on the resolution. i'm glad that you are already in conversation, and we will look forward to being able to respond, and the director will then give us an update on this. thank you very much. >> thank you, commissioners. item five is a vote to hold a september 6, 2018 joint meeting with the planning commission to discuss the 2017 cpmc annual compliance statement. as you remember, you approved a revised version of your rules and regulations, and it requires that you vote on special meeting dates. >> so commissioners, before you is a need for us to motion that we hold a september 6 joint meeting with the planning commission. a motion is in order. >> so moved. >> is there a second? >> second.

>> are there further discussions to this motion? if not, then i'll move onto the vote. all those in favor of the joint meeting on september 6 with the planning commission to discuss the cpmc annual compliance statement for 2017, please vote aye. [voting] >> all those opposed? the resolution has been passed. thank you. >> clerk: thank you. i'll note there was no public comment for that item. item six is the health care accountability ordinances. commission, this is for your approval today, and if by any chance you need more information, you're able to delay the approve. but if you get what you need today, then you're able to act on it. mr. chang, yes.

>> good afternoon, commissioners. thank you so much for your time. my name is patrick chang, and i am here from the office of policy and planning and i'm here to present to you our recommendations for the revisions to the health care accountability ordinance minimum standards for 2019-2020. as secretary mark mentioned, we're here to ask for your approval, to be effective january 1, 2019 through december 31 of 2020. i'm happy to take any questions and comments that you might hav have. so just a little background, chapter q of the administrative code went into july of 2001, and this was a pioneering piece of legislation in the u.s. to

reduce the number of uninsured in san francisco, and make sure that workers have access to insurance that's comprehensive and affordable. d.p.h. is committed to this law, and it's something -- especially in this environment of uncertainty in the health care environment and especially with things that have happened under this presidential administration, this -- this ordinance is one way for us to really reinforce these values and to make sure that, you know, people have access to affordable coverage. and so the a.c.l. applies to certain contractors and certain tenants much such as those vendors who are over at the airports, the ports, and nonprofit providers. there are exemptions based on employers size and type and other contract parameters, and the law provides two options for employers who are required to abide by this law to comply.

one of them is to offer coverage -- individual coverage to each employee that's at no cost to the worker, and the other option is to pay a fee to d.p.h. to provide services for those who would be uninsured. and this annual fee is adjusted annually based on the increase of the h.m.o. premiums in the states. so ideally, employers would offer coverage to the workers, and employers could save about 45% in cost if they did offer a compliant plan based on current market premiums. so this slide just shows the relationship of the health commission and the work group. these standards are reviewed every two years, and the health commission has full authority to -- to revise the standards. since 2004, d.p.h. has

partnered with a work group that has consisted of a range of broker, employers, nonprofit and for profit, also health plans and labor unions to really share their expertise and their perspectives that these standards with workable, and we try to balance affordability and plan availability for all those involved. and so i'll describe more about the work group shortly in a separate slide. this slide shows the relationship that officer labor standards enforcement and d.p.h. has in enforcing this law. and this also is designed to provide employers and brokers with the support that they need to fall into compliance with the ordinance. so in general, d.p.h. oversees updating the minimum standards every couple years, and also reviews health plans on -- on an ongoing basis to make sure

the plans the employers are providing do comply with the standards. the llc oversees more of the enforcement part around auditing employers, responding to any complaints or violations. they negotiate settlements with employers who are found to be noncompliant, and they also coordinate payment plans. so the work group was convened from april to may of this year, and we had four meetings -- and i also want to thank them. some of them are in this room, and they've been involved in this process -- some of them since the inception of this law, since the original writing of this ordinance, and so i want to thank them for their experience and their wisdoms that they really lend to this process. so there were 13 individuals who submitted bids this year, and they ranged for four profit employers, labor unions, health

plans, brokers, and they've been really invaluable since we started running this work group over the last 14 years. the work group reviewed 170 plans from the small group markets, from second quarter of this year, and we really look at the small group plans to make sure that small businesses in the city have to comply with the law have a reasonable amount of options that they can choose from. so going through all the health plans that we looked at, some of our discussions, we really try to pore overall the parts and facets of the plan, such as out-of-pockets, the coinsurance, deductible to really balance out what does affordability really mean for employees, and how does it balance out with the premiums? and so as you can imagine, there's a lot to look at, and there's been a lot of changes

in the health care environment over time. and so we have some really wonderful work group members who really lend a really meaningful perspective for their constituents on these areas. over the -- over the years, the work group's also been very creative with how to make use of reimbursement products out there, whether it's an h.r.a. or an h.s.a. these really have been more prominent in the health care market over the last few years with rising costs across the board and -- so these types of plans and compatible plans have been really helpful in balancing out the economic needs for both employers and employees in a variety of ways. so i'll jump right into the standards themselves, and i'd like to share with you the work group's recommendations for the

standards. there are 16 standards currently, and one of them -- so this isn't a standard, per se. currently, the a.c.l. allows for any type of plan, whether it's an h.m.o., p.p.o., any metal tier level, as long as the plans meet all the standards as they're described by the minimum standards. this year, the work group would like to recommend that all gold and platinum plans for the cost sharing would be deemed automatically compliant. and we looked at this, you know, also because these are designed to provide the most generous benefits. they would really give, really, the strongest benefits for employees while also simplifying compliance for employers. and so we suspect that this may even encourage some employers

just to opt to provide some of these most generous plans. so simplified on their perspective which would be ideal. because bonds plans are historically and actuarily the least variant, they should be all compliant, so this kind of narrowed down our review process, primarily silver plans. you know, so standard one, currently, this prevailing standard is that employers would pay the full premium. this wasn't an easy recommendation for us to all agree on that, that these -- this standard is maintained moving forward to really preserve the intent of the law and to preserve access to affordable care for employees. our second -- the second standard pertains to out-of-pocket max. currently, it's ses at 6,850 --

set at $6,850, and the recommendation from the work group is to align this -- this standard with the california patient centered benefit design for silver plan -- for silver insurance and co-pay plan. historically this has been lower than the a.c.a. plan and national limits. so if we were to anchor it to this standard, it provides protection for employees from the rising costs, and also for employers and brokers to plan for subsequent years. so, for example, for -- for 2018 currently, the state benchmark for this level is $7,000. nationally, the a.c.a. allows for a plan to hit $7,850. next year, the national a.c.a. limit would be $7,900, and if we peg it to this benchmark, it

would cap the a.c.a. allowable limit at $7,550. we don't know what 2020 is, that will be available spring 2019, but we expect this relationship to hold as it usually has. the third standard is -- allows a medical deductible of $2,000, and employers must cover all the actual expenditures that count towards this. especially with the rising cost of health care, this is something that the work group agreed to maintain, so employers will still cover the costs of any expenditures that count towards this, but we -- but the only change would be to clarify some of that language to reduce confusion for employers and brokers, that they would not have to prefund the full amount right off the bat. and so we do believe that this will continue to remove that

financial barrier for people to seek care such as those who would belower wage earners where having a high deductible is actually a barrier to seek care. so to make sure that this is clear, d.p.h. is going to distribute some materials for employers to reinforce this law. regarding description language, currently, the current deductible is set at $250. the recommendation by the work group is to lower this to $200. we arrived at this by looking at all 170 plans, and we saw that silver plans still generally priced the deductibles at or below $200, and lowering this -- lowering the maximum for the a.c.o. to

this amount would not reduce the number of potentially compliant plans for employers to choose from. and also taken in concert -- we understand we're allowing the max to rise with inflation in the market, and so we wanted to lower the -- the hit that employees would be taking in other areas as much as possible. standard five, currently requires that drug coverage be provided and covered by plans, including brand name drugs. the work group agreed to maintain this standard as is moving forward. coinsurance is standard number six. currently, it's at 30%, and that means, you know -- that means that -- about a silver plan, and so the -- the recommendation by the work group is to reduce it to 20%.

and similarly, to the deductible, we thought dropping the prescription to 20% wouldn't impact the number of health plans available for employers to choose from. so this in concert with the other recommendations, we wanted to be able to provide some more protection to the employees, since the potentially out-of-pocket costs would be rising over the course of their plan year. standard seven currently allows for a maximum copayment for a primary care visit of $45. the recommendation for the work group is to maintain the standard. we also acknowledge that this was a very, very widely discussed standard, and there's -- there are concerns that $45, it is a high out-of-pocket cost, especially for, you know -- whether it's a

low wage earner or not, $45 is a lot, and it hits even harder for lower wage earners. so this was a concern, but at the same time, based on -- on the marketplace, lowering it below $45 would have drastically eliminated a lot of plans that would be potentially available to employers. and so in concert with all of the other reductions and increases, the work group settled on maintaining the standard moving forward. so -- standards 8 through 16 are more forward. right now, they're all required, and some are required at no cost, specifically preventative care and preimposed prenatal services. so the work group's

recommendations are to maintain these standards, but clarify some of that language that goes along with those standards to -- to point out that the types of services that are required are outlined by the benchmark plan. and we wanted to sync it with the bench mark plan because some states offer -- they have different requirements where some services are not required by the state for small and individual group insurance, such as preventative hearing surgeries, preventative surgery, acupuncture. those things are required, but in california, we wanted to make sure we preserve that level of coverage, especially anything that might happen at the federal level that would erode this coverage. so in conclusion, altogether, this package of recommendations increases the number of plans that would be available to

employers to choose from. it also stream lines the types of plans -- the most generous plans that could be available, and we are optimistic that this is an elegant way to encourage gold and platinum plans to be offered, and also four times more silver plans for employers to choose from. and granted, given inflation over the next two years, that may change, but as a health department, we support these recommendations as a whole, and look forward to your approval of this. and at this time. i'm happy to take any questions that you may have. >> at this time, i want to take any public testimony, and then we'll take questions. so rk ma, we have three minutes each. >> clerk: if that's what you'd like, yes. >> yes. the speakers are greg brown,

debbie lerman, and mark kramer, and then we'll proceed with discussion by the commission. >> clerk: so again, i have an egg timer. when the buzzer buzzes, that means your time is up. >> thank you, commissioners and staff and everybody else. having been on the work group -- and by the way, i must compliment patrick chang. he has to deal with tough circumstances sometimes because there's disagreements, and he's done an excellent job with his staff, and the other people from the city, they're a pleasure to work with, so i commend you on that. as one of the people on the group, i was most concerned -- the purpose of our hcal was to cover more people with insurance and make it affordable. i was one of those people that was against the $45 because having talked to a lot of workers, i find that some of those workers are not taking advantage using their health care premium, which just puts more money back in the health insurance company's pockets. the reason is the $45 every

time they have to go in. that's a lot of money. we have workers under city contract that earn $12 an hour. i represent workers at the airport that earn $15 an hour. when you go in and paying $45 and getting the treatment, it's going to get expensive. and a lot of them were going to san francisco general or free clinics. some of them were not. one of the advantages of this program was it cut some of the money going over to san francisco general and to the free clinics and took away some of that drainage. well now, it's coming back. so we might be insured, but we're not that well insured if you can't go in for treatment. my favorite example is allergies. number of people having allergies as a percentage continues to go up just because of, like, climate change. if you go to the allergy shot sequence, i used to have to do it. i go in on monday, go in and get four shots in each arm on

monday and then friday. and that went on for a while. and then, when they think it's safe, they go to once a week. well, if you go in twice a week, and you're paying $45 a pop, you're going to go broke pretty quick. there's other illnesses like that where, you know, it's going to affect your quality of life and everything else. i will tell you that i'm really oppos opposed to the 45, but i will tell you that one or maybe none of the silver plans have a $45 co-pay. if you see the comparison chart sometime, you see all the plans, and you'll see certain patterns real quick. and it's amazing. nobody offers certain anything under $45. it's amazing how that works. it defeats the cost of having

health insurance. if we're going to have $12 an hour employees in the city of san francisco, and employees making 12, 13, 14 an hour, we've got to do something else. real quick, nonprofits are a big issue for us every single time. i've been on this work group a couple times now. i will tell you that every time, we're always going to the nonprofits, bottom. we're also -- always having to go to the lowest common denominator. once they get reimbursed, they start nickel and diming us and start hacking away at it. >> clerk: your time is up. >> thank you very much. >> so thank you very much. >> next please. >> hello, commissioners. debbie lerman from the san francisco human services network. we're an association of about 80 health and human service nonprofits, most of whom have city contracts, many with the department of public health. i also want to thank patrick

chang and the d.p.h. staff, other city workers, our nonprofit representatives that served on this task force from larkin, rams and delores street community services, as well as the labor representatives and the brokers and the wonderful work that they've done. i have also served on this task force since 2004 i think seven or eight times now. as patrick explained, our approach is to find that balance between affordability and availability for both employers and employees. we want our employees to be able to have health care that they can use. we want our workers to be well so they can come to work. at the same time, the balance for employers -- we've always said we want to make sure that a substantial percentage of the health plans on the market are available. we continue simply mandate gold and platinum plans for every employer because if you do that, you will have nonprofits

that cannot afford the plans and that will ultimately have to cut services. that would take the ability of the money to raise salaries, take the money out of the ability to deal with the rising rents that we're struggling with in the city. it is a balance and employers need flexibility. they are not all able to afford high -- these really high level plans, and that is an acknowledgement that we've all had to make. we would all prefer lower co-pays, and the fact that $45 co-pays are the standard doesn't mean that that's what everybody has, and it doesn't mean that every worker is making $15 an hour, which is the minimum wage now in san francisco. so the airport stuff is a whole different -- there's a whole living wage fight going on board around those issues, so that that isn't really relevant here. but really, the thing to understand is that this is an unfunded mandate to a large degree. we do not get reimbursed for

these standards. those workers who are on city contracts, some of those costs get reimbursed, but the city does not fully fund the cost of our contracts, as i'm sure you all well know. you're lucky if 60 or 70% of your contract is funded by the city. but the reality is whatever health care plan you're providing to your contract workers, you're also providing to all of your other employees. you can't give this group a favored health plan and a lower level health plan to everybody else. so if the standard provides -- mandates a really expensive plan, you've got to come up with the money somehow for the rest of your employees. some employees, most of -- others might have ten or 20% of their employees working on the contract, so that is the struggle that we face. that is why we support the proposed recommendations and hope that you will approve them today. thank you. >> thank you.

next speaker, please. >> carl kramer, san francisco living wage coalition. three points i want to bring up with the health commission. point number one, as you heard, there was strong concerns from labor and worker advocacy organizations that the $45 copayment for primary care provider visits deterred low-income workers from seeking checkups and preventative care. the study by the san francisco department of public health office of policy and planning, called san francisco's health care accountability ordinance and health care landscape reported that the california average copayment to visit a primary care doctor is $25. it was strongly felt there should be further efforts to find ways to reduce the cost to low wage workers.

there were questions raised about whether the city was providing funding to nonprofit service contractors for increased costs of health care coverage required by the health care accountability ordinance. there is language in the acao for those increased costs to be considered. in the ordinance, it states when preparing proposed budgets and requests for supplemental appropriations for contract services, city departments that regularly enter into agreements for the provision of services by nonprofit corporations shall transmit with their proposal a written confirmation that the department has considered in its calculation the cost that the nonprofit corporation's calculate, that they will concur in complying with the acao. the san francisco living wage coalition made a public records request for the above-mentioned written confirmations for the

past two fiscal years to the department of public health, which is -- has the most contracts with nonprofits, but so far, no one's been able to find those written confirmations. so without quantitative information, it's not possible to measure whether nonprofits are being adequately funded to pay increased insurance costs. this has had a causal effect on the acao work group of lowering minimum standards to shift the burden of costs to employees in order to lower monthly insurance premiums for nonprofit employers. the third point was that there was a discussion of having a continuing work group on extending health benefits under the hcao to dependants, spouses, and domestic partners of employees and providing funding to nonprofit service contractors to provide family health care coverage. there is a precedent to having this kind of continuing work

group. after the hcao work group on minimum standards finishes its recommendations. after the hcao finished its work groups in the summer of 2004, there was a continuing work group which included the living wage coalition which continued meeting over a year with ann kronenberg with a health benefits program. >> okay. thank you very much. commissioners -- commissioner green? >> yes. i was wondering about dependent coverage, and how that affects your calculus, and how that affects the coverage of your employees.

so what's been the discussion on that and how is that being approached? >> that's a good question. so currently, the hcao only governs individual coverage for the employees, and so dependant coverage, it has come up in our groups. unfortunately it's outside the scope of the minimum standards at this time, so we haven't -- we haven't been able to go really in depth on that, and so any changes to -- to the guidance on what these standards would be, what has to have a separate supervisors process, legislative process to amend the ordinance itself. >> is dependent coverage available through these various silver plans that you're offering? >> that would be up to the discretion of the employers themselves. to my understanding, some employers have worked with their employees to extend that coverage and kind of shared the

cost of the premiums in a way that makes sense for their own operations and for their finances, but currently, there's nothing in the law that requires them to do so. >> commissioners, further questions? i had a question in regards to that. a potential recommendation that you were looking at extending this to other than employees, how -- how would that work, actually, since our mandate here under the standards is to deal with the employees themselves? >> commissioner -- >> and is there a recommendation that you're offering that -- that includes that, 'cause i don't see that in the proposed resolution. >> the work group didn't arrive at that recommendation, and the health department currently doesn't have a