cultures. and having folks some their families be cast out or saying there's no way we can afford to put you in these places because it's too expensive really does a disserve to what these institutions and these places have been to the city over the years. maybe it's type to think what is our mission here in the city of st. francis? we still need the quality -- the quality of care and dignity, respect that these elderlies and families have that have helped built this city and this nation. end of comment. >> just a comment relative to the day program. that's the only thing i can address. but the location in the presidio is ideal because the catchman area of the program the people it's currently serving is right there. for us to move the location

would mean the timeline would be too long, and the clients that we normally serve, we wouldn't be able to serve. so yes, the presidio is an expensive location. that wouldn't necessarily be moved to the people we continue to serve, but it's near our current location. also in our bigger concept that we're putting forth, we need other day programs, dementia specific in the city. we need to identify where can we place other centers to serve other neighborhoods, and that is part of the discussion we're having with our donor, that we're talking about a citywide approach to this, not just a one center. so -- >> that's good. >> and we serve a significant number of veterans in approximate our existing program right now, funded through the v.a. >> thank you.

commissioner green? you mentioned that you're working in other geographies in the area and in the state. i'm a little confused what the relationship is with cpmc in particular. you mentioned free space, but if i understand the employees were cpmc employees, so can you explain the relationship in a little more detail and also whether you plan on sending those employees back when you open in the presidio. >> so our formal relationship with the cpmc is limited to the swindell's day program and all of the employees are i.o.a. employees. the employees that we referenced previously those are in the special aspects of swindell's. so those are distinctly different areas of the program. so -- yes? >> i mean, yes what? i'm sorry.

you're saying there are two different groups of programs, there's the swindell estate. >> there's residential. >> there's residential, and the day program, and the day program is under cpmc employment? >> it's under i.o.a. the day program has been operated since the very beginning under the institution. >> under the i.o.a. it's the swindell residential that's under cpmc. >> right. >> and that's where cpmc has been helping to adjust those, also? no, no, that has to do with the foundation. sorry. okay. i see. but the residential program is the one that actually is being closed? >> as i mentioned, the residential program is actually

closed. the state came out and officially closed it. all the residents who had been living there are now -- >> oh, they have moved. >> it is closed. >> e oh, it is closed. and those people are either at another location, the hospice, and -- >> for the most part, alma villa. two patients were hospice eligible, and one private paying patient close to go elsewhere. >> okay. thank you. >> you're welcome. >> commissioner chung? >> so i have questions, 'cause, like, that's already a done deal. so -- and we really appreciate you giving us the courtesy notice to come in. and since we're looking at the impact, and you mentioned that there are some, like, newer technologies and treatment for alzheimer's, and can you share that with us. >> well, actually, i don't think i did mention that, but

i'm happy to share that with you. no, no, we have a very active program based at davies that specializes in diagnosing and treating patients with cognitive programs and dementia. remember, i said prop q is the programs that are either closing or transferring ownership. i wish we had the opportunity to come before you and tell you about all the new things we're doing. so i'll take advantage of commissioner sanchez brought up, what are we doing for the elderly at the new mission bernal campus, and we're delighted that we're opening a new ace unit, acute care of the elderly, specifically designed to take care of older patients. i will tell you when it was first proposed, the definition of older was 65 and older, which was a little too close to home for me, so we moved it up a few years. we're also going to have special geriatric beds in our

emergency department because we often see elderly patients in the e.d. who become confused, and we think if we have a special place to take care of them at mission bernal, we can reduce the likelihood that they need to be admitted. we're also delighted that patients on the ace unit, when it comes time to discharge, if they're safe to be discharged out, they will be discharged to the san francisco village, which is a wonderful organization that we've been helping so that he can help us when patients go home after a medical stay or surgical illness, that they have the ability to continue to thrive in their homes. sbie -- [please stand by]

>> given what was said about the difficulty of availability, of the patients, could you share with us where those residents, those patients might have gone.

>> no, because it's just one patient and that would be too close to violating their confidentiality. i will say, for private-paying patients, as many of the patients a. >> the second question then would be the staff impact for caregivers for the facility that is closed? they have all been placed in similar or equitable positions. >> the facility just closed. in fact, we're still in the process of and we will find jobs for those looking for a job. they were all working until the transition happened as of last week. we're still working with them. >> that means that some

employees have lost their positions. >> just to clarify, they will all need to change positions because ac as i mentioned, theyl worked in the unit and the unit is closed. we have other opportunities for them within such a large organization. >> thank you. >> and my next question is regarding the potential location in the presidio and you mentioned the expansion of services. you will then not only need funding for the build out and the rent of the facility but if you are going to expand programs, which is great, would you also then need to be able to hire additional staff to serve the additional -- they're not patients. they're clients, yeah.

that will be now able to come to the larger and expanded facility? >> if we receive the gift that we are asking for, that would be sufficient to launch a major expansion and so there would be employees involved in that. this is a visionary concept at this point. it's not like a very d delineatd approach. we're attempting to get the interested donor in the concept specifics on the presidio is black and white. the rest of a build out of an expanded program would be a conversation with that particular donor as to how it would be rolled out over many years. yes, there would be the expansion would result in employment and other pro ten shall centers and all depending on the gift. >> thank you. >> first of all, i know that discussions around such a

generous gift are sensitive. they have to be treated as such. i was wondering if you had a sense of the timing? if that would happen -- if perhaps that would all be settled before the closure of it? >> timing is critical. an open parcel in the presidio is in high demand. it's giving us latitude with time but i don't control the donor's timeline. we'll have some indication by the end of august. >> and the existing program will close when? >> i will not say that the existing program is scheduled to close at all. because the program is being relocated. we don't have the new location. we have until next spring to make that relox.

>> the timeline is feasible to prevent an interruption and service. >> we will make it happen. it's not a choice. >> so i'm just trying to get clarity. the alzheimer's is closed but the facility isn't yet or is? >> the facility is closed but they have stuff that needs to be packed up. >> staff will do that. >> thank you for clarifying that. where are the day program? >> the day program is still open. they're two separate programs and two separate locations and they just happen to be on the california campus. >> ok -- the program is closed

and that location on the cal campus is no longer being used, right? >> correct. >> the program there is the day program wouldn't continue when the campus closes? >> it wouldn't continue at the campus. >> ok. >> all right. >> so physically you would have to move and that is what you are looking for and presidio at the moment is your best hope? >> we greatly appreciate it. >> well, the commission wants the program to continue, so i think you have -- >> to i.o.a., do you have a plan

b? >> yes, all eggs are not in this basket. there are multiple donors we're talking about relative to the presidio and then we have have a real estate people continuing to look for alternative properties. >> an understanding that this is one-time dollars for a donor that could go multiple years, are you having a strategic financial plan how to -- because you are bee facing this same question in four or five years. >> the model that we're using would be a pre payment for 20 years of half the rent. the operation of the program would be responsible for paying the other half? so the donor would essentially be preparing the rent. >> that's your plan? >> that's the plan. >> that's the way it works for that parcel. >> yeah. >> i would go beyond most of the memories of this commission.

commissioners, are there more questions on the swindle residential care facility and or the when there is a day program. there are two separate things happening here. hearing no further questions, why don't we move forward to our next item. >> item 10 is change of management of the following out patient department to sutter. pacific medical location. breast health, mammography center. non evasive center and the specific campus out patient psychiatry. >> and my third and final prop q item for today is the change in management to sutter pacific medical foundation. so, they will transfer five out

patient department services listed on this slide to sutter pacific medical foundation, which is sutter health foundation in san francisco, marin and sanoma. they have over 240 doctors that provide primary and special professional services throughout clinic. the first is a breast help ma'am omammography center. it's august 5th. the clinic will be located at the medical office on saint luke's campus. and all this detailed information is in your memo. the second change is for the n n evasive cardiology. the expected transfer date is august 5th and the clinic at saint luke's campus. the third and fourth change is the diabetes center at saint luke's and california campuses.

the saint luke's diabetes center will be located at the medical office at saint luke's campus. and they are still determining where the california diabetes center will be located. the fourth change is the out patient psychiatry clinic at its campus. this expected transfer date is still to be determined but will not happen before may first of 2019. and the clinic will be moved to ctmc davies. in terms of impact, cpmc has reported that 7,497 patients will be effected by this management transfer. the majority of those patients would be saint luke's patients. about 15 staff will also be impacted. and at this time, ctmc has reported no changes to services, accepted payment sources or staffing models. we did receive a couple of additional questions from you

regarding this change which we have shared with ctmc who might be able to speak to those today. so, at this time, while cpmc has reported there's no changes for patients, as a result of this management transfer, additional information might be necessary to determine what the impact will be. information such as the new location of the california campus diabetes center as well as sutter help ability and commitment to retain these future services in the future. things that need to be considered before making a determination. that concludes the information i have on this item. >> thank you, very much. we have three requests for testimony. dr. kim barnes, dr. theresa palmer and kim leoney.

dr. barnes. >> my name is ken barnes and i was -- i am a physician and i worked at saint luke's for 30 years. i also work with san franciscans for housing health jobs and justice. i want to talk to you about the proposed transfer of the hospital-based diabetes center at saint lukes to the sutter pacific medical foundation, which i find somewhat problematic. with such a transfer it appears the diabetes oversight by the department of health, would no longer be operative. they're employees of the foundation not the hospital. hiring and firing would be located in the foundation and there's nothing stopping the foundation from putting the educators into individual office

practices. how will there be accountability in terms of spanish language capacity in serving latino patients that make up a large part of the patient's going to the diabetes center? foundation practices have been known to limit medical patients through percentage caps or designating certain days they will see them. if this is true, does this mean that less spanish-speaking patients would be part of the foundation? a medical foundation practice of objecobject stick tricks, what happens to those with the costly diabetes type one and type two.

where will they be served. this possibility brings to mind fears of the influence of gentrification. will a foundation serve this new demographic at the expense of the current users of the hospital? it's unclear if the medical foundation has a obligation to provide community benefits. as does the hospital. the diabetes centers have always contributed to cpmc's community benefit program with free classes, outreach, support groups and exercise programs. how will the closing of the center impact the neighborhood women's center, also housed at montego. that practice serves many, if not a majority of medical recipients and uses the current diabetes center extensively. where will those medi-cal

patients be served? my sense is this changes up a fire wall between the community. the effect of being the lessening of accountability. two of the simple questions, is this the direction you want to see this process unfold? thank you. >> thank you. >> dr. palmer. >> the out patient psychiatry moving to davies, is probably to go on the third floor of the north tower, which was, could be a skilled nursing facility. which cpmc is shut down. having wonderful care for the elderly unit at saint lukes

doesn't justify shutting down chronic care services like sub acute and skilled nursing care. the third floor of the north tower at saint davies could be used for sniff or sub acute care, which needs to be reopened, and these are services that cpmc has withdrawn from the community, at the community's did hdetriment to increase its n revenue. >> kim tafagloni, please. >> cbmc has done everything they can to shed any long-term commitment to any san francisco resident. some of these changes, like this proposal, i believe it will be

detrimental. moving people's healthcare around becomes a thing of habit, right. like the diabetes center. i know where it's at when you changed someone's habit, they're likely to fall off. and i would need to see a map to see how the flow would happen. i think moving things under the foundation is a way of keeping things out of the public eye, which is very much the m.o. for cpmc. in the previous issues, cpmc didn't tell you that all their plans or all their new programs are all short term programs. there's not a single long-term program. which if someone needs a nea a r more of care, cbmc, we're out of that business. we don't want you. you go to the next place.

the supplements that they provided. those are gone. so, i am highly suspect of anything cpmc does because they really are not into to long-term care for any san francisco an and i want you to be aware of that. it's always a double-edged sword. so i am highly suspect of this proposal. and i'm really thinking public accountability is needed where cpmc is because they will never do the right thing by anybody. thank you. >> thank you. >> do you want to indicate the reason for this management transfer and if in fact a representative of the foundation were here? how the foundation fill the gaps

of what happens as you transfer these programs. >> thank you, very much. this is dr. elizabeth bellardo the chief executive officer of the medical foundations and she will comment as well. let me just start by reminding everybody here that contrary to what you just heard, we have a tremendous long-term commitment every single person in san francisco. has manifest by the fact we will soon be opening two hospitals to serve the people of san francisco for at least the next 50 years. it's deeply disturbing to me that people don't recognize that. as to the specifics about these transfers, let me just remind you that we know reduction in services as a result of these changes. this is a transfer in who is operating the various clinics. these programs psychiatry, non invasive cardiology, breast health and diabetes will be

continuing to be offered here in san francisco, same patient. instead of being operate bid the hospital, they'll be operated by our medical foundation partners as are the vast majority of out patient services that sutter health and most other health systems provide. in fact that's a national trend i'm sure those familiar with on the panel aware of. with two new hospitals opening and two new ones closing, now is the time for us to advance as practices as they relate to our operations concluding the management of our out patient programs. as you know, sutter health operates hospitals in northern california and hundreds of related clinics, offices and services and it's common practice to have hospital programs managed by hospitals and out patient programs managed by the physician foundations. sutter pacific medical foundation is our partner in providing comprehensive healthcare across the continuum

here in san francisco and they will continue to assure access for patients through these and really many, many, many of the programs that we're proud to offer. >> thank you. >> nice to meet you all. i'm an internist, a practice physician and as well as the c.e.o. of the bay area foundation which includes both san francisco foundation, the east bay foundation and the medical foundation. the north part of the cpsd foundation in santa rosa. i always start with -- we believe and our quality metrics show that patients are best cared for in a system of care. in a system of care is not a hospital centric care center. the system of care means out patient and inpatient care many of frankly, most diabetic patients are diagnosed as pre diabetic as out patients and they're cared for best in the out patient setting long-term.

they can get pre diabetes care to prevent them from becoming diabetics. they can get care for diabetes. we do both gestational diabetes care and care of the elderly and as you may know there's a new study that came out which just shows that patients in systems of care do better in their diabetes measures, there's less negative outcome and less more bid tee and mortality. we have provided diabetes out patient education for 1.4 million patients it's been around for years and i'm committed to my patients and their care. they will get language appropriate and ethnicity appropriate counseling on their diet. certainly the diet and the

cultural appropriateness of has panic family is different from the south asian and different from chinese. we believe that it's very important to give culturally appropriate care to our patients and we have information. i'm very excited about this opportunity to expand our services in the health of the patients in the community. i'm very pleased with that. >> thank you. commissioner green. >> yes, i am a little confused about spmf and the health plans you take. because i know that cpmc, for example, takes blue cross programs and medical but i know my colleagues in the foundation are not on medi-cal and as not example, blue cross plans, we've had this problem because we prefer our patients to spmf doctors and find out were contracted with these plans that they're not.

i'm wondering if you can explain how you plan to expand and mirror the health plans that cpmc is a part of so we can ensure that all the patients can have continuity care and i guess the second question i have is spmf taking the services that will duplicated and i'm curious whether spmf is planning to take over the breast health and cardiology and so fourth at the van hvaness campus and if not, y not? >> i am plead i don't know the answer to that one. i've just taken over as c.e.o. in that area so i'm not sure about everything. on this, first of all your question on insurance programs. you are absolutely right, there are millions of insurance plans around and in emergency services obviously people can go to the hospital and get taken care of. non emergency services, people

need to check their insurance plans. we have met with and reached out to plans and we're here and available and willing to work with you on these programs so that they're available for anyone who wants to use them. additionally, for medi-cal, as you know, many, many patients have signed up for medi-cal hmos and that is just like signing up for kaiser hmo and

do you know the percentage of medi-cal? >> we have reached out to the insurance plans to contract with all of them, including hill and all the other plans to offer those services. so we have no intention of not offering the service, we want to offer them to everyone and we are working with their health plan administrators to write those contracts. so it's our intention to contract with all blue cross plans. >> this will be done by the time all these changes occur? >> so the contracting issues as you well know, laurie is complicated and it's complicated because it takes two sides to make a contract.

what doctor stated it's our intention to offer those plans to continue access to the services we are mentioning. it's up to the plans, frankly, to decide whether they want to continue that. in terms of paramix, the diabetes center at saint like's. surprisingly 36% is commercial, 25% is medicare, 25% is medi-cal fee for service. 2% is medi-cal risk and 0.3% are self-pay. i can answer the question for the other activities as well. >> i also want to comment on the concept of community benefit. we have both a duty and an inclination to community benefit in the foundation and give millions in community benefit every year.

free services, uncompensated care and community benefit classes. we have thousands of outreach classes. so we are very committed to the community and community benefit and especially education research. >> so much non-invasive cardiology is already done in the foundation. our current plans are the mammography unit, which is a very large unit is going to move to the specific campus and at least for the foreseeable future is going to continue to be operated by the hospital. however the national trend, as you know, is for diagnostic services, whether lab or radiology, to move into outpatient providers. so my guess, but it's just a guess is at some point in the future, most of those

outpatient services will no longer be provided, not just by c.p.m.c. but frankly any hospital in the country. >> as you know, matt [off mic] limiting our ability to [off mic] >> all of the money that goes to -- >> please speak in the microphone. >> sorry, all reimbursement within the hospital and foundation goes to sutter. it's one bottom line. it's not the physician group is contracted with the foundation to provide services. but all of it goes to the same place so it's not a difference. the foundation and the hospital

are one. we have one single member on the board. >> commissioner guillermo. >> you spoke about these transfers would be able to provide a benefit for the patient. so i'm interested in, sort of a bigger picture of that system otherwise it looks like each of these becomes a discrete transfer for, you know, any purpose that anybody might ascribe to it, so i'm interested in getting a little bit of a big picture of that transfer of patients from the acute care setting to a more of

an outpatient, essentially community-based setting, so that we can maybe look at this in that context. as well as you mentioned community benefit which was one of my questions. how does all of that fit together? >> some day we need to sit down and spend a lot of time talking. if you look at health care as a whole, it's moving from the hospital to the outpatient setting everywhere. whether it's electronic monitoring in your home or home care, in-home care, there's lots of things going on. the concept of the hospital as the center of health care is really quite antiquated. unfortunately, you can't sort of break it all down and start again and say oh what's the best place to do this, we will build this for this, and this for this. so what we have done is said where is the best place to put assertive as we know it now and

as we have the opportunity to make those changes we make those changes, so the foundation is growing. they are making big investments in primary care and in growing the outpatient setting and availability of outpatient services for patients in san francisco around this beautiful new hospital that's being built. so to sort of round out the care that we provide. so this is our opportunity to make those changes. and as we continue to grow and change, we will take those opportunities and make those changes. >> community benefit? >> what would you like to know about community benefit? i don't have the numbers with me but i can certainly provide them to you. community benefit comes in the form of free care, providing care in the various foundations, it's done in different ways. whether it's teaching, research, free care, classes is a huge part. physicians giving more time, we pay the physicians, they then

give their time to h.u.f.c.'s and other community benefit services. >> are you then -- >> do we monitor it? because you are answering the question, my response is it just the foundation that manages the community benefit resource allocation, community benefit plan, or is it a separate community benefit plan or department versus the hospital, or versus the system? because i'm talking about system. >> right, right. so the system has a community benefit goal. so that's one of our measures, how much community benefit you are providing within your community based on your size and other things. so the hospital has a community benefit target and we have a community benefit target and

that's monitored within the system and watched. i think that answered your question. our community benefit is coordinated in the way that every year, or i guess every couple years, the hospital and community clinics in the community services, look at needs assessment for a community and look at what needs to be done and how they can participate in that. so a community benefit in one town might be different. in sunnyvale we teach nutrition classes, run the project cornerstone, we do lunches for kids. so there's that type of community benefit. you do what the community needs. i'm sorry, i'm trying to answer, i really am. i'm not sure what you are asking. >> sorry, i don't mean to drag this on but you mentioned community benefit was a part of the consideration as these

services are moving into the foundation. so my assumption was that there was going to be a coordination or integration of the resources that you have with community benefit relative to these services that are transitioning. >> i think we made, there was a disconnect there. one of our speakers said there's no community benefit in the foundation and i wanted to be sure that you all understood that there is community benefit in the foundation and we do have a responsibility for community benefit. however, it is true that much of community benefit in the foundation is in the form of education. so many, many education classes are transgender classes are classes for suicide prevention for teens. all of that fits in community benefit and that serves sort of the needs of the whole community.

you look at the whole community. did that make more sense? sorry i didn't confirm the disconnect there. >> commissioner sanchez? >> thank you. i just want to make sure i heard you correctly. you said in reference to the diabetes patients that are now being seen at saint luke's, the new services will provide culturally competent linguistic staff? >> the same staff -- >> staff or professionals in the new site, which is the one on van ness? >> we did mention a new diabetes site ativan necessary. -- at van ness. the cal campus, we will find a new site for it. we haven't determined where that's going to be just like

other programs at cal campus, that campus is closing. we haven't determined it might be pacific, it might be van ness, it might be elsewhere. >> i'm sorry, but i do want to cite, because of the 2-mile rule your colleague mentioned in the presidio, his comment a little of this geographic area, two miles. two miles of saint luke's includes a number of unique services that have been going on for over 50 years in the community. the mission health center. central latinos of san francisco provides nutrition, citizenship, english, health education. they also provide transportation. they also provide meals.

7 days a week. a number of the non-profits are transferring to that because they are the only physician that now consistently cooks in that area, everything fresh. on the other side within your area is on lock which also has a large diverse population. plus we can name a number of other sites in this area. and two blocks away is the rodriguez early childhood education program on mission street which is over 70 years old which provides nutrition, training for staff and diabetes because of the student population there. the grandparents come in. the parents come in and it's all part of this communication and education. all i'm saying is within this two-mile area there's a number of unique resources that are

now being linked with sfgh and others to provide some of these services, including choir system from u.c.s.f. etc. but i still haven't seen any discussion and or collaboration to utilize these services to enhance the ability to maintain these cultural services within the new parameter of the new st. luke's. that's sort of a little bit on the radar. so hopefully, as i said, it took a long time to get spanish-speaking staff a number of years ago for the diabetes center out there plus some other programs. >> so commissioners, as i'm sure you are aware, we work very closely with the san francisco community clinic consortium. our primary partner in that, and this is a decision the community clinics make we are the primary hospital for all of their patients.

i'm sure that director garcia can talk about that. mission neighborly health center, i think still san francisco general. i think the hospital has done a very good job working with the community clinics in identifying the appropriate place for patients to get that kind of care. we are working with community clinic consortium. when we get asked to do things we try to say yes. >> if i may, commissioners, if i can just ask a couple questions and make comments. dr. rivera, we are pleased you had the conversation about reflecting who we serve in our communities is so important for us. this is one of the issues we had the conversations with sutter about the diabetes clinic and the concerns that staff from those programs show and you could hear that today. the fact you are going to be leaving the hospital setting, which is, as you said, from a system approach, outpatient is where it's at and that's where we need to do our best work.

the disparities in our community are really in the latino, samoan and african american communities. i wonder could we hear a commitment from you, particularly to work closely with us, because as we move forward, you won't have to come to a prop-q hearing when you reduce or eliminate a service. but it is, and i know your working relationship as an example with missions neighborhood health center, which will be really important. but we would like, because you are a new person in around here, i just want to hear a commitment from you to work with us closely. we have, you know, i think, common interests and i would like to work and i know our staff would like to work with you in terms of looking at those common denominators because i know we could do better. whether at the patient or

hospital level. prop-q is important, we would like to see what happens at the hospital level. we would just like to hear a commitment. we have our chief medical officer for network here. it's so important, alice chan. dr. brown and i worked closely for two years on the development agreement. five years, okay. two intense years of negotiations. and i just think, hearing a commitment to those populations, i think, would serve us well. and getting to know you, as the c.e.o., we look forward to that. but a commitment to these populations is going to be really important for the future and working relationship for the health department. we are here for you and with you to assist you in how to serve this population i think we have expertise in. i just wanted to give you that opportunity. >> thank you.

i'm absolutely committed to serving the community and getting to know the community. as i say, i apologize, i'm new to this part of the organization. and just beginning to learn about the needs. but, if you grilled me on the community needs in the south bay where i have worked for a long time, i could tell you all the f.u.h.c.'s on a first-name, in fact we actually just won the award for the organization that's most honored for helping the community through our work with project cornerstone, our work with the y.m.c.a. and our work with the food banks and other things. we are absolutely committed to helping the community and really having a partnership. hearing what the needs are and how we can help with those. especially classes and other things. we really are excited about that.

>> i find this discussion concerning the change of management is somewhat more of a trust that the statement made that c.p.m.c. has reported no changes to services except payment sources or staffing models from our presentation and slides is actually not reflected in any of, in either your letter to us, for example. i am pointing this out because our responsibility now is to determine if that management transfer is as best as we can tell having a detrimental impact on the health services in the community. the responses to dr. green could also be interpreted to mean that not everyone who

currently is able to access certain services at the hospital base clients will because certain plans may not choose the rates you are offering them. i agree, it's a contract negotiation. but understanding contract negotiations, that could have detrimental effect if, in fact a u.s. or 500% of everyone's cost. i like the fact you are shaking your heads saying no. but it would be really nice to hear a more positive, or see a more positive commitment, as i think director garcia was hinting towards, to show that, in fact, both, or in this case, because it's going to be the foundation that's going to have to carry out at least some sort of semblance of a

responsibility that this very short statement seems to envision that we aren't changing services. we are moving across the street to the montego building. we will keep the same staff. we will have the same culturally competent staffing. we will be available in echocardiograms just like we were a hospital. that would mean also these normal, lower say income medi-cal patients will actually still have access. i don't see that. >> sir i want to clarify, the only group we don't have assurance about are commercially-insured patients. a limited number of blue cross plans we still have to get a contract with. now, as you all know from your experience at chinese hospital,

negotiating with insurance companies is not straight forward. it is our hope they will agree to accept the same rates that they currently pay to the hospital for these services. honestly we would not be truthful with you if we said we could answer for them. but that's our intention is to say this is our plan, do you agree. in terms of medicare and medi-cal and vast majority of patient insured services, it's not an issue. >> i understand. obviously you can't be held hostage to unscrupulous differing programs or plans. i think if we were able somehow to get a clearer definition of what the management transfer would be and while you can say there is no real impact, we are going to maintain all of these. if that could somehow be translated into some type of,

for example, whereas in our documents, that then allows us at least what we could have understood to be the intent that you have. i think that helps us move forward in terms of looking at how we could say the health care of the city isn't going to suffer from this change of management. and i think we have several weeks. that we take some time to see if we can craft something. many years ago we had this same -- not this same issue, but issues of, for example, i don't -- dr. brotmo was here at that time, we talked about employee benefits. that was finally worked out and

available within our whereas's. understanding from you these are so. i think that this is something that we could leave to crafting, in terms of improving within our document what we understand you have said today to show whether or not there really is any change so that a clinic moving to the montego office building will have the very same services. that is your intent. will have the same access. if those things could be placed into our whereas's, and i leave that with staff to try to work out. and i think the same issues that dr. garcia has raised for us from a continuation of working together to try to continue to move forward on services. that might also be reflected in some of our issues in terms of

the alzheimer's and what not. the intent we could place the organizations together willing to move. it's all part of health care is dynamic and moving. can we actually have a resolution that then could say that these are changes that can make sense are not going to harm but even serve our community better. is that something we could work towards? >> we could certainly work toward that dr. chow. we could certainly try. we all understand part of this proposition to process is to have a public hearing of the changes that are going to be made. and i'm sure the commissioners understand that ultimately the decision to make those changes are hospitals and foundations but we work very closely with

the departments to make sure that what we are doing is as fair and equitable as it can be so we are happy to take that back to our team and work with director garcia and her staff. >> right, i would just like to see we could memorialize some of these issues going forward. >> what blue cross decides is not under my control but -- >> very interested in the medi-cal population. >> right. >> and the people we are currently serving right now. i think those are all things if we were able to place into, you know, it's a moral commitment and we are all aware of that. prop-q is only a moral, a more public hearing to understand what is happening and i think that helps for you to tell the public and tell us and the

public your intent. we really appreciate that, it's again another reason we take more than one hearing in order to try to see if we could work things out. >> we are quite proud the new facility we are building at daviess for inpatient and outpatient psychiatry will be a much better place to provide that care. if we could have a prop-r? [chuckles] >> staff? >> prop-r should then call for you to come and tell us all the good things you are doing. thank you. commissioners, any further comments or questions? therefore we will be looking at august 21. it is possible that if, in fact, going back to the whole issue of the svindal services

in the day center that we may want to also be looking at some of that and possibly that might call for a delay if we can understand more of that and i think that we certainly want to give every opportunity to see that the health care of the community is in fact enhanced rather than reduced by the proposals that you have brought to us. >> yes, and as i think you know, august 21st is in the middle of a very busy week for us, because we are opening a new hospital on mission bernal on august 25th. i know full attention is going to make sure that goes as smoothly as possible. >> and this commission is very pleased you are hoping that new hospital for our communities. if there are no further