tremendous job outlining and giving a broad overview and responding to what the landscape is but we also know that we have near term issues that have got to command our attention in a very immediate way. >> absolutely, we will make that specificity. >> thank you. >> would you like me to highlight or do you have specific questions. i don't want to read the spreadsheet to you. >> for me, i think the way you have outlined this to date has a lot of clarity to it. you have filled in and so forth. i guess the question that is ultimately going to come to us as we start thinking about strategy where are the

resources both time and staff and whatever else it will take to execute on this. as we get into maybe that's where organizational excellence is a category. if we are going to have to expand staff or redeploy staff in a different way to help us to do something or if we are really talking about new partnerships, kind of who might they be kind of thing. some of that specification needs to be threaded in here somehow. i don't know if that's where you are planning to go next or not. >> yeah, that's exactly where we wanted to go next. we wanted to present the high level and get your support, buy-in and questions regarding that. and we have drafted some of those plans you are suggesting some sort of a work plan. pamela, mitchell and i have had a preliminary discussion about

resources. we are coming up again on the budget cycle, so it's timely for us to have this discussion as far as any resources or reallocations we might need to do within existing resources. we plan to have all that prepared for you at the october meeting. it's time to move on this at this point. with your approval we will be able to do that. and we are already ramping up on some of these activities we know are before us regardless. >> concierge services. i'm trying to figure out how that would work. >> so the model is to help

employees, guide them through their health journey. so basically you would help an employee -- you would help them set an appointment, really to advocate and help move the member through the health care system. >> that would be our staff? >> it could be an expansion of the staff, it could be in partnership with existing health plans, it could be a specialty vendor that provide that's type of service. i don't think we have the answer to that question in particular in terms of the specific vendor but there's a variety of providers that can do that. >> some of these classes,

pre-diabetes, there's no influence on that. it's difficult to get one -- >> i'm sorry, i'm having a hard time hearing? >> pre-diabetes classes. prevention. all of this is when you are sick. even in blue shield, physical therapy is not good at all. we have talked about that a lot but nothing ever changes. so are just basic things that have to change and even the skilled nursing issue that was not an center of excellence at places they use for sure. but those are just examples of things we have had problems with, we haven't been able to get resolved. just basic stuff, you know. you would think that pre-diabetes classes would be easy and free. >> stephanie and her team has done an amazing job on the well-being side.

there are so many services that haven't been optimized or utilized and how do we spread together what you have today in capability to knit that experience, there are opportunities to talk about how we can streamline and optimize programs available today. >> optimize. >> if i can just say, one of the things i like about this version as it's evolving is number one, all these issues are in the plan holding ourselves accountable to look at our own data and finding out where are the areas that we need to prioritize. we have heard discussion of mental health and discussion about centers of excellence but it's in the plan, actually, it's buried in there but there's a lot of reliance on our staff in our own organization to help us prioritize. obviously we would like to do everything at one time but can't.

and i think there's a lot in here that looks like a laundry list of issues. and one of the reasons why i thought the "new york times" article on what comcast is doing is quite interesting is because they are trying to go through the same laundry list we are going through and trying to design, really along the same strategic plan in terms of their employees. the plan, though sometimes it's lost in the forest, the trees are there around looking at our own data and moving forward. >> commissioner scott, you mentioned the planning process and how i think that it's been a tremendous opportunity for us

to sort of build our shared knowledge amongst the entire team of staff, stakeholders, board, everyone understanding and getting us aligned to go in one direction. there's a lot of value in that, often having done as many plans as i have done over the years, they sort of get ingrained in what you do and yes they do adjust and change over time but the planning process itself is enormously valuable, not just the end point. so i think that's been very helpful. i think the other thing that we are clearly seeing in the comcast article that's why i included it, there's a growing movement amongst employer purchasers of health benefits to kind of take the reigns a bit because there hasn't been the kind of movement that the employers need to contain and sustain affordable benefit packages.

so to that end, i've had a meeting with the silicon valley employers forum, and with purchasers to see where we are aligned, pacific group on health, catalyst for payment reform, considering what we do with the ten county survey. are there other similar interests we can do to have some purchasing power? because as big as we are, we're not necessarily big enough to influence the kind of changes we all recognize we need in order to have a sustainable system. so i think there's a lot going on that if we are measured and data driven and work in partnership, we perhaps could have a bigger impact. our obligation is clearly to the members first. but we are in a pretty big fish bowl. i think having power and aligning our needs and our desires for where improvements

need to occur, could have a significant impact over time. >> i didn't have anything else. i think abbey is coming back in november with a full draft of the strategic plan. >> i'm sorry, you may want to speak up. >> i didn't have anything else other than the next steps abbey indicated in terms of coming back in october with the full details of the strategic plan that would include the measurement strategy as well as organizational excellence plan and project and execution plan. >> commissioner w. lim: just one comment. once we finalize this i would like to see a glossary of terms at the end, we have a lot of acronyms. it will be publicized

eventually so i would like to see a glossary of terms for all the acronyms. >> yes. >> commissioner w. lim: thank you. >> thank you. >> president breslin: any other comments from the board members? public comment? thank you. >> good afternoon, board members, and welcome to our new secretary. clara, president of ercs, i enjoyed participating in the group yesterday and finding this an interesting process. thinking that we are going along the right lines and thank you, commissioner scott, for some of your comments. i didn't have to make them, so i appreciate that. but i'm wondering also, i think we are an unusual employer in the sense that we also cover all of our retirees for lifetime. and a lot of private employers and some of the other public

employers don't necessarily offer those benefits so they come off when someone becomes eligible for medicare. i think we have to consider geography as one of the issues to throw in here somewhere because we not only have active employee who's live in other areas, my favorite people in tuolumne, hetch hetchy. it impacts their families, dependents. we have them all over the world, all over the country. i think we also have to take a look at the nature of the work. and i realize workers comp is a very separate section. but it takes care of that individual when they are injured. it really doesn't deal with much with regard to prevention. and i think we need to find a way to collaborate more with various departments where we

have, for example, utility plumbers in the p.u.c. water system in hetch hetchy where we have the high tension layer, the overhead workers dealing in the muni system but also hetch hetchy, but also firefighters experiencing different unique types of cancer because of the chemicals. i think we have to look beyond what we can do to address those issues. and when we talk about concierge services, i'm thinking education of our members and how to navigate the system and how to best utilize their health benefits to care for themselves and also their families, is very important. so they can understand how to maximize their benefit at the least cost to them but also how to stay as well as possible. and in many cases when we have employees working in remote

areas, we have dependents living in those remote areas. i think we have a lot of challenges. most of our people are here in the bay area. but we still have to address those issues with people in more remote areas. so maintaining city plan is crucial. yesterday we had a firefighter whose first question in the door was, what's going to happen with city plan? because a lot of people move away and need those services. i just wanted to bring up some of those other issues and after reviewing more carefully we may bring in more suggestions as well but thank you. this is an exciting process so far. >> president breslin: any other public comment? seeing none. item number 6, please. >> clerk: item 6, discussion item. open enrollment update, mitchell griggs.

>> good afternoon, mitchell griggs, deputy director of the san francisco health service system. president breslin and commissioners, i wanted to give you a brief update about open enrollment this year. we began this process last year of including it in the september meeting. we went through a really big demonstration with all the configuration and people saw the rates and the mailings, now that you can remember that from last year i want to brief you for what's changing this year. so on slide one, we always want to introduce what our theme will be this year. what are you seeing are images in the shape of an o like last year, when we want people to see some from a distance that means open enrollment. we will use this on all of our posters, flyers, environments

that our open enrollment mailings go into. so this year, you will see the individuals that are included in this photography are actually employees and retirees members. what we want to do and we began late and handled this year we got a photographer and went to several departments and took pictures of employees in those departments and their surroundings. this goes back to our tie into our strategic plan to engage membership. we feel if we are trying to communicate to members one way draw attention by showing something they can relate to. which is themselves or the areas where they work. versus using stock photography which may be pretty pictures of san francisco. we wanted to personalize. it's a big job and we have an arsenal of our own photography to use throughout our

communications throughout the future. benefit guides will be available to new hires and current employees and retirees through the next year and on each area, city college, retirees, school district we utilized hhs retirees or individuals in those particular employers. on slide three, i just wanted to briefly show you the numbers here, open enrollment mailing. total of about 76,000 open enrollment packets we will be mailing. just about 1,000 more than last year. to make that big mailing happen, there's several different segments here. the first thing that we do is create mailings, very specific letters, very specific communications to each one of these groups which is the

employers mostly and retirees with and without medicare. i broke down the numbers a little bit there for you. one up to three of the next, members included in self service which is new this year and members eligible for city plan choice, not available. also new this year. medicare members with non medicare dependents living in kaiser region. we added oregon, washington and hawaii. on slide 4 we wanted to do a deeper dive and talk about our self-service roll out which is the first time we will offer e-benefits or people could enroll during open enrollment online. speaking of our letters, the self-service segment of that we had a letter to retirees,

including about 4,000 or 4,400 retirees in self service this year. this is a unique challenge for us. technically, i won't get into the details but to get access through the health system now that they are no longer an employee has been a challenge. vision of the controllers office has worked together to do. the first open enrollment mailing weren't to those retirees included in self service. there's about 4,500. encouraging them, letting them know it will be out there for them, that mailing will be followed by another mailing, with a password to go on. the other letter on the right will be included in the open enrollment mailing that will be receive today everyone else. providing instructions how to get online and encouraging them to do so.

manager of enterprise and analytics really did the heavy lift on getting this completed self service as well as configuration for open enrollment as well as several other things. i want to give her the opportunity to speak to these things, so i will turn the presentation to her. >> thank you, mitchell. anna with analytics. on our next slide here we are showing who is included in the self service roll out. i know it's probably present on everybody's mind but why isn't everybody included so let me address that now. i think probably the first department in the city that is really leveraging people soft and self service benefits for the retiree population so we are really excited to be a leader in that area.

people soft where we do our payroll, leave of absence and also now with the financials, the vendor management and of course our benefits administration there, but getting people to the self-service portions, the roll out from that through the controllers office is really focused on active employees that's 30,000 there that aren't fully on the system because not everybody in the system is on the city's windows active directory. i won't go into technical details, we are all on different systems so because of that, we can't get everybody who is inactive on there and they have just been working hard to try to get all the active employees there and they won't be done with that until roughly end of first quarter next year. so we came and held up our hand and said wait we would like to

get some of our retirees going. because they are so focused with resources trying to get all the city and county employees there first, we took on, with some help with d.t. and controllers office, we have taken on the on boarding of the retirees. we had to have an agreement how many we could do knowing they are trying to on board 30,000 active employees. we wanted to make sure the experience is positive for everybody involved. we can't have another 20,000 retirees calling the d.t. help desk while you have 30,000 other people calling. you know what the phone calls just into our offices in october, can you imagine throwing 50,000 phone calls that way. that's the reason why we had to scale back the retirees. also not every retiree record exists in the system the way it needs to exist today.

the scope was to look at most recent retirees and work backwards from there, they are more familiar with people soft. that's what you need to log in. that's how we got to the 4500 population there and again with the city departments who we have really focused since not everybody is on self service, departments on self service today and have some familiarity with the environment. that was a lot of negotiations trying to figure out who the population was. there's 24 city departments in addition to the 4,500 retirees. on the next page you are seeing a few screen shots just quickly of online open enrollment, the e-benefits. we have been working diligently with vendor as well as our systems division over the past few months to layer a skin over peoplesoft.

peoplesoft is not very intuitive out of the box. so we are laying another interface on top of it so it will help people navigate the environment and ideally will just make it very easy to make your elections and click to the next screen. here is a look. these are out of our user acceptance testing environment of what it will look like, we will have alerts on the main page, there will be articles on the main page, links under the employee link section, it will say employee link even though you are a retiree, because it's the employee portal and we don't control that part of it. next slide, you are actually seeing the environment itself. you could see at the top there's those green dots that help you navigate where you are in your open enrollment elections. a very clean look to it.

your back buttons. next buttons. we are right now putting together all the help documentation. some additional web pages with resources for who to contact. there's videos posted there, there will be documents posted there to guide people through. any computer tablet, mobile device, smartphone, you will be able to use to access our e-benefits. the next screen is another one showing again where you will review your election and i will have mitchell cycle through them. it's just a few screens we threw on here, your old elector. audit tables built behind all of this, because we have to capture this information that we traditionally have captured on paper and put in your files and finally we have our

confirmation statements, not the official we will mail in november but a record of what a self-service user submitted. elections aren't finalized until we have everybody's proper documentation, etc., that's why even though they will be able to print out this statement, they will want to look for the actual confirmation we mail out late november. we are still moving, it's still not migrate today production but we have another week and a half and i anticipate it will be there. but a shout out to everybody on the hsf team and the controllers office and department of technology, identity and access management group and d.t. service desk. they have been very interested in helping us make this a reality and i will turn that back to mitchell. >> before you leave, through the president.

as you get to the stage of confirmation, you crossed all the other thresholds for the enrollment. is there an email sent back to the individual saying you completed it, or here is your number confirming you have done it? something in the environment itself. beyond the document that you might send later? >> there's the statement that you print out and it's date and time stamped. you could go back in over the course of the month and decide to make other changes. so all of our documentation, both the language in the environment and all the help materials is clear that we take the final version as the version of truth. >> and i, as the enrollee get a copy of that? >> you will be able to print it out. there's no system email generated because it works off

peoplesoft. >> i understand. but it's like the voting environment. you walk away and you don't know if it really got counted or not when you just run your thing through the machine. >> that's why we encourage people to print or save to their computer that statement. even with your paper enrollment, if it didn't come through our fax and you are like, hey what happened you will have your copy to get in touch with us. >> thank you. >> thank you. >> president breslin: commissioner lim? >> commissioner w. lim: is it biweekly, monthly? >> yeah, and it's based on your pay group. so for active employees it's a biweekly amount, for retirees, it's a monthly amount. >> commissioner w. lim: i'm not

sure, if you could specify biweekly or monthly and on the cost summary is it for the year, that kind of thing. >> great. thank you. >> commissioner w. lim: and a side note, i noticed with the three big departments, department of public health, public utilities commission, sf muni, if they are aren't there, it's the system they are using? >> yeah, they are on a different active directory. we look forward to getting them there. [please stand by...] .

>> very good job. any other questions? thank you. public comment on this item? no public comment. we will move on to the next item excuse me. we will have a break. a ten minute break.

>> president breslin: we are back in session. item number 7, please. >> clerk: item seven, discussion item. 2017, 2018 influenza season report. >> maybe we could do a little -- a high point on this report. we have a closed session. >> absolutely. i am with enterprise systems and health service system. you will see a centers for disease control and prevention summary of the 2017 and 18 flu season that you can read in your own time. it is a short summary. essentially back , it was one of the highest percentages since 2009 of the flu pandemic. just as a callout, nationally, we are having a severe flu season last year. when we talk about flu season,

we are talking about a period from october to may. we went ahead and took a look at our own experience to see how we were affected at the health service system. so, moving there, i won't necessarily read everything. i encourage other people who are not familiar to do so, but it is a contagious and respiratory illness. every season and can be a little bit different and we do know that some people are certainly more at risk for serious flu complications. the young, the older population, certain health conditions and it is recommended that the best approach, from the cdc on prevention, is annually getting your flu vaccination. of course, those events that mitchell was referencing in the previous presentation that we have going on, do include our flu shot clinics that are hosted and scheduled by our san

francisco health services and well-being team. taking a look at slide three, very quickly, you can see these were off reports from the california department of public health that showed weekly snapshots of flu activity. the reds on the map of california were regions that had significant elevated activities for the flu season and even as we got a little bit later into the season, moving towards late april, things have calmed down and the rest of california, here in the bay area, we were still blowing red in terms of having that elevated activity. the next few slides, and i won't go into detail, but these are some ways that the department of public health analyse is what is going on with the season. they look at clinical reports for the influenza -like illnesses and laboratory data

and they are compiling weekly reports and just to call out. here the takeaway. as you see the slide on page 4, it is several years worth of activity and our most recent flu season in february. we had a spike. we had much more flu activity happening this past february than any february in recent years. and that same pattern is certainly called out with other types of metrics that we look at so the pneumonia and influenza admissions we will see again. a huge spike in february -- that is this year. and the significantly -- significantly higher than what we had seen in previous years. onto slide six, laboratory specimen tests. these are indicators of people

coming in with health conditions and so the number of specimens that tested positive for influenza when you're doing the percentages of all those tests that get cent in, the black line with the red dots, if you have a colour version of this, much higher than in any other year. of those tests that were being submitted, a much higher percentage were confirming the presence of the flu virus. so that was a look at what was happening statewide. as we move onto slide seven, we take a quick look at a few items to see how we were comparing in our own population. we are right on track, mirroring what was happening for the states. here we are using the same metric to identify based on

office visits, the influenza like illness visits for early active and retirees in february. much higher than we saw in the previous february. more than double. and the cost was more than double of our previous year in terms of payments for those episodes of care related to flu. we do break out the medicare population separately because, as you no kak we don't have the full financials for the retirees but same thing when you're looking at the utilization there a considerable spike in terms of the offices related to flu over previous years. and then going into slide eight, this is where we are looking at our own population for pneumonia and influenza admissions. we are using the rules, not going into them now unless you need to, but we are excluding for various things and including for various things. so we are all using the same

types of analyses. this is really looking for any admissions where flu was present , as primary or secondary diagnoses. so the costs, up to our net payments in just the period of march, and a lot of that was, in fact,, the flu with other diagnoses. we excluded some conditions, but sepsis was big for example. there were weakened immune systems and weekend conditions and being susceptible for other viruses. we see that going on here as well. and then quickly, looking at the lab data, all those lab tests that are being sent off. we have got a number of those

lab -- the data increasing significantly in january to the previous flu season and the season before that. twenty-seven of those lab visits jumped to 72. and of course, the cost per patient were also increasing. up from 106 up to 164. that was in the retiree population. also, and upwards trend although not as severe as what we are seeing in the active population. finally caught just looking at the whole episode of care on slide ten. we had 464 episodes related to flu just in the month of january it continued february and march. that was the real peak that was happening. you see all of those from 2018 that are much higher than the activity where you were seeing in 2017. the net payments increased from

300,000 to about $838,000 over the course of the flu season compared to the previous flu season. and likewise, the medicare population episodes of care around that significantly higher than in the previous years. so what will we do about that? again, the cdc recommendations still is the best way to avoid getting the flu is to go with your vaccine. we highly encourage you to do that. here is a look at the work being done by the san francisco health system well-being team in terms of the number of vaccines and clinics that they have been doing annually. it is a five-year shot view of the work they have been doing. in fact, on slide 12, we are taking a sneak peek about what we have coming this year. of course, there will be 25 clinics between october 21st

of november second. we are expecting 4300 vaccinations and you will be able to find the calendar of all of those events on our website. our well-being team is also getting various worksite educational materials out there. posters, e-mails, in leveraging the champion network. we've got special inserts going to our medicare retirees with general flu information and health plan information and we have several webpages that are in process of being developed that will provide all sorts of information for any individuals who are looking to find where to get their flu shot. in summary, yes, it was a very severe flu season. hopefully we will avoid that this coming year. we had significant increases in utilization and cost. again, almost two and a half times of the cost were incurred.

january february and march were most affected months for us. fortunately, in our population, there were no instances of flu raid related deaths. that is not true statewide. definitely want to take some very -- take the flu very seriously. if i encourage all of our members, if you're not able to attend one of our own hosted flu shot clinics, do consider getting your flu shot from your own doctor. vaccinations should be covered. that is true for kaiser, united healthcare, as well as for blue shield members. notes that in blue shield, if you get your flu shot at a retail pharmacy, that is not covered under your benefits. we will have all that information of where to go and what is covered and what isn't covered so you can make sure you get your free flu shot.

>> president breslin: thank you. any comments? >> as the infectious disease -- anyway. as an infectious disease member of the board, i think we can look at your presentation as excellent. and not get too far away from the strategic plan. and think how the strategic plan helps us in this regard. frankly, lab specimens drop off because we don't need to take them anymore. you know you have an epidemic going on. by subject members to the time, the discomfort and the cost, in terms of getting the confirmatory test. likewise, we should be maximizing geographical concerns so all of our members, no matter where they are from have access to flu vaccines as soon as it happens. thirdly, the responsiveness of health plans to the calls, i

think i have the flu, is a critical value. why wait to get an appointment to come in and spread it to everyone else in the waiting room if you can have algorithms that treat on the phone and get the prescription ready for you in 4-6 hours at your covered pharmacy? these are all issues that fall into the strategic plans as we look for ways to improve the service that we demand and our members, you know, should have. this is an excellent way to go back and look at the plan and say, where can we make this operational? >> not to catch you offguard to, but we have got a number of calls from members that have blue shield that are concerned about having to go to their doctor for their flu shot when they don't need to go to the doctor otherwise. and we know primary care practices are pretty impacted. we can probably relook at that and whether the pharmacy is a

good place for people to get flu vaccines. >> thank you. >> president breslin: public comment? any public comment on this item? seeing none, we will move onto the next item which is item number -- >> clerk: item eight. medical expert second opinion carrier options. >> good afternoon. in front of you as a presentation on expert second opinion services. this comes from and ask and i cannot remember which board meeting i was, but from you all to come back with more information about not only best doctors, but how a member could seek a second opinion through their health plan carrier. blue shield kaiser, united healthcare. this is the purpose of the

presentation. if we get into detailed questions, i would request permission in advance to call up the carriers to address those. starting on page 1, i'm trying to think high-level about this. i see three ways that a member can get a second opinion. through best doctors, through their health plan carrier, or self paying people, out on their own. so there are two ways to the medical carrier and best doctors looking at each one of these, on page 2, this is a summary of how a member receives a second opinion through kaiser. so they would contact member services and they help arrange the consultation with a physician or if it is a specialty that is not represented within the network, they would arrange for consultation with a nonplanned

physician for the second opinion the test results of a second opinion are put into the electronic health records. the information is available to the initial physician or provider as well as the second opinion can see the initial providers take on the case. if a member is requested or denied -- denied a request for a second opinion, they file a request. in addition, what i don't have on here as there is always physician to physician and provider to provider consultation happening in the kaiser network due to the framework. for blue shield california on page 3, you would need to get a referral from your primary care provider or they may initiate a second opinion if they desire one for the member. if the care is provided by the

primary care provider, the second opinion would be provided within the same medical group. if it is provided by specialists as a second opinion, as authorized by the members medical group or through the health plan, the insurance company portion of that. they would be some prior approval that would need to happen to seek that care. the results of a second opinion would be shared through the medical group's data sharing system and may also happen through provider to provider discussion for next steps.

looking at pages four and five for united healthcare on page 4, the nonmedicare population, because it does differ. on the nonmedicare plan, members have the option to contact a doctor at any time to make an appointment for a second opinion they do not need to notify the current provider that they are seeking a second opinion. the services must be otherwise covered under the plan and the cautionary is applied on the network status. if they are in network or out-of-network out of network. the sharing of the results from the second opinion is really up to the member to share with the initial divider. united healthcare does not sit facilitate that process. -- does not facilitate that process. on page 5, members can have the option for a second or third opinion to determine advisability of undergoing surgery or a major nonsurgical diagnostic or therapeutic procedure. there is more specific language outlining the third option or the third opinion. the member would contact another doctor to seek the second opinion. to the initial second opinion

differ than they have the option for the third opinion. the same rules apply that the physician, the services must otherwise be covered under the plan and that the medicare provider is willing -- the willing provider -- the provider must be willing to bill healthcare. the member has a choice to share that second or third opinion with the initial provider and united healthcare does not facilitate that process. on pages six, seven, eight and nine, this was just another view doing the side-by-side of some of the key questions about preauthorization and can they go out of the network? i will not go through that. on page 10, is a high-level summary of the reminder of best doctors on the services that they provide. members can contact best doctors directly to obtain services and then they have the choice to

share that second opinion information with their initial provider. on the last page and on page 11 capped not asking -- providing a recommendation for action, it is next steps that we are thinking about and we are open to any other ideas that you may have. it is to continue to review the reporting that we received from best doctors and engage with medical carriers on activity around second opinion. if we can get into some reporting of how many people are seeking those, it is a challenge because it is a coding system. appeals, again, are not necessarily called out as to which one are related to second opinion and which ones art. -- aren't. but looking at how we can capture that information going forward and recommending that we explore the market as it relates to the expert second opinion, which to be specific and direct, is a services provided by best doctors.

>> president breslin: any comments? >> yes. the thrust of this request was whether, indeed, best doctors was duplicating services that we are being provided in plans. if we are already -- if a member is already covered in getting this service through the plan, is it an overlay? best doctors do that. quiet -- while i appreciate the analysis, is very informative and very thorough. this is kind of where we need to ultimately try to get to as to whether best doctors, because -- whatever it is per member per month cost, layered on top of whatever else we are doing. so somehow, we need to get to that point of analysis now that the side-by-side chart -- it was profoundly informative for me. that is really the answer we are

seeking. whether we need to have the best overlay or are we already getting that through the health plans we additionally, why can't some of these things be the same at a threshold level? in one case, you seem to be able to go out on your own and initiate this process. the other, you must go through the pcc. people may have a problem with that. the doctor had said this is what i think now you are challenging what i think, or what i am recommending for you. it is pushing the member or the patient, in this case and a bit of a fix. by best doctors being a third party, you are relieved of that pressure and that patient-doctor interaction. i'm just saying that this is not the end of the discussion. we have to, kind of, get to the original question. this will be helpful to get there.

>> vice president follansbee: thank you very much for this overview. as someone who is a retired physician, and worked for all these health plans at one point or another, my contract was there but then i was a kaiser physician in the last half of my career. the system is much more complex than this. i think that it's hard to codify that. the thing that i am impressed by in this presentation is the best doctors claims to really get the case initially reviewed, and then forwarded to a physician and it really was an expert in the issue that the members are asking review of. none of these plans seem to do that. none of these actually seem to, on the surface, you know, some of them are member initiated. i want to see dr so-and-so because my neighbour like her or him or whatever. otherwise, you can pick someone

and we will go to mother. so there is still not a lot of patient member engagement in feeling trust that this opinion is actually reflective of another level of review. i will tell you that i know that in some health plans, certain surgical procedures are -- or oncology care is reviewed by a whole team of doctors and pathologists and nurses. so they are getting multiple opinions to come up with a treatment plan that made it look like one doctor decided that i just needed surgery for my breast cancer, but in fact it was a team. it is hard to codify this. i think as we look at our own strategic plan, i will keep coming back to it. and then the complexity of medicine and the need to demand best care, that this does not

suffice at all on the surface. for what we want for our members , frankly. >> it's an informative good start. it certainly answers the initial question. >> president breslin: to me it is informative. united healthcare came out the very best here. they were able to go outside the plan. if you can't go outside your plan, i don't see what good that is. because sometimes the doctors will agree with other doctors. there is some sort of buddy system sometimes. i thought that what united healthcare did was really good here. you could even get a third opinion sometimes. i thought kaiser and blue shield were short and blue shield seem to be really restrictive and kaiser seemed quite restrictive too. so maybe we can do some work on this. may be they can do better than they are doing and be more open about this.

>> i agree with all of your comments. this is for a start. it does have to be part of the strategic plan. as we talked about engaging and supporting members and thinking about how do we do that as one, it may be through existing programs and in enhancing or changing and modifying or through partnerships with outside parties and making sure that those are all lined and providing the support we need for our members under that plan. >> president breslin: interesting, as i recall a report from best doctors, they didn't have any referrals on kaiser. >> they did have quite a few. we are pending, we were hoping we could have updated data for today but hasn't come in from best doctors yet. i think the way that we pose the question to best doctors on the other side of the coin is how are they integrating with the health plans we their

relationship due to their business model, with patients so they don't go back to a physician. i think there's opportunity to try to enhance this service that may be needed by some of our members. >> vice president follansbee: i remember the discussion. i think the discussion was that there were a number of members who have kaiser who have used best doctors. what was the concern from the staff was that kaiser member services was not recommending best doctors to members you may have come to them with concerns about another opinion or the advice they were getting on the didn't seem to understand that best doctors was an option for our health service system members. that was a concern. not that the kaiser members couldn't do it on their own, i think they were.

>> thank you. >> president breslin: any other comments? thank you, very much. any public comment? >> good afternoon commissioners. i am a retired employee. one of the things that i hear from our members who want second and sometimes third opinions is that they really don't want to stay within the network and get the opinions they want to go outside because there is some perception that sometimes within the same medical group or within the same network that there will be more collaboration with the original diagnosis, which may or may not be valid. but i think one of the questions i recall was best doctors was only serving members and not dependence. and when we are looking at -- i actually know dependence that benefited from best doctors but i thought that was mentioned at one of our previous meetings. i know that were the other

systems, whether it is kaiser, blue shield or united health care, it is everyone in the system. but i saw the director nodding your head. best doctors is not restricted to just members. it includes dependence as well. >> correct. >> thank you for that clarification. >> president breslin: any other public comment? seeing none, item number 9, please see eight item nine is action item. cafeteria plan, 2018 annual update. >> chief operating officer. this is the plan year 2019, cafeteria plan document to review. this is an annual thing that i present to the board. it is an action item because of the fact that this is one of our plans documents and any material changes to this document has to be reviewed and approved by the board.

this is from section 125 of the internal revenue code. we required to have a complaint document. back in november last year, we had an education session on section 125 of cafeteria plans and why it's important for us to follow these rules consistently. throughout the membership. included in your pocket is a summary of the changes. there are not that many this year. the first change i would like to draw your attention to is on page 30. it is updating the name of the executive director. the second change is updating on section. >> commissioner ferrigno: , updating on the annual election amount maximum under i.r.s. guidelines. currently the health care fsa is maxed out at 2500 per year. the i.r.s. has increased that so we are increasing that as well to 2,650 per year.

in section b. 5.1 and c5 .1 are the same changes. i realize after a thorough review of the plan document that there was one situation that the plan could terminate that was not included in our rules but we are following operationally. that is a healthcare f.s.a. or dependent care f.s.a. that can terminate situation if the participant does not make the required f.s.a. contribution. and the last change is in section d5 and this is annual changes every year. we update the amount of flex credit amounts for employees who have the flex credit benefit right now. they get extra flex credit earnings for benefits. again, that's updated -- this is updated every year based on the rates you approve in may and june. that concludes the changes for