>> the health service system board will now come to order. please stand for the pledge of allegiance. [pledge of allegiance] >> all right. roll call, please. [ro [roll call] >> president breslin: all right. item number four, please. >> clerk: approval with

possible modifications of the minutes of the meeting set forth below. the documented attached were the regular meeting minutes from october 11, 2018, as well as the special meeting minutes from november 18, 2018. >> president breslin, i have edit on page 13 of the october minutes. it's the third from the bottom of those bullet points, public comments, none. commissioner scott noted that the governance committee will be updating the terms of reference for this year. those could be capitalized, terms of reference. at this time, the terms of reference are wholly sufficient to cover the conduct of the board during the blackout period. that was the intent of the comment. >> president breslin: yes, okay. would you like it to reflect exactly that? >> yes. that the terms of governance are sufficient enough to cover the conduct of the board during the blackout period. >> president breslin: any other corrections? any other corrections? seeing none, i need a motion. >> i move that the minutes of the october board meeting be approved, along with the minutes of the education form for november . >> commissioner lim: second. >> president breslin: all right. any public comment on this item? all those in favor? [voting] >> president breslin: opposed? it's unanimous. item number five, please. >> clerk: agenda item five, general public comment on matters within the board's jurisdiction. >> president breslin: okay. public comment on this item? >> my name is diane aehrlich. there's been several commercials now that medicare can also offer help with home health aids and also transportations to medical appointments. my understanding is united health care does offer the help with transportation to medical appointments, but kaiser offers neither of these things, and i would like for -- in the future, for the board to consider also kaiser to also offer the help with transportation to medical appointments and to -- for both plans to consider offer help with the medical home health aids, since as we get older, all of us are going to need these services. >> president breslin: will you look into that, abbie? or does anybody from kaiser know about that?

would you like to comment about that now or another time? >>. >> president breslin: in answer to their question why they don't include that now? >> we do have some support and especially through community services, so that's part of the discussion we're having, is how do we get that information out to everybody so that everyone's aware of the services that we provide. so much more to come, but we've been deep into these discussions. >> thank you. >> president breslin: thank you. no other public -- oh, come forward, please. >> hi. i'm gail auh, and i'm a retired teacher. i want to talk about the importance of having more than community input with the rides to the -- let's say kaiser. because i hear that they're very expensive. they cost more than $100 for a ride, so that's difficult for people, especially as the demographics get older. for me, i live alone, so it's kind of an important issue. >> president breslin: thank you. any other public comment? seeing none, public comment is closed. now we'll go to number six, please. >> clerk: president report. report given by president breslin. >> president breslin: i have -- i have nothing to report, so we can go onto item number seven. >> clerk: okay. item number seven is director's report. report given by abbie yant. >> good afternoon commissioners. i think most of what i have to talk about today is already written in our -- in the director's report prior -- sent to you in addition to the presentation that mitch will be making on the open enrollment that went exceedingly well this year. i do want to call out to your attention, though, the fact that stephanie will be making a presentation to you later on, but this will be her last service board meeting, and i think many of you know that stephanie came here about five years ago and started from scratch our well-being program that benefits many across the city and has really created quite a network of champions and department leads throughout the city and established a very, very strong foundation for well-being and will leave us with a great challenge for continuing to grow the program. she has recently promoted carrie beshears to be a leader

in the department, who's -- carrie's been with us for a few years, as well, and she will step in in an acting role while we recruit for replacement for stephanie. i wanted to take this opportunity on behalf of the board to present stephanie -- where did she go? >> there she is. >> -- for a certificate, excellence in achievement -- [inaudible] >> karen, i didn't know if you had a few remarks, and i know that supervisor mandelman has a few remarks, as well. >> president breslin: commissioner scott, go ahea >> stephanie, having been with the university system and how their wellness program got

launched, i think i commented that you had an incredible task ahead of you. but your enthusiasm and focus and professionalism have really brought this program to fruition. and i cannot thank you on behalf of the board as well as the members of the health system for the great service that you've rendered in the city and county of san francisco as well as to the other member entities that are a part of this system. so thank you for sharing this portion of your career with us and being such a great professional leader in this field. >> thank you. >> president breslin: commissioner mandelman? >> supervisor mandelman: i did want to bring you the -- a certificate of honor from the board of supervisors, signed by everybody, thanking you for your service. so thank you, stephanie.

[applaus [applaus [applause] >> president breslin: thank you, stephanie. i want to echo everything it says here. do you have anything you want to say? >> i'm prepared to give the retirement report later. it's bye-bye a distinct honor. i'm crying, claire. be nice. really happy that i am leaving for very happy reasons, to move back to atlanta, georgia, and spend a lot of time with my little ones and own a house for

the first time. then i get here, and i feel the people that i'm going to leave continue their amazing work. i have no doubt that the program will continue with carrie at the helm, but i'm going to miss you, and you guys are amazing. [applause] >> president breslin: all right. any public comment on this item? >> claire svonsky, retired employee of the city of san francisco. i just want to thank stephanie.

she made a big difference at our rasccscff meetings. it's made a difference in our members and their better health. and we will miss her greatly, and it's very sad for us, too. i'm crying, too, stephanie because she made a very big difference. activities and well-being are so important to retirees and seniors, and ageing in place are extremely important. the kinds of things that she would bring to our meetings, just exercising in place for five minutes, made a big difference in everyone's life. we look forward to carrie coming over, as well, and everyone else coming to our meetings, but stephanie has made a significant difference, and i hope we keep the program going. because it's not only important

for active employees -- i've seen the difference it's made for the employees and the p.u.c., but it's important for the retirees and the trade. so thank you, stephanie. we will miss you a lot. >> president breslin: any other public comment? seeing none, we will now go onto open enrollment report. >> clerk: agenda item eight, open enrollment. up dates on self-service. presentation by mitchell griggs. >> mitchell griggs, chief operating officer at the health service system. in this time every year, we take a moment to -- just to brief you on the successes and

the numbers and statistics of what happened during open enrollment in october. and i believe i started in september telling you some of the things going on this year. so just wanted to highlight what was unique benefit wise for this open enrollment. one very big thing is we started self-service or e benefits for the first time. this is people being able to log in to a computer and do their enrollments instead of paper as they've been doing for the past decades. another initiative we did was a communication or photography, member engagement through our communications and trying to do some things to get people to read our benefit materials or to read our e-mails. and so i think some of these things were very successful, as you will see in the numbers that we're going to talk about. so on page one of the presentation here, we're just giving you some overall

numbers. we met all of our customer service calls, like the speed of answer. it's less than 30. benefit rate, 3%, which is good for as many calls as we had. we had about 12,000 calls this year, and that is an increase of a little bit over 5% than last year. last year was a pretty significant year. we added a new plan, trio h.m.o., and so that instigated a lot of calls. we were surprised at the number of calls that it generated this year because there was essentially no changes in the health benefits. and our in-person assistance increased about 22% last year. including our off-site events member assistance where we speak to the members at our health fairs, flu shot clinics, a small decrease this year.

but our inbound applications, these were our paper applications which is in addition to the self-service we did was about 12,000, which is a little bit of a decrease from 2017. so this year, i'm looking at -- we had these increases in our member engagement, so our face-to-face meetings with our members and our telephone calls, and i do think that has to do with our engagement and improvement. engagement with photography or redesign of our benefit guides. so on page two, it's just some graphs that you can see year over year of the past three years. notably, 2017 was a big enrollment year, but the big thing this year was inbound calls and inperson assistance. i'm going to skip slide three and just move to page four. and this particular graph is

showing me all of our benefit open enrollment materials got to people's houses by october 1. definitely everyone had their materials by the first. as you can see, we had a much bigger increase in calls on the first day, and that's what we want. we want as many calls to happen earlier in the month. so later in the month, you can see it kind of dropped off, kind of got normal and dropped off by the end of the month. that gives us time to process paper applications or those types of things. and on page five of our report, again, these are applications, our paper applications that we receive. and again, i'm seeing that we had a huge intake in the first five or six days of the month, which is good. again, we want that paperwork

in our office as soon as possible and then dropped down pretty severely at the end of the month. so what did all those paper applications mean? on page six, you'll see the first pak on the migration. we're -- first page on the migration. what the enrollment numbers were for the health plans just before open enrollment and then after open enrollment. we will have a full detailed demographics report probably in february , which we'll dive a little bit more into specifics about this. but what happened is we had a little bit of movement out of trio h.m.o. close to 800, i believe, but we had some members come out of

wave, some members of kaiser, and some city members enroll in trio so that decreased it to about 426. and that 426 were leaving trio and going back to access plus. >> so -- so that means they're not -- they haven't been happy with trio, obviously. >> so there are many things, i think, that says -- and we're been trying to dive --

[inaudible] >> but we've already started working with blue shield and draw up some communications for next year to make sure people understand exactly what trio is, especially the people that are already seeing trio doctors. they actually can pay less. >> president breslin: did you talk to any members about it? was it maybe these doctors weren't accepting it, even though they were on the list or something? >> there were some. there were something that they felt their doctor didn't take trio, but that was just an outreach. we had to have blue cross/blue shield talk to the doctor or explain things to the front desk. it never ended up in the case where the doctor didn't take it. it might have been just some misinformation. in addition, as far as kaiser is concerned, pretty much the same year over year. they did have 35 employee only

leave kaiser, which is a bit unusual, and most of those did go to trio. on page seven, just briefly, we're not able to clue politi families into the totals in the prior page, and as you recall, split families are when there's a retired family -- on page eight, this is the first time we're including the migration for delta dental, and it was interesting to see the total subscribers increased by 527. so we haven't looked at that over year from year. perhaps there's some retirees enrolled for a year or two,

disenrolled and then enroll a year later. also with the small away, perhaps that enticed some people, as well. but that's a good, 527 rolling back into delta dental is rather specific -- significant. so vision premier, on slide nine, this is a very popular benefit. lots of questions, that increase in phone calls had a lot to do with this. people asking about the premier benefit. as far as member satisfaction, they really liked this plan. they were very happy about it, and it's very obviously because we -- the enrollment increased by 3800 members. and another successful year for voluntarily investment. legal shield, that was a pretty good communication.

the legal shield person actually is a retired city worker, and so she was very -- did very well at our health benef benefit fairs talking about that plan. and supplemental life, again, a popular benefit, but again, a successful year for our voluntary benefits. so on slide 11, we're going to give a little bit of an overview of self-benefits. >> i have a question. >> uh-huh. >> how did you determine who was going to be eligible to do the e-benefits? >> eligible for the self-service for e-benefits? >> yeah. >> everyone. we had to look at the technology and look at departments that are in self-service or would be in self-service by the time open enrollment is arrived in october. and self-service, currently, it means people who are doing

their payroll, doing their time sheets through peoplesoft. you know, they're maintaining their addresses or other demographic and contact information. so we can only do it to those departments, identity management, having to log in. it's a security process where you can be at home and you can log in and do it. so we had to work with the department of technology, and we were limited to the departments which are on the right-hand side of this slide. still a good number to start out with. it's a little bit of a soft rollout, which ended up being a good thing which it allowed us the band width to work with a lot of these departments individually. and we randomly selected about 4500 retirees. we thought that was a good number to start off with so we could get their feedback, too.

but hopefully, next october, we should be able to roll it out to all retirees in all departments and all employers. so that said, we did 13,253 were able to do self-services this year. about 24% of those 13,000 actually went in and took a look. not everyone actually made a change, but a lot of them did go in and see what it was like. so in slide 12, just to highlight, every eligible department actually participated. some, you know, every department that had access to employees did go in, and some of the top ones were the department on status of women, h.s.s., of course, you better have been in the top there, and

controller's office, and department of child support services and the planning commission. and on slide 13, we had a survey, after people completed this self-service, we asked that they complete a survey because we want member feedback. the first question is how likely is it that you would recommend e-benefits to a friend or colleague? as you can see, it's extremely likely. about 70% rated it as a nine or 10. and on the second question, how would you rate the quality of e-benefits, and again, got pretty high benefits there on page 14. and on page 15, we asked what do you like most about e-benefits. this was an open-ended question, so people can type in

what they wanted. they said easy and fast and simple. they said they were glad they didn't have to travel to h.s.s. to make arthur changes. doing it at home, paperless, at-a-glance. that was a big one, too, feedback that i got, as you'ren rolling or changing your benefits -- as you're enrolling or changing your benefits, you have a cart so you can see what you're doing. some things we asked on page 16 of what could improve, some individuals wanted on-line chat, change in the way we log

in, and change in voluntary benefits. we have our own environment for your basic benefits, but we have these other benefaddition benefits. ability to remove a dependent or beneficiary. right now. people can't do that because of history and how peoplesoft looks back in history. you're not able to remove a beneficiary. you can remove them from your benefits, but they're still visible as a potential benefit. again, on-line f.s.a. calculator. that is something we do have in peoplesoft, it just doesn't work quite well with the self-service yet. wanted more clarification on some of the benefits. and on slide 17, we asked a couple questions; if they found

it convenient. 96% said they did. if they would go on-line and enroll next year, and 98% said they would. and on slide 18, just a couple things that we know that we're going to have to do and we're currently doing. and some of them we talked about, suppressing dependents that are no longer eligible. we are already beginning talks with the controller's office system division about doing new hires throughout the year and family status changes, so hopefully by the end of the first quarter we'll have that available. and then again, expand it to all c.s.f.'s and employees and with the voluntary benefits and improve how to upload documents. that concludes the open

enrollment report unless there are any additional questions. >> any additional questions or comment? >> i just have a comment, mitchell. you're survived another one. you and your team. >> yes. >> and you are to be commended. each time that you've gone at this, you've tried to make it easier for members to utilize and get through the process, and i think it's paid big dividends. we haven't -- at least i have not seen some of these to-the-whole-board e-mails that kind of percolate up as we're going through the process. so thank you for all that you've done for everyone that participates in it. >> okay. any other comments? thank you. looks like it is very successful. >> yes. >> yes, it was, and we also want to thank stephanie fisher. her collaboration throughout the past five year has actually improved our member outreach and open enrollment.

that's including having the flu shot clinics with some of our offsites and -- clinics with some of our offsites. stephanie and i got in there and really made it happen, and the city's been really supplementary about that process, so thank you, stephanie. >> president breslin: any public comment on this item? seeing none, no public comment, we'll know move onto item number nine. >> clerk: agenda item nine, health service system reporting as of aoctober 31, 2018, presentation by pamela levin. >> good afternoon, pamela levin, chief financial officer, san francisco health service system. this report provides you summaries of the actual

revenues and expenses for the employee benefit trust fund and the general fund administrative budget through october 31 as well as the annual fiscal projections through june 30, 2019. as far as the trust projections, the final trust balance that will be reported in our financials when they're issued next week is 77.4 million. based on the activity through october 2018, the fund balance is projected to be 72.2 million, which is a 2 -- 5.2 million decrease. we're seeing favorable claims experience for city plan and unfavorable claims experienced for blue shield, access plus, and trio. there's favored claims experience for the dental plan,

and we're project today have 7.9 -- projected to have 7.9 million in pharmacy rebaits, a year-end balance of 1.3 million is projected for the health he care sustainability fund, which is also known as the $3 budget. no performance guarantees have been received so far this year. we've had two reimbursements under the adoption in syracuse assistance plan. we have one that is about to -- pardon the pun, pop out, and we're looking at paying that in the next month. and the amount of forfeitures for unused flexible spending account balances will still not be known until june. we're projecting to end the year with a balance of 188,000.

that's in personnel because of the slowness of filling positions. i'm happy to answer questions. >> president breslin: any questions? >> the significant audit? >> so the audit has been delayed. it was supposed to be issued i think the 23rd of october. it looks like it's going to be issued december 21st. the biggest problem was the transition to the new financial system. the most critical audits to be issued this month are the enterprise departments because they have bonds that are -- their bond ratings are tied to that. we have everything prepared and look like we might be out the gate first, but it may be -- we may be delayed in order for them to issue those other -- >> and there's no adverse

findings of any kind, i'm sure. >> we're still working through it, and i anticipate that there'll be no adverse findings, although we are going to change some of our procedures to -- to help in some of the testing that the auditors do and do that early. we're working that out with ann. >> very good. thank you. >> president breslin: i just have a comment. on page five, under, if self-insurance, and then, you have insurance products, and you have what's called the new city plan, which i think that should be uhc-mapd like it is on page six, under insurance products. >> so -- i'm sorry. i'm having a hard time hearing you. >> president breslin: are you? >> what is your question? i'm sorry. >> president breslin: well on

page -- page five, under insurance products, you have the new city plan, and it's referred to as uhc-mapd under the next page, under insurance products. >> right. so -- >> president breslin: so it should be -- i think to be consistent, it should be uhc-mapd, which is what it is in the booklets. >> yeah. >> president breslin: i didn't take a further look through the -- >> yeah. you can see the medicare is fully insured, and the rest of city plan for actives and early retirees is self-insured -- [inaudible] >> it's confusing. thank you for pointing that out. >> president breslin: yeah. okay. thank you. any other comments? any public comment on this item? no public comment. we can move onto item number ten, which that item is going to be deferred to another

meeting, perhaps our next meeting. so we can now move onto item number 11. >> clerk: agenda item 11, medicare advantage marketplace overview, presentation by mark clark -- mike clark. >> today what we're presenting on is a current state of what we see in the medicare advantage marketplace as well as the specific commentary now that we can look back to the almost two years after the implementation of that decision that was made in june 2016 on

specific information regarding the sfhss medicare plans that are offered to members. and then, we do have in the appendix just a general overview of the medicare program, when you hear terms like parts a, b, c, i won't be referencing those, but they're certainly available if you'd like more information on medicare in general. so on page 2, i get i start my report and then build on the rest of the information to support my comments. but four key conclusions that we see about the medicare advantage plans -- i call them m.a. you'll see m.a. throughout this presentation. that refers to medicare advantage. first of all, in general, m.a. plans are continuing to grow their market share among all medicare eligible americans.

and sfhss was an early adopter of that, having the kaiser program for many years, and then adopting the uhc-mappo in 2016 and implementing it in 2017. when we also talk about benchmarking, all ten counties we reviewed who participate in the annual ten-county survey that we perform for rating purposes have at least one m.a. plan. so it shows that especially in california, it's very prevalent in offering among the counties across the major counties in california. this movement to exclusively m.a. plans in 2017 for sfhss has generated substantial savings. i'll show a chart later in the presentation. our estimate is about $10 million annually. there are a lot of advantagements being driven -- advancements being driven by

the federal government for cost effective, high quality care. i know there was a discussion about the macrolegislation passed in 2015. you'll see in the footnote. those medicare payments continued to accelerate and m.a. payments and m.a. plans are at the forefront of executing those advancements. and then as noted by the earlier commentary by members of the public -- how that health care is delivered in new and innovative ways, and again, m.a. plans are integral of that. so i'll touch on each of these four components as i go through the presentations. >> president breslin: just pretty much the highlights, please. >> sorry? >> president breslin: just pretty much the highlights, please, not every line.

>> so why employers offer the plans. again, medicare covers a majority, but the original medicare plan has gaps. so employers tend to sponsor plans to help fill in some of those gaps and also offer prescription drugs expense coverage that are not part of original medicare. so when you go to page four, issues that we see with certainly medicare programs, medicare supplement plans, while they may fill in some financial benefit over and above regular medicare, they don't provide the effective program management that m.a. programs do. so m.a. programs have been around about 20 years, and they've definitely grown in prevalence as we'll look at later. so having developed because of

the short comings of the original medicare program, where the federal government is focusing today through policy actions in continued support of the m.a. program, bipartisan in washington are topics such as beneficiary benefit flexibility, again, offering an expanded array, and the enhanced payment models. and then, clinically, so it's not just about costs, and certainly, m.a. programs do help make the delivery of the programs more medicare retirees more cost effective, but also aspects of how m.a. programs clinically support the members through the management coordination of overall air delivery, providing that timely care and complex case management, managing inpatient

hospital out will i sedation, including reducing readmission rates, more cost effectively supporting those end of life needs, and with the macra, providing those added benefits to help enhance the member experience. and then, a chart on page seven, i'm obviously not going to walk-through it, but this is a helpful side by side to look at topics within the framework of providing coverage for medicare retirees and how those are handles between original medicare and medicare advantage. and in the medicare advantage you'll see there's some reference to h.m.o. models and p.p.o. models. here in california, we offer one of each. kaiser is an example of an h.m.o. model, and northern chasm, but also available to your retirees across the across

is the uhc-mapc program across -- across the country is the uhc-mapc program. in present state, there's almost 20 million that are in the medicare advantage environment, taking an m.a. plan, and you can see how that population has almost doubled since the stooart of this deca. this is really highlighted on slide nine. when you look right now, we're really right in the heart of baby boomers ageing into

medicare. if you look at what, you know, the baby boomer population is, born between 1946 and 1964, so the oldest boomer has been eligible for seven years. this growth over the course of a five year period, from 20 2014 -- 2012 to 2017, about a fourth have decided to take medicare advantage. so overall, while it's only 31% of the population, 4.8 million of the growth of those who were eligible, and 6.1 million total have elected medicare advantage. so it's become very popular as a vehicle for new medicare

retirees. and i provide some at this time sticks on slide ten. as i mentioned earlier, close to 22 million -- and i provide some statistics on slide ten. slides 11 and 12 really touch on this aspect of flexibilities that are being sustained by advancements that c.m.s. is providing, the center for medicare services. the concept of supplemental benefits are being expanded --

[inaudible] >> -- the notion of value-based insurance design, so targeting design features that can provide an enhanced level of benefit to members to meet their needs, and then some examples that we show on slide 12, some of which have been implemented, and some of the sfhss plans, you know, you can see the listing here, including items that were touched on earlier by the public comments. and then on slide 14, the sources of savings versus original medicare really fall into three primary sources. one is trying to optimize reimbursement that's being provided by the federal

government into the program. two is tied to the provider relationships and emphasizing provider collaboration and the delivery of care and the resulting compensation for care, and then, improving member health through enhanced preventative benefits and other notions that help to enhance the care environment. and so all of this helps to improve the quality of care that m.a. plans provide to eligible retirees. >> president breslin: i just have a question here. federal subside eyes on modified based on actual member status to support equity among plans. so the subsidies are based on the member's actual health,so the member's actual health,

right? i just received an e-mail that as part of the lawsuit against sutter, they were upgrading people to be sicker than they were. so how do we know in our group whether that's going on or not? whether it is is not -- and not that issue specifically, but we should be -- if they're in fact getting more money for individuals in our group, then we should be benefiting at a lower rate. so do we know how much the code is for most of our people? i mean, do we know the risk scores, like, say for the uhc and mapd? >> so risk -- risk adjustment does play into how the health plans for sfhss are compensated that then results in the ultimate rate after that subsidy that is charged to

sfhss. so it is true that plans who are managing a higher risk population as determined through a combination of factors, including claim experience, knowledge of diagnosis, and those sorts of variables, do receive a higher level of subsidy from the federal government. and in the end, that helps to lower the plan rate then gets charged to sfhss. >> president breslin: i understand that, but do we see that, that people are getting a larger peop larger reimbursement for? >> yeah. i think we'll talk about that when we walk-through aggregate experience with both of your plan partners is an understanding of how the risk factoring is playing into the reimbursements that are received by those plans for

sfhss and then how that plays into your underwriting. >> but aren't we cross checking that with our all-claims database, when we get the plans, we're reviewing it and comparing what our interpretation with theirs as we're getting into this risk adjustment discussion? >> well, so i would say this. through the all pair claim database, we understand how the health risk is, let's say, different, between the individuals who are enrolled in each of the two plans. and so that helps inform us on when we get to renewal time, if we see changes year over year in the aggregation of the health risk. that will be inform