>> the commission will please come to order and secretary will call the roll. >> clerk: [roll call] >> clerk: the actually prior to the second item i'd like to make a few announcements. >> first today is the lunar new year of the pig and want to wish everybody a happy, healthy and prosperous new year. this is also black history month. we wish to make note of that as part of what san francisco continues to celebrate this month. as most of you know the health commission has concluded its nationwide search which

attracted over a hundred candidates and the mayor in her state of the address last week announced dr. grant colfax as her choice as director of health. many will remember dr. colfax from his previous work here as the director of hiv prevention and research. before he went on to the obama white house as the white house director of national aids policy. he's currently the director of marin county health and human services and expect him to join us in approximately two weeks. i wish to thank the commission for its hard work in vetting all the candidates. it was most of the most collaborative searchs i have participated in with the commission and that is having worked under several directors over the years. this time all the commissioners are involved and served as the

screening committee and submitted recommendations to the mayor. all of our directors in the past have brought special skills to the department and visions for this department which have created what we have today a legacy which we believe and will bring us to the next level. as we move into a new year and as the department opens a new chapter, the commission looks forward to this period of working with dr. colfax in a challenging and yet ope tune time for all in public health. we certainly also wish to thank mr. wagner for keeping the lights on, for really serving as our acting directory in the rint

-- interim and keeping the department on course. thank you very much. we know you had extra duties maintaining our finances and keeping us solvent and continuing work in the department. [applause] we can proceed to the next item. >> clerk: item 2 is the approval of minutes from the commission meeting. >> commissioner: is there a mole motion and second? >> second. >> commissioner: any correction to the minutes. all those in favor say aye. those opposed? it's approved. >> clerk: item three is the

director's report. >> good afternoon, commissioners, greg wagner, acting director. as you mentioned dr. chow on january 3rd, mayor breed delivered the state of the city address and in addition to appointing dr. colfax as the dph director, she covered a number of issues in that speech in the director's report and the text is available at the front but spent a lot of time messing a number of things of priority nor commission and health department and those range from a real focus on behavioral health issues and health issues related to the homeless individuals in the city. a focus on housing. a number of initiatives around

housing including affordable housing bond and housing for teachers and it's consistent with the work the commission has been pursuing and the department's strategic goals. on january 15 we announce the introduction of sb127 at zuckerberg san francisco hospital to help caltrans implement the strategic management plan goals. that's to ensure state highways that run through the city, 19th avenue and vaness are safe and accessible streets for everybody using those thorough the areas.

on january 4th a new mental services act innovation project was approved in san francisco. entitle the fuerte. that's an intervention culturally tailored to address the needs of latin youth age 12 to 19 and includes school-based youth prevention program using the psychological lens and competency framework. so this is a unique collaboration between the school direct, behavioral health services and ucsf. it's an exciting project moving

forward for the department. a note we will be launching our health department employee engagement survey february 11 through march of this year and that survey is part of our true north objectives of making the department a great place to work for our employees and understanding what the positives and negative things we need to work on to make it a great place for people to work. so we have a recent detection of the asian citrus psyllid and carries a bacteria that can

cause disease in host plants. it's not harmful to humans but a significant issue for citrus plants. as a result san francisco county has been placed on a plant best quarantine by state agriculture officials as of january 17. our department is working closely with the california department of food and agriculture on a treatment program so there's a real effort around that but we tried help get the word out about that for awareness and so there's appropriate actions taken to prevent the spread. in december cvs held an event including setting an order and standardizing and sustaining and

improvements in the pharmacy workplace and mapping for the pharmacies treatment and there's an advancement of the program and an important priority for the network. there's an addendum added on the table out there. black history month planning committee of dph along with the human services agency are going to be presenting the impact of intergenerational trauma in african american youth in the foster care system at laguna honda to commemorate black history month. the day long event will have

speakers discussing the history of foster care in the united states and a pathway to creating equity in the foster care system. lastly, chinatown public health center january 31 shared healthy guideline for lunar new year at the first healthy eating and active club meeting at the event they distributed brochures about healthy eating and tanger ins which symbolize prosperity. that's a grease program and on -- that's a great program and they'll distribute tangerines and additional literature on healthy eating as part of the celebration of the new year. i'll end there and happy to have

staff answer questions. >> commissioner: thank you. the director on the report. i'll ask the director to perhaps give us an update on the billing practices at zuckerberg san francisco general. we know it has been in the news we've also worked with the mayor's office for a program released to the public a few days ago and thought it would be good for the commission to gets an update and understand what we'll be doing in the future. >> thank you, dr. chow. >> we have spent time as there's

individuals receiving care at zuckerberg san francisco general and end up as part of a practice where certain health plans do not cover the full cost of care and end up receiving a bill for the outstanding balance for the services they received. that is industry wide and affect as a small number of the patient. it's a flaw of the way the insurance regulatory system works in california and elsewhere. despite the fact it's a small number of people it's a real issue for those individuals who experience that because it's number one, a financial burden on those individuals. it's also an experience from our

hospital not consistent with our values and what we want to be as a health system. some of this coverage has been brought to the forefront and using it to embrace we acknowledge this problem and take action to correct it. we have had a group working. dr. erlich is here and we've been working on this issue. on friday there was an announcement we'll be sending out new balance bills to patients for a period of time while we evaluate our policies an practices and we're on the way of doing that and we'll have a fresno -- freeze on that

practice until we have revision to the program. one thing we've gotten to work on are looking at the policies in place for financial aid. that includes the sliding expenses and coverages and looking at those to identify where the gaps are in those policies that are allowing people to slip through the protections in those policies an end up with these bills. secondly, we're implementing changes to our operational practices and policies at our patient financial service. a lot of the goal there is part of what happens to patients that end up in this situation is

experiencing the health care system in this country including at our hospitals can be complex and confusing. we're sending communications out and statement s out and it can be a stressful and confusing experience for patient don't know how the system works. we're trying to revise our communication with those patients and do a better job of communicating and non technical or in lay person terms and what the opportunities are to reach out to the hospital and talk about their financial system. get engaged with counselors to navigate the system in apublic for financial aid and keeping

them aware of what's happening during the process. we have been renewing our efforts working through the city to look at legislative or policy changes that could happen at the state or federal level to close some of the gaps in the system. we don't operate in isolation and there's a regulatory framework that sets the conditions that we work in so we'll be pursuing those courses as well. that work is actively underway. our intention is as we start refine solidify our recommendations we'll bring those back to the commission. in addition, supervisor peskin has called for a hearing at the board of supervisors and we'll

look forward to preparing and having the conversation at the board of supervisors as well. there'll be more to come here at the commission but i just want to make sure all the commissioners know we're very actively working on this. >> commissioner: commissioners, the update is helpful and i know if we have other thoughts present them to mr. wagner so that can be put in the mix. otherwise, i think you heard where our department is going in terms of trying to respond to a very real need on the part of the patient. a need to clarify our policy and yet be fiscally responsible. any other questions at this point? if not we'll move on to the next item please. was there any public comment. >> clerk: there was no commepub

comment wft -- request for the director's report and we'll move on to item 5 the finance and planning committee. >> the finance and planning committee melt tuesday before this commission meeting and the contracts we have approved to add to the consent calendar can be referred to on the current consent calendar. one item i want to extract and indicate for the contract reports we have approved the contract. except for the curry senior centers which will come back in march for our approval.

>> clerk: if i may add the dph staff asked to remove the curry report. >> also, i'd like to thank commissioner bernal to chair the rest of the meeting in my place when i had to step out to take a call early. thank you. >> commissioner: thank you. >> commissioner: next item. >> clerk: item 6 is the consent calendar and as commissioner chong note the january vote would not include the curry senior center. >> commissioner: the contract report for the consent calendar is before you including number of new contracts are there any extractions from the consent calendar?

seeing none we'll vote on the entire consent calendar. all those in favor say aye. >> aye. >> commissioner: those opposed? it passes. >> clerk: item 7 is the first hearing on the fiscal year 2020 and 2021 budget. >> i can start and jenny lui will take over. generally the way we approach our budget process is over a span of a few hearings. this is the first of the. -- report.

we did one from the mayor but this is our first calendared hearing on the topic. generally what we'll do is at our first hearing will you review and we usually do the basic outlines of what our financial circumstances look like so that's our projected baseline hospital revenues and the non policy factors affecting our budget including inflation, things like material and pharmacy the cost that it take to update our budget to reflect the new wage and benefit rates and we also show where we are with regard to our target from the mayor's office.

jenny's going through all of those things and there'll be a subsequent budget hearing prior to our full submission to the mayor's office. normally we would do that at the hearing two weeks from now because we generally submit our budget to the mayor's office february 21st. in this case we had a conversation with dr. chow and what the mayor's session and we have a new health director starting two weeks from today in on the day the hearing would occur. we have asked and been granted permission to push that back a little bit so we can give the dr. colfax a chance to spend some time thinking through the budget and working with us on it prior to presenting it. so that will be a little bit later. it will be in a march hearing. the second hearing is where we usually look at the items that

are a little bit more on the policy initiates or discretionary spending choices that the department is proposing and asking for the commission's approval for with the budget. with that ail turn it over. >> good evening, i'm the budget director. i'm here to present on the five-year plan and give an overview of the current 1920 approv approved budget and initiatives for the upcoming budget cycle. they released their five-year projection in the summer and that's what they do every five years the revenue and expenditures city wide. the top line where it says sources is the expected revenue growth they believe will happen over the next five years and below that are the uses or the expenditures by the different

categories which shows they're expected growth over the five years as well. so what you're seeing here is over the course of the five-year period by fiscal year '23-'24 they expect revenue will grow by $758 million and gro -- continue over the five-year period but at the same time the uses below are growing at a much faster pace of $1.4 billion. so what this does is creates a structural deficit when have you about 14% growth and 25% expected growth in your expenditures. you enter a deficit situation. by the end of the five years what you would see say deficit of $643 million. that's not something anyone wants so here we are and we have the opportunity to change what

things will look like in five years. but for now, this is the question at hand is over the course of the two years there's about a $270 million deficit we'll need to address in the upcoming year. in terms of a longer term trend remember the last column where we saw the $643 million deficit projected out? what this slide shows is the fifth year of the five-year projection for the last five years. what you're seeing is when they initially did the projections they expected a deficit of $400 million. but over time by fiscal year 2016, they had published a projection which had shown the deficit had grown to $800 million and over the last years

the corrections made the projections have come down and so we're on a good trajectory for the last three years and this is something we want to maintain. most of the solutions in terms of getting the projected deficit down in the fifth year has been related to revenue. the five-year projection is a base case and they're taking the base trends and historical trends for growth, revenue and expenditures and projecting it out and the assumption is there's no major deviation from that. the outlook has looked like expanding since 2009. what this slide represents measures the economic expansion in years for the last century.

the dark blue bar represents the current period of economic expansion we've had and should we continue this for an additional six months we'll have had the longest period of expansion ever. at the same time it suggests it's likely that the expansion may turn around and not actually turn around and get into a recession because we don't know how long we can maintain this growth. while we're entering the year of pig and it's quite likely within the five-year period or probably within the two-year budget period we may see a point where revenue do not expand but recede and contract.

and there's indications the economy may be cooling with interest rates. it's not the case the mayor and controller are assuming but it's important to keep that in mind what that looks like should that happen. this is just a modelling of a recession scenario where the do dark solid bar is what the projection assumes for the next five years. the dotted line is a modelling of what a recession would look like and we could have losses over the course of the next five years. this is in addition to that $643 million structural deficit we already have. this is what we're up against now. it's important to be aware it may be a possibility in the

future. so with that the mayor's given instructions to department to give accountable on outcomes and requested efficiency proposals with a 2% reduction in the general fund use and increases to 4% in the second year. in addition they're requesting on paper a paper proposal for contingency of 1% and growth of 2% in the second year. she's also asked the departments look to prioritize the fund and use budgets for the highest and best use. and we've been instructed to not load new positions into the the system and new positions would be considered by the mayor in line with her priority. so we'll move on to an overview

of dph's budget to give context where we're at. in the last budget cycle the '18-'20 budget cycle the upcoming budget looks like we have $2.3 billion approved. we're the city's largest department. of that, san francisco general represents the most significant portion followed by behavioral health and laguna hospital. expenditure wise, salary makes up more than half of our department's expenditures and it's followed by the non-personal service the contracted services you guys approve on a regular basis. and it really represents primarily direct services as well. the bulk, almost 85% of our department's budget is around personnel and contracted services.

this graph shows the revenue and general fund support and revenue support we have within the department. the blue bar represents revenue by division and then the orange bar that sits on top is the general fund that comes in to offset to make whole our total expenditures so what you're seeing here is the bulk of our divisions are predominantly backed by revenue. overall the department does leverage over $1.5 billion of revenue for its $2.3 billion budget. this is more of a table view of the slides. what you see here in that bottom corner is the general fund support, we do a great job of leveraging our revenue and we're roughly 66% of revenue back and

33% general fund. still, our general fund subsidy is not a significant number. and this is the technical initiatives and some of the more policy decisions from subsequent hearings. our first set of initiatives are around revenue. and for the second column represents 2021. what we see is san francisco general in the first year said we have $52 million of revenue

and this should be 29,996,000 revenue. and i wanted to talk about the drop. we have seen drops in the second year before san francisco general particularly with the most current waiver which was designed to have a decrease of revenue over time. but what happens in 2020 is the medical waiver expires and that the point, we aren't sure what the funding world would like like in terms of waiver, no waiver.

what's at risk for us is the public hospitals redesign the prime program as well as proposed reduction in the our disproportionate hospitals and they combined represent $60 million for us. given the uncertainty we weren't sure what is happening year two. we took a more conservative approach and are assuming we'll be able to retain half or $30 million of those revenue in some form whether it's a new waiver or different type of funding mechanism. but there's uncertainty around that and we'll have to monitor and revisit. there's been many initial conversations throughout the state with counties and the federal government what that would look like but at this

point we have no details so there's more to come on this. there's an assumption we're making here. every year we've had environmental health see adjustments. they're revenue neutral. they've been mandated to cost recover and so they are recovering all their costs. there's no significant changes in their fees. it's mainly being adjusted by the consumer price index. i will note for this year for this upcoming budget cycle, they are planning on a move to a new central city permit center which centralizes all the city agencies that handle permits. it's an exciting opportunity to improve customer service so you have someone trying to open up a restaurant, they don't have to

go environmental health and the fire department and a tax collector it's an opportunity to improve collaboration. there's significant costs associated and they're included in their fees for this year. there were items keeping up the pace of our expenditure growth as commissioners and in prior years we used to have a structural deficit in our department which required us to have a mid-year supplemental to ensure we had the funding to maintain operations for that year.

we worked with the mayor's office it was a $415 million correction. since then we've enjoyed being a balanced budget the last several years. and in our last quarterly financial mr. wagner presented recently you'll see we ended the fiscal year with about $300 million of expenditure surplus it represents part of our $2 million operating budget. what we want to do is just make corrections to our salary and to our materials and supplies to make sure that we maintain our operations. on the salaries, it's a little bit of a technical issue where there's assumed salary savings

and assumed special class. there's holiday pay and overtime which are fixed numbers in the budget. though city employees get increases in wages of 3% to 5% the numbers have remained mostly flat and we're looking to correct salaries. it doesn't increase our position authority but increases our expenditure authority. and in prior years we've seen 8% to 10% in assumptions. what we haven't done is actually

corrected the non-pharmaceutical portion of our budget. we're seeing some of that inflationary catch up for our materials and supplies at the hospitals. it represents the clinical materials and not office supplies. so we're proposing here a $2.1 million correction to san francisco general. and an additional $355,000 correction to population health. it's an area we haven't corrected before but what we're seeing is with all their prevention work testing is key and pivotal to making sure that we actually stay ahead of the game. the test kits are expensive but we're doing more and the cost is increasing through propose one-time adjustment in materials and supplies cost there.

finally, we'd like to continue and increase the pharmacy budget at the jails to continue support for patients. so what we're seeing is a number of patients who enter our jail health program they are all right on hepatitis c treatment. it's a regiment and i think it lasts for several months, but don't quote me. it's effective but an expensive treatment of $450 a day. they're in our care. we're not going stop treatment. we wouldn't stop chemo therapy for a cancer patient that came in. we need to maintain their treatment when they enter. so i flag this because it's slightly different than a pharmaceutical inflation. it's sort of a new type of cost

that we hadn't seen in the jails before. the assumption is we can export 24 people in the jails for a cost of $330,000. lastly, i touched on the inflationary, annual correction and held harmless and this is the part of keeping up with the business and it's almost predominantly pharmaceutical costs. where's that leave us? have you our general fund reductions up at the top. there's a portion of our revenue that have been assumed. some revenue have already been assumed and we don't want to double count it. that assumption is really keeping us held harmless for the

pharmaceuticals and the salary infringes negotiated every year by the mayor and department of human resources. mroe you'll see the revenue you propose as well as emerging needs. where this leaves us is a $4.7 million down payment. we've met target and we have additional revenue to help with contingency reductions and for any additional meetings we need to propose in the future. so in term of next steps and with the rival of dr. colfax we'll have a plan for the contingency reduction and completed balancing plan and a subsequent date and we'll request the health commission for the proposed budget and control of the mayor's office.

that's all i have. any questions? >> was there 'public testimony? >> clerk: i have not received requests. >> commissioner: we're prepared for questions or clarifications? we're still missing the pharmacy and inflationary costs? >> we included d1 and it's $6 million. >> commissioner: it was included in 2021. >> in my haste i didn't get the dates right. for 19 -- '19-'20 we correct that in the last budget cycle. every year we're always updating

the second year of our inflationary because we do two-year budgeting. in the first year we did two years and every year since then we've always had to correct the second year because the second year -- >> commissioner: under inflationary you're correcting the second year but we don't have to correct the first year. >> there's about $5 million to $6 million in the prior year. >> commissioner: commissioners, you may remember the lert and numbers all addressed the details in the document that you all have before you.t and numbers all addressed the details in the document that you all have before you.t and numbers all addressed the details in the document that you all have before you.et and numbers all addressed the details in the document that you all have before you.t and numbers all addressed the details in the document that you all have before you.t and numbers all addressed the details in the document that you all have before you.et and numbers all addressed the details in the document that you

all have before you.rt and numbers all addressed the details in the document that you all have before you. and numbers all addressed the details in the document that you all have before you. the defense department has laid out the details for all the different budget initiatives as of this point. and we'll then be bringing in and there may be adjustments from our new director. commissioner green? >> thank you for making this so simple. thank you very much. i was wondering if you look at revenue and concerns about the waiver and hospital component, do we have indications whether bringing effort along and coding whether there's any add revenue and have a projection how this works in the second year. is there any sense of that? >> i'll defer to mr. wagner. >> so we do anticipate there'll

be an improvement in our collections especially once we get epic up and running and as part of our planning we've been developing targets for what we should expect if we do everything as we're supposed to do to implement and we've got a revenue cycle consulting team that's come on to help us build those targets and adjust our operations. that will offset the loss of those other revenue if we're able to execute on that and i expect we'll be able to. so that will be improved capture of charges in our billing and accel rai acceleration of revenue by shortening the time of collections. if you looking at the scale of that, we have probably not -- it's probably not enough to off set a loss of the larger

programs should those occur. part is as we've gone over time through changes in the waivers and implementation of the affordable care act, a larger portion of our revenue comes from capitated revenue and a smaller portion from fee for service revenue over time. but nonetheless, that's a big benefit of the epic system because it will ideally allow us to improve our collection on those fee for service and capture claims data that needs in the calculation of our capitation revenue and that will flow through but probably not later. >> commissioner: it will probably effect a tiny percent of the budget. in regard to the emergency,

there's materials and supplies adjustment and i'm curious to know how do you make an estimate to that and because if you actually have two years in a row with the same kind of estimates do you foresee that in the future as well. and the other item is the following item which is the continuing hepatitis c treatment for patients. do we see that as an ongoing item as well. >> to take the last item first. the goal is to continue treatments and we'll maintain the $333,000 ongoing in the budget. for your first question how we calculated the structural, it's looking at our financial statements from the prior year and looking at what they look like and i made an estimate in the second year of human cpi as

well. basically when we look at the financials, san francisco general is running slightly higher salary deficit than driven by census. if we try to control for some of that we're looking at a portion that's inflationary. we made an assumption of half a percent of their operating salaries to be corrected in the subsequent year and laguna honda hospital has been running about a $2 million deficit which represents 1% of the selling fringe budget and based it on using those percentages. >> i didn't have the question on the salary adjustment because that factors into variables. i'm curious about the materials and supplies adjustments. and it seems like that's

something that can be controlled more than proceed as emerging so i'm curious. why there's an item with a constant figure and are we projecting this is going to continue at this amount. >> that's a good question. we were looking at our prior year and trying to make assumptions of what would happen. in the current year we did receive the structural correction from the mayor's office and it was one time only and wanted to see what the trend was and we're on par to be on budget. we wanted to maintain that dollar amount ongoing. we had a significant structural

correction at the hospitals in 1315 and i think there's more than overdue to do right-sizing and catch up with materials and supplies but something we'll watch. whether we come forward with the inflationary requests every year, i'm not sure. it's more of a reflection of making sure we main tame and keep up with our expenditures now. it's much easier to correct this now than when it grows to $40 million and $50 million. >> for the hepatitis c treatment for patients do these treatments have to be on an eight-week regiment? are we saying we anticipate them to be in jail that long or

started before they came in or they're going to continue after discharge? >> these are the patients that have begun treatment prior to their incarceration. we tried to come up with an assumption and it's hard to know what will come in with what but the reasonable assumption is maintaining 25 to 25 people for about a month at a time. there could be variation but those are the assumptions. >> that becomes an issue of efficacy.

they were receiving treatment and under the care of jail health services so the goal is to maintain the services and working with our community providers making sure they continue the services. the goal is to maintain it. we don't want a disruption. does that make sense? >> it does. the question i have is because as a guideline like for the regiment, how do we ensure it's actually going to produce a cure after they finish the regiment because we're not really there to follow from the beginning and at the end. that's something i'm curious about how we're investing the dollars to make sure it

contributes to a positive health outcome. that's the question i have in mind. i know it's a tiny number. i think it will wind up being 0.000% on the budget but that's the kind of value we're looking for to contribute to positive health outcomes and to really have a significant impact on these patients quality of life. i'm curious about that. to see that emerging need would meet that i want to have more conversations around how we determine that. >> i'll follow up with dr. pratt on that and we may not know what happened before but the goal is to maintain it now. she's committed to making sure there's a one-off for patients in jail health but i can get

more information from dr. pratt. >> i want more assurance it will continue. >> that's the goal. more to come on that. >> commissioner: commissioners, any further questions at this point on the budget? so as mr. wagner said, we would be working with dr. colfax and reviewing this budget and at the appropriate time at one of our march meetings we will then bring back a final proposal for your consideration. >> thank you, commissioners. >> commissioner: the next item please. >> clerk: there's no public comment for this item. commissioner chung i believe the jails will be prevented quarterly at the community public health committee and i can request dr. pratt include a follow-up as well as the presentation. >> that would be great.

we've talked how agencies work together and how do we create these into agencies and also do we have a real plan and we ensure we don't drop them. it's an equity issue. >> clerk: the next item is 8 approving the san francisco department of public health for the legislative plan. this is an action item the legislation was introduced at the last meeting and asked questions and middle-class -- ms. patil here to answer questions. >> clerk: on the last commission hearing on january 15 we provided you with a presentation with an overview of the department's 2019 state and

federal legislative plan. we also discussed legislative action we took in 2018 in some upcoming health related issues for 2019. we included our state and legislative plan. i want to note based on great feedback we receive from the last year, we made amendments to the plan. commissioner chung you recognized the -- raised the issue of the violence against women's act. that funding is passed down to the department on the status of women here in the city for violence prevention efforts. we mended language in our plan. on page 3 and page 4 of the federal plan we included

language that says we will support proposals that strengthen violence prevention efforts including those that address street violence and violence against women. and we have focussing on a federal platform considering the evolving federal landscape how health care is delivered to veterans. on page 1 we have language to support proposals that preserve and expand services and take positions as needed on proposals

and the impact of the health care delivery system. and also included the state plan that highlights the need to focus on veterans especially when it comes to affordable and supportive housing. the summarizes the amendments we made based on the amendment you provided. pending your approval we'll take the state plan to the mayor's office for their final approval. >> commissioner: any public comment? any requests for this item? commissioners, comments? otherwise the resolution is to be placed on the table for our consideration. if somebody would move it. >> so moved. >> seconded. >> commissioner: it's been moved and seconded. we had an extension discussion at our last meeting. i think staff did a nice job in

incorporating the comments made. if not, we'll prepare for the vote. all those in favor of the resolution please say aye. >> aye. >> all those opposed. the resolution has been adopted. thank you very much. >> thank you, commissioners. >> clerk: item 9 is an update from the san francisco medical services administration. good afternoon, commissioner. i'm james stern, ems administrator. >> i'm john brown a medical director. >> i'd like to acknowledge and thank the staff that is behind our -- >> commissioner: would you please speak in the microphone so the whole public could here. thank you. >> i want to take the opportunity to thank our wonderful staff behind all the work we're doing. they're dedicate and passionate about create world class ems st