>> president chow: ladies and gentlemen, i'd like to call the commission meeting to order. mr. morewitz, would you please call roll? >> clerk: [ roll call ] i believe commissioner loyce would like to say something before we begin. >> yes, i'd like to introduce from the mayor's office. >> president cho >> commissioners, good afternoon. i'm here for one reason. you're rarely ever going to see me here at the commission, but this is important to come to say thank you.

to say thank you to greg wagner sitting back there. the mayor would have liked to have been here, couldn't be here, so she asked me to come and publicly state her great appreciation for all that greg has done over the last few months. having to do both jobs and to do both jobs as well as he did is just tremendous. i'll tell ya, i've sat in a number of meetings with the mayor and various department heads. they don't all go so well. they always go well when greg was in there. greg really served this city well. he served all of you well, the department well, and you should know how lucky you are to have him with you. dr. colfax, you have a good hand to rely on back there, and, greg, thank you for everything. [ applause ]

>> i know you want to return to your usual space in the audience, where people can't find you, but on behalf of the health commission, we'd like to present you with a certificate honor, and it reads, as a public health hero, it reads, for your outstanding leadership serving the san francisco department of public health, acting director from august 2018 to february 2019, while still fulfilling your vast duties as cfo, you led the department with grace, dedication, provided stability and vision during a time of upheaval. we're grateful for your invaluable experience at the san francisco d.p.h. at this time. [ applause ]

and the commission recognized that you missed many meals during the course of your tenure. pastry grill for you, as well. >> thank you so much, commissioners. i was not expecting this, but i really appreciate it. it's been an honor to do what i can to help serve. i really appreciate the leadership and the support from the commission and everybody at the department who's doing so much incredible work. so i really appreciate the honor, and i'll in turn honor all the people at the department that have been going through this with me. so thank you so much. >> thank you. don't leave yet. would my colleagues like to say anything to mr. wagner? commissioner sanchez? >> commissioner sanchez: yes, there comes a time in many people's lives in professional service, in public service, in particular, where certain changes happen and challenges are there, whatever, and it

reminds me of a book a long time ago called "men and women to match my mountains," and when we had specific challenges, greg, you not only stepped up, but you kept the ship afloat in all sectors, and you kept the team and the conclusion models where it's been operational with the highest degree of dignity and professionalism and respect for all our employees and, in fact, what's continued to be one of the best departments in the nation and the world. so i know for all of us it's been an honor to have served you when you first came aboard from a lieutenant, to a captain to a fleet, just awesome. you've served with dignity and respect for all and really kept the spirit and tradition of what we are about at the san francisco department of public health, so thank you for a job

well done. >> thank you so much, commissioner, i really appreciate it. >> and i also want to join the chorus and thank you, and especially i think it's not just a challenge, you know, you're doing two jobs while trying to balance a budget for us to present to the mayor, so that's an even, like, taller task than normal people have to do. and you do it with so much grace, and i'm really -- i admire how calm, cool, and collected you've always been. that's not one time, you know, that you seem like you stress at all, so you make that easy for us, as well, so thank you. >> thank you so much, commissioner, i really appreciate it. >> thank you again, greg. >> thank you all. [ applause ] >> president chow: item two on today's agenda is the minutes from the february 5, 2019

meeting. commissioners, the minutes are before you, any deletions, edits, additions you'd like to make to the minutes? >> move for approval. >> second. >> president chow: all those in favor say aye. >> clerk: we did not take public comment on the item before you voted, and it looks like there's someone in the audience who would like to make public comment. >> mark, where is the timer? >> secretary: this is what we're going to do. at two minutes the buzzer will go off and you'll finish the sentence you're in and we'll go on. >> two-minute limit you got here? >> secretary: two minutes, yes. >> two minutes, all right. >> hi, michael batrellis. i'm a sunshine advocate, and regarding these minutes from your last meeting, what i want to address is the item about grant colfax is now the head of

the department, and what i want to address briefly has to do with what we used to call the swiss recommendations, which said that people, hiv-positive people, hiv-positive people on drugs on hiv meds who were undetectable for at least six months with no sexually transmitted diseases would not pass on the virus, even if they had sex without condoms, and the swiss recommendations are now the undetectable equals untransmissable. you equals you. my concern, grant, is that back in 2008 when the swiss recommendations came out, you made policy for the health department in the hotel room in boston during the troy conference. i'm hoping that you will not create hiv policy for the city

at a conference when you're out of town, and that you will hold at least one public meeting before you make a position. the other item i want to address, you're talking about in the minutes about matters related to what you call zuckerberg s.f. general hospital. well, i'm hoping you eventually get around to addressing how the zuckerberg name needs to be erased for many reasons from s.f. general, and i'm always happy when i see in the chronicle, like i do today, lawyer best remedy for s.f. general bill. the headline does not say zuckerberg s.f. general, and that is really terrific. thank you. >> secretary: commissioners, i apologize, and you are now able to vote. >> president chow: we return to the calendar item, and i will call the roll for the voting on acceptance of the minutes.

all those in favor? opposed? hearing none, before the next item, i want to take the opportunity to welcome dr. greg colfax as the new director of public health. i look forward to working with you again, we had a long relationship, a couple days ago, both in the a.e.'s office, so i'm appreciative of the fact that you're here, and i know you bring a great skill set to the department of public health, and i look forward to working with you again. [ applause ] >> secretary: and item three is the director's report. >> so thank you for that warm welcome. thank you, health commissioners. as you know, i've been in the job for about six hours, so i really want to express appreciation for a seamless and welcoming onboarding process, especially working with greg and his leadership, mark and look forward to returning to this great city and working with each of you, mayor breed, board of

supervisors, the commissioners, to provide san francisco with the right services at the right place at the right time and believe we can make san francisco the place that realizes full health equity so all residents have a opportunity to optimize their health in a city providing safe, clean, and affordable options for all communities. summarizing the written document you have in front of you, first of all, with regard to adult urgent care, mayor breed will hold a ribbon cutting ceremony for the new clinic space. the center's relocating to first floor in building five on the zuckerberg san francisco general campus and the urgent care will officially open on february 21st, and as someone who worked in urgent care at zuckerberg for almost a decade, i'm pleased to see it, it will have 12 patient

rooms, expanding by an additional three rooms in the former space and this was a $1.8 million capital project that was partially funded by prop a and the city's capital budget. so this was a collaborative process with the department of public works, and the urgent care will be the first clinic to relocate to building five as part of the larger long-term effort to relocate primary care services there. second item is methamphetamine task force. as you know, methamphetamine continues to be a public health issue in the city and mayor london breed and supervisor mandelman announced the methamphetamine task force. the department of public health will lead and coordinate the task force along with mayor breed and supervisor mandelman. challenges for treatment options, policy changes, and

integration of behavioral health and physical health efforts to better address this continuing public health epidemic. the task force is going to be multidisciplinary. it will include people from the department, as well as folks from law enforcement, researchers, treatment providers, emergency responders, and so forth. and the goal is for the task force to issue recommendations in fall of 2019 to help move our community forward in addressing this issue. on february 13, the annual heroes and hearts event was held at pier 48. it was a vibrant evening honoring and commemorating zuckerberg san francisco general and san francisco general foundation invited former congress person patrick kennedy, a national mental health advocate, as keynote speakers, and guests for the inspirational views on mental health and addiction care in america, from

kennedy, as well as from san francisco, mayor london breed. a key to the work is the hospital foundation has established a transform mental health and behavioral health fund, which is receiving record breaking support from community and businesses and following up on issues we heard earlier today with the ongoing issues of behavioral health in the city, and really this fund will help in resources, systemic infrastructure, and tests not scaled interventions. on february 7, the department commemorated -- bought national black hiv/aids awareness day, in partnership with hope san francisco and community members, there was an event held at the community space in sunny dale. the day began with community members speaking their truth regarding black history and several youth recited poems around hiv and hiv testing was made available. the event ended with a positive

skit and an incredible dance performance from community youth. and going back to my earlier comments around health equity, we know unfortunately even though we've made great progress in the hiv epidemic, health inequities continue, particularly in the black/african-american community. this event really highlighted those issues and certainly will be a priority as we move forward as a department. speaking of which, with regard to hiv, the lancet health journal featured the getting to zero initiative, which highlighted our efforts to end the city's hiv epidemic, and you'll recall the mission to getting to zero is downgrading to 90% by 2020. there's a roster membership now of over 250 people with five different community, excuse me, including focusing on scale-up

of pro really looking at how adolescents and young adults are cognizant of their risk and what interventions we need to do to prevent new infections. the data suggests the efforts are paying off. in 2013, before the program began, there were 394 new hiv diagnoses, and by 2017 this had fallen to 221 new hiv infections, a 44% decrease, and very importantly, hiv-associated deaths have also fallen by more than 50% over the past ten years. another key issue highlighted recently in the press, a key program, key initiative, is the healthy san francisco model, which is really served now as a model for health care programming, not only within our city, but has played it forward to other cities and jurisdictions across the -- across the nation.

you'll recall health of san francisco offers access to care for those 18 years and older who earn up to 500% of the federal poverty level and have no other health care coverage options. it's offered to qualified residents, regardless of employment, immigration, or health status, and even with implementation of the affordable care act, there are still people who need this important service. very importantly, los angeles and new york city are exploring whether to implement healthy san francisco-like programs in other jurisdictions, new orleans, denver, pittsburgh, and miami have also expressed an interest in healthy san francisco-type programs. another example where it starts in san francisco and it goes elsewhere, for better. san francisco's measles vaccination rate, highlighting this because it was recently in the news that washington state declared a state of emergency to a measles outbreak, and that has resulted in health officials in our department re-enforcing to families the importance of immunizing their children.

thankfully, titan state vaccination requirements have greatly reduced the risk of a measles outbreak here, and since 2015 when california eliminated the personal belief exemptions, students with all required immunizations in the city has increased by 2.4%, and we're at a healthy 94.9% vaccination rate overall, so it's very unlikely that we would see a measles outbreak in this jurisdiction, but again, when we see what's happening in washington, we want to re-enforce the public health importance of getting people immunized. plans to improve zuckerberg san francisco general, long-term billing practices. we'll go into this later in the agenda today, but just to highlight the fact that on february 1, the mayor and supervisor aaron peskin and our department announced immediate steps to improve billing practices at zuckerberg, so patients who are in the middle of payment disputes between the hospital and their insurance provider, very importantly, this included temporary halt, excuse

me, to balance billing patients and mr. wagner will be presenting a little update on this later today. so just a brief update with regard to the activities in the department and those related to the department, and thank you very much for your attention. and if you have any questions, i'm happy to answer them. >> president chow: commissioners? thank you for your report, dr. colfax. >> secretary: i did not receive any public comment requests for this item, although i just see one, mr. batrellis, you have two minutes. >> hold on, i have a timer here. >> secretary: starting the timer now. >> hi, michael batrellis again. grant, amazing report for only six hours on the job, and my concerns have to do with the getting to zero. first of all, one important issue that's not being addressed by getting to zero is the high price of drugs.

i see this as a blot of shame on sfdph that you have not taken public stance, continuous public stance, against gilead in our own backyard for their outrageous pricing on all of their aids and hepatitis drugs. a big stumbling block to getting to zero is the high price of truvada, and i think that you've got to put this on the agenda. now, regarding stigma and getting to zero, one thing that needs to be addressed are the awful social marketing campaigns that were conducted against gays. in the 1990s and early 2000s. this ad shows a person with an s.t.d. as a walking, talking time bomb. this is from city clinic. this ad creates stigma by

equating a person with an s.t.d. as a time bomb. that is not healthy for the community. there were also these ads from the aids foundation about more than just an f. we were continually bombarded, provoked, with these awful social marketing campaigns that have contributed to the stigma and need to be addressed. this is what i want to discuss with you, grant, and lastly, we need a public campaign congratulating gay men who have survived the epidemic from the activism we did and for surviving a plague. it is time for a positive social marketing congratulating gay men for all that we have done during the plague. >> president chow: thank you. >> secretary: item four, general public comment. mr. batrellis has put in a

request and that's the only request i received. >> hi, michael batrellis again. so, grant, i put in a request to meet with you, because i think that you have a terrific opportunity to take some bold leadership on addressing some of the past wrongs and creating an agenda that really puts san francisco at the forefront doing things that aren't being done, such as this positive social marketing campaign i just talked about. i think that this commission needs to put the high price of gilead's drugs on the agenda. you are paying out a fortune every day to get the hepatitis c cure and provide it to people in the jails. i don't think it's okay that

you've not had this as an agenda item. and that can be changed going forward. the last matter has to deal with commissioner dan bernal, who as we all know is pelosi's district manager here. we need to have you holding public meetings in the evening. your boss cannot hold town hall meetings. okay, i understand that, but your duty as her representative, pun intended, is for you to hear public comment at meetings you organized, regular monthly town halls with you. if you have enough time to serve on the health commission, you have enough time to put on biweekly, if not monthly, town halls to hear from mrs. pelosi's constituents. right now you are not hearing about how constituents want the green deal embraced by mrs. pelosi.

is that the timer? >> secretary: no, you have about four seconds. >> four seconds. so, dan, get with the town hall meetings, please. thank you. >> secretary: commissioners, item five is a community and public health committee report back. and i spoke to commissioner loyce, because so many people are here for the employee awards, with your permission, we can come back with that after item six, so everyone can do what they need to do to support their colleagues. so the item six is the sfdph non-hospital employee awards. i'm not sure who's first, but the commissioners will read off your names. as the name is read, please enter over there, come across here. you have the option of shaking hands with all the commissioners and dr. colfax. stand here, and commissioner sanchez will hand you your award, and we can applaud you. >> the first is everyone working for the nurse family partnership. and it's a real privilege to

honor you. i'm an obgyn physician, and i know how incredible this accomplishment is. this is an evidence-based home visiting program serving first-time low-income moms, who are matched with a public health nurse early in gestation and until the child is 2 years of age. during the partnership, clients learn about developing their maternal role, parenting skills, healthy behaviors, and self-sufficiency. each client meets with a nurse every two to three weeks, averaging a total of 80 home visits. since its inception in 2014, the program's 15 nurses have served over 800 moms and approximately 200 graduates. many of the mothers who participate in the n.f.p. have completed their educational goals, become gainfully employed, some have started their own businesses, and most are no longer dependent on public assistance. what an incredible

accomplishment, all of you should be incredibly complimented. the nurse family partnership team deserves recognition for their fidelity to an evidence-based model for home visiting that truly makes a difference in the lives of mothers and infants. congratulations and thank you so much. [ applause ]

[ applause ] >> president chow: commissioner chung? >> commissioner chung: the next award goes to maurice rodriguez and maureen davue from population health division, operation of finance and performance management. as part of the population health

divisions office of operations finance and performance management, maurice rodriguez and darlene developed and successfully implemented a pilot project. the purpose of the pilot was to test the viability of docu-sign for the dph population health division as an application to create administrative efficiencies as part of its performance improvement efforts. a major goal was to provide a e-signature to p.h.d. to decrease turnaround times for processes that required approval signatures as part of the daily business process. overall, the use of docu-sign significantly decreased the completion time for several standard business processes. based on the success of the initial pilot, maurice and darlene worked with the h.r.

department, fiscal department, and i.t. department to expand the use of docu-sign. we thank maurice and darlene for their innovation, dedication, and hard work. they are both long-term d.p.h. employees, who are a tremendous asset to d.p.h. thank you so much. [ applause ] [ applause ] >> president chow: commissioner bernal? >> commissioner bernal: yes, next we have shaun partwood, facilities manager, who was nominated by the primary care

leadership team. [ applause ] so shaun joined the newly restructured facilities unit in 2016, tasked with providing engineering and utility services for many of our city-owned and leased buildings. in 2018, shaun became a manager for a staff of 30 that provide services to primary care offices and facilities. spent numerous time related to environmental remediation issues to help keep our older facilities operating smoothly and ways that touch employees every day, maybe in ways they don't even know. shaun shows great creativity and problem solving in complex repair problems and often makes do with limited resources. he's thoughtful and respectful in his interactions with others

and excellent customer service skills. he's effective at coordinating teams, including both his own staff and various trades and construction projects. he is also quick to learn new systems. he is mindful of challenges that our staff face and learns to minimize the impact of day-to-day operations of the clinics for both patients and staff. shaun is an exemplary employee providing excellent service to the sfdph community. congratulations, shaun. [ applause ]

>> president chow: one of the things that we as commissioners really enjoy is the opportunity to honor the staff who work for the department of public health and go unnoticed every day and every way, and we like to be a part of the process acknowledging the services you deliver, so thank you for your service. i have the honor of introducing lisa o'malley. [ applause ] environmental health branch food program, she was nominated by stephanie cushing. lisa o'malley has worked for the department of public health 38 years. during this time, lisa has worked as a environmental health inspector, senior environmental health inspector, and currently the manager of one of the food districts. lisa has been the manager in town of chinatown for many years and has been instrumental in establishing a collaborative environment between the health department and the regulative

community. lisa is so well thought of in the community, that she was asked to be grand marshal one year during the chinese new year's parade. lisa has performed thousands of inspections of food establishments and has trained and mentored many new inspectors, provided food safety training to hundreds of businesses and was recently instrumental in establishing the first online food application for the state of california. lisa has been recognized by the california council of environmental health directors as a food safety leadership award winner in 2015. lisa has been tireless advocate for both her employees and food safety in san francisco. [ applause ]

[ applause ] commissioner guillermo? >> commissioner guillermo: thank you, commissioner loyce. it is my particular privilege and my personal privilege to introduce the next award to feyda guzman, who was nominated by mark markowitz. [ applause ] she is officially the executive assistant to the director of health. in this function, she shows excellent proficiency in managing the director's schedule, correspondence, and all other administrative tasks. she oversees all aspects of the director's hectic office, which includes training and administering three other staff,

which support other sfdph executive staff. she serves as gatekeeper to the many d.p.h. staff members, ccff department heads and members of the public who wish to see the director. her responsibilities also include interacting with the mayor's office, the offices of the board of supervisors, other city departments, and many other public officials. she makes sure that the director's office runs smoothly and efficiently so sfdph leadership can do their jobs. unofficially, fey is the house mother to 101 grove. everyone in the building knows her, because she makes sure to get to know new staff when they move into the building. when someone doesn't know who to call about a problem, fey has names and numbers. certainly does. if it is taking a long time to fix a problem in the building, people go to fey and she gets it done. she seems to have her finger on the pulse of the 101 community and throughout d.p.h.

she provides compassional support to staff in happy and hard times. fey is a wonderful example of how one sfdph employee can impact so many individuals and help strengthen the sfdph. [ applause ] [ applause ]

>> secretary: one last round of applause for everybody. [ applause ] thank you, everyone. so going back to item five, there's a report back from the community and public health committee meeting from today. i believe commissioner bernal is going to do the report back. >> commissioner bernal: yes, thank you, mark. we had a packed agenda today. the first item was sfdph equity update focusing on racial equity in both our work and the workplace. we had a great presentation from ayanna bennett, dr. ayanna bennett, and from ron weigelt of the human resources department. they spoke about the department's leadership, staff, and resources, as well as the mayor's initiative through the human rights commission with the goal of equalizing people's experience in both our work and in the workplace. we talked about their strategies

for normalizing discussions about racial equity through discussions and training, organizing through leadership, staffing, and securing and analyzing data, and then operationalizing what we've learned through policy and examining work flows. there was also discussion of the black african-american health initiative, and the next item was a resolution regarding incarceration as a public health issue. this resolution will be coming to the full commission at a future meeting. we had the privilege of hearing from a lot of members of our community, including former commissioner guy and laura thomas. we talked about treatment is the first option as incarceration and interaction between the health department and the criminal justice system with the recognition that people with mental health issues are definitely better off in health care settings than in jail settings. the last -- the last item that

we discussed was the department of public health behavioral health update. we had a great presentation from ka vo kavoos bassiri. i don't know if he's still here, but thank you for all of your work over the years. we spoke about intensive care management and transition to lower levels of care. also the presentation addressed different features of the board of supervisors' audit, including behavioral health service providers performance, intensive care management, as i said before, transitions to lower levels of care, and also serving adults who do not stabilize in the system. >> president chow: commissioners, comments or questions about the report? hearing none -- >> secretary: looks like we have a public comment request. >> president chow: okay.

>> hi, michael batrellis again. so, dan, you're on this committee, and i did not know this. this is another opportunity for you, as the district representative for my elected representative to the house of representatives. this is another opportunity for the public to engage with you. i am asking you, before you get around to holding regular town hall meetings, that you use social media and mrs. pelosi's public relations department to tell us all of the public meetings you are required to attend here in your duties as the health commissioner, all of these meetings where the public can come and engage with you. and there really has to be a change from you and mrs.

pelosi's office in better engagement, regular town hall meetings are required. and until then, i think you have a duty to tell the community that we can engage with you at these health commission events. so, the question is, will you start doing that? i hope so. thank you. >> commissioner bernal: i would like to remind the public that if you're going to speak to public comment, it needs to be relevant to the issue that we just reported on. we have general public comment, and you're certainly willing in general public comment, but public comment should be related to the very specific item that's on the agenda. >> secretary: all right. excuse me, there's no talking out of turn, and let's move on to the next item, which is item seven, resolution to recommend to the board of supervisors to authorize sfdph to accept and expend a gift of $200,000 to

laguna honda hospital gift fund from the richard and bonnie green survivor's trust. ms. hirose? >> good afternoon, acting president james loyce, members of the health commission, and director colfax. welcome to the department, director colfax. today i'm here to request your approval to recommend to the board of supervisors to accept and expend a cash bequest of $200,000 from the richard and bonnie green survivor's trust. the cash gift will benefit the laguna honda hospital gift fund, which enables us to provide support to and enhance the well being and quality of life to the residents at laguna honda. we are grateful to the green family, who we have learned that mr. green's father may have received care and was a resident at laguna honda. i would be happy to answer any questions you might have, and i

thank you in advance for approving the resolution. thank you. >> president chow: commissioners? >> i commend the family and spirit of the nation to the gift fund. it plays a very important part of laguna honda pertaining to activities for our patients and designated benefactors under the rules and procedures of our gift fund, so i would move approval of the motion before us. >> second. >> president chow: moved and seconded. all those in favor signify by sayi saying aye. >> thank you. >> secretary: item eight, zsfg patient billing and financial assistance update. mr. wagner.

>> good afternoon, commissioners, greg wagner, chief financial officer. we have a -- do you know how to get full screen? so we have a presentation to go through today and get your thoughts and feedback, but as

many of you know, there's been increased scrutiny over the last several weeks and months about our billing practices as zuckerberg san francisco general hospital, and a lot of this is focused particularly on patients who are insured and who come into the hospital and have some portion of their costs paid by insurance, but are left with the remainder of the bill personally. and this is a relatively small number of patients that end up in this situation, but it's become a very apparent to us as we've kind of looked closer at this and been hearing about it and thinking about it, that the way that our practices are currently set up are not acceptable to us and they don't reflect who we are as a department and as an institution. and, you know, a lot of what that is, is kind of the

acknowledgment that there are people who are either not taken care of them as a whole person, both their health care and their financial needs that are associated with their health care, and in some cases where patients end up having their bill resolved. they are still going through this period of stress and uncertainty that we know is a part of our health care system in the united states, but we would like at zuckerberg san francisco general and at the health department, to do as much as we can to not be a part in that negative aspect of our health care system. so as we're kind of thinking about this and focused on it, you know, our approach in the health department is to acknowledge where we're not doing something at our best and is aligned with our values and embrace that and look for ways we can change and do better, so

we're really coming to you kind of in that spirit to talk about areas that we think there is improvement and some of the activities that we're focused on to try to improve the experience for our patients at the hospital. again, the kind of area that we're focused on is this topic of balanced billing, and that's where a patient's insurance covers a portion of their hospital bill but leaves them in a situation where they are receiving a bill for the balance of the costs, thus the term balanced billing. so in a lot of situations, let's see, in a lot of situations throughout the state of california, patients are not affected by this due to regulations around how insurance is governed and regulated, but there is a portion of individuals who, because of the plan that they have, they are

exposed to this practice and the financial impacts of the practice to go along with their insurance. so i'll say kind of right up front before we get into the conversation about what we're doing in response to this and where we think that we can improve, that on february 1, and dr. colfax mentioned this in his director's report, but on february 1, the department, working closely with mayor breed's office and supervisor peskin issued a statement that we are temporary halting the practice of balanced billing and taking a 90-day window to review our policies and practices and come to the health commission with recommendations where we think we can improve and also bring the mayor's office and the board of supervisors. the temporary pause, i think, is a way for us to take those patient accounts that are out there right now, that either have recently received services

or there's an account where we are still having that in process from the past and say let's just take a pause, we're not going to continue to send out statements or notices to that patient, but we're going to take a pause, re-evaluate our policies, and then apply that new policy going forward, and at the same time improve our communication with the patients. so just to give you a sense of the scale of this problem, the vast majority of the patients that we see at zuckerberg san francisco general are either medi-cal, medicare, or uninsured, but enrolled in one of our patient assistance programs, be that healthy san francisco, our sliding scale program, our charity care program, we have a network of programs that are there to provide financial support for patients. so that's about 94% of our total

patients at zuckerberg. of the remaining 6%, that's broken down further into h.m.o.s and p.p.o.s. another about 2% are in the h.m.o. category. those plans are not subject to balanced billing under state regulations, and then the remaining about 4% is p.p.o.s. and within p.p.o.s, there are certain plans that are not subject to balanced billing, but a portion of those plans under the regulations that are potentially subject to balanced billing. so you can see that this is a relatively small proportion of our patients, but the fact is for those individual people that go through this experience, it doesn't matter whether it's a minority of the patient population that we see at zuckerberg, it's a real experience that they are confronting and going through as a piece of the care at zuckerberg. so here's another view of this

to give you a little bit of a perspective about who this may apply to. so there are up to, it's not an exact science, because in order to really pin this number down, we have to go into each account and look at that individual account to determine what the individual circumstances are, but there are up to about 1,700 patients that we have identified that may be affected by this balanced billing practice, and that's probably at the upper end. so you can see on this bar graph that's up on the presentation here, we had in fiscal year 17-18, these are all fiscal year '17-18 numbers, about 104,000 patient accounts. of those, you can see at the end of the graph there are about 4,000 of those that had a p.p.o., and of those with a p.p.o. plan about 1,700 of those may be subject to balanced

billing. so again it's a relatively small number of people that come through, but for those individuals, a very real concern that we need to address. so we've identified kind of three categories of areas where we're focused on. the first of those is, as i said, we have a number of programs that are already in place that are meant to provide financial assistance for patients that are not medicare or medi-cal or don't have financial coverage for their treatment, and those programs are a sliding scale program or charity program, or discount program. we have a catastrophic medical expense, but we have identified there are situations for people who could qualify for those, and those are generally programs targeted for people at or below 500% of the poverty level. there are gaps where people may fall through the cracks between that safety net of programs, so we're going to be looking at and

revising our policies for how those programs fit together. so examples of those are people who are on healthy san francisco, but their healthy san francisco enrollment lapsed and they come in for a hospital visit, they would have to go through the process of re-engaging in the financial support system in order to get back on the sliding scale program, but what we should be doing is immediately getting them back in and enrolled in healthy san francisco, so they don't have to go through that process of navigating this bill that comes to them. so we're going to try to bring you some proposals that close those gaps in our existing programs. a second category is for patients that are above 500% of the federal poverty level, and at zuckerberg, as with most hospitals, our financial assistance policies are weaker as you get into the higher income levels and that is, of

course, with a reason, historically, but as you know, in san francisco, 501% of the federal poverty level is a wage that is often somebody who is, with the cost of housing and living in san francisco, struggling to keep ends meeting at those levels and those are not individuals who can afford to pay cash out of pocket for a large hospital bill. so as we've looked at this, we've really identified that those -- over 500% of federal poverty level, our coverage for patients in that circumstance are fairly weak, so we are going to be revising our policies to try to improve coverage there. and then lastly, improving patient experience and communication. there are a number of areas where we need to be very proactive about reaching out to patients, communicating about what their circumstances are, and we'll talk a little bit more about some of those.

so again, this is a little diagram of our existing financial assistance programs and who they affect. as you can see, the bulk of this is focused on our individual patients that are 500% or below the federal poverty level. federal care and discount programs go up to 550% of the poverty level. we have the high catastrophic medical expense program that extends beyond that 500%, but the coverage under that program is fairly weak. so opportunities that we think that we have, number one is something that we can start doing right now, and we are starting to do right now, is improving our communication with our patients. so we have a number of staff and a number of programs that are doing this on a day-to-day basis, but some things that we've identified is, number one, as soon as we have a patient come in for services, we can begin to proactively assess the

patient's eligibility for services. right now it's a more passive process, where we let the patient know that we have these programs, but then we're more passively waiting for patients to apply for assistance, so we can do a better job of being active and engaging patients earlier in the process. second is to engage the patient as we are working with their insurance to let them know what's going on, let them know that we're in process with their insurance company and there's an outstanding payment from the insurance company that we are intending to collect before we go to the patient. the last one on here is to delay the first patient statement that would contain a disputed amount or that we're prepared to process as out of network, so that's, again, when we're in the process of working with the insurance company and trying to collect what we believe the insurance company owes. we can focus on doing that before we reach out and start

sending statements to the patient. so we will continue to implement all those changes. we're also doing additional steps to publicize our financial services hotline, make sure that patients really know right away there are people here that are waiting to help them engage and talk with you about what your bill is going to be, what the options are for the financial services programs that we have in the department and being proactive about that. we're also creating and distributing an faq to better help patients understand the financial concerns and opportunities associated with their care. so some key principles we're using as we go through our process of pinning down recommendations that we'll bring to you, number one, we want to protect patient financial well being, while still making sure that we are collecting what we

believe that we are due from commercial insurance, and so that has implications for how we would design any programs or recommendations that we'd bring to you. implementation of an income-based scale of financial assistance programs, where there's financial assistance that is connected to income, but covers people who need it at a higher level than it does today. we want to look at where we're applying asset tests, so that's where we're taking into account not only your income, but also your non-cash assets to determine your eligibility for these