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

we have been for the last several years working with a number of insurance providers to determine whether we can enter into contracts.

part of the challenge with this is that the deal, the kind of fundamental bargain of these insurance contracts is you give a discount in exchange for volume. we happened to have a hospital that is very full right now, and if we were to kind of enter into that standard bargain, we would be, again, providing a windfall to the private insurance without a benefit that supports our patients or our hospital, and we are also working with our state partners. that includes our state associations, but also our legislative delegation to try to determine whether there are changes to state law that we could pursue and advocate for through the city that would improve the patient situation in the financial world of health care. so that is a lot. our next steps are that we are going to the board of supervisors on thursday to have a similar conversation about some of the kind of categories

of approaches that we're taking in response to this challenge, and we hope to get feedback there, as well, and then we will similarly, as we develop full recommendations and share those with you, bring those to the board of supervisors and work with the mayor's office to implement those. so that will happen on thursday this week, and then we will be working actively as we have already started working over the next roughly i think we're at about 70 days to finalize these recommendations. so that's a lot. i'm happy to answer questions or clarify as helpful. >> secretary: did not receive any public comment requests for this item. commissioners? commissioner bernal?

>> yeah, i think that's a great point, because that is fundamentally at the root of a lot of this, where patients who are coming to our hospital are not always able to make a decision about what's in network or out of network. they are coming there to have their life saved and they are often not in a position to make that choice. so i think there are a couple of things, areas, that we could focus on. number one is to have -- put this system in place where we have, regardless of what your insurance is, we have a fair out of pocket cap, so that you're not being financially exposed by the fact that you were taken to a trauma center and that wasn't a decision that you made. the second thing that i think we do need to look at is at the legislative level, the state and the federal legislative level,

other changes we can make to account for the fact we have hospitals like zuckerberg that is a public hospital and it is a trauma center, and we serve a much different population than a lot of hospitals, because we're a safety net hospital that also has this trauma and emergency function to go along with it. so one of the things that we have talked about is, is it possible that there are legislative solutions that would help allow us to -- allow us to change the way that the payment dynamic works, so we can take the patient out of the conversation between the public hospital and the insurance company and try to advocate for a structure, where we're fairly compensated for our costs as a trauma center and a public hospital, but that burden doesn't fall on the patient.

>> president chow: commissioner green? >> commissioner green: i wanted to commend the department and hospital administration for the speed and the detail and the thoughtfulness with which you responded to this. it's incredible that you've come together with this kind of a detailed plan in such a short period of time and the seriousness and thoughtfulness which you've approached it is really quite commendable. >> thank you. >> commissioner green: i was wondering whether you had any detail about, among these p.p.o. plans, which have been the most difficult for patients to be successful in appeals. in other words, do you know which plans have been the most difficult to get to pay ultimately, and also whether any of these plans in particular are employer driven, because that might be another approach, as well, if united health care, for example, is a popular plan, yet if big employers like the gap find that their employees are going to a trauma center and having to pay out of pocket, that might be another point of leverage. i wonder whether you've gotten anymore details about that group of people who have really ended up with serious out of pocket

exposure. >> yeah, i don't have the data with me now, but we can certainly provide that to you. and part of what is challenging in this situation, particularly on the p.p.o. side, you have a large diversity of plans, many of them that are for people who are from out of state and so they are plans that we deal with, a lot of plans that we deal with at a very low volume. there are a couple of larger plans that's more frequent, and so we can provide that data to you, but that really is one of the challenges, is even if we were to pursue a practice where we're able to do some agreements with certain plans, you do have this large volume of these smaller insurance plans that don't -- we would never reasonably be able to enter into agreements with all of them and then so you'd still have that subset of patients that are affected by this practice.

and that's another reason that i think we're kind of trying to approach it from we'll do what we can on the plan side, but we're really focused on the patient and what is the patients' exposure. >> president chow: commissioner chung? >> commissioner chung: thank you, mr. wagner. it sounds to me like there's also some kind of administrative disconnect. the reason why i say that is because i thought most plans cover a certain portion of out of network costs. i've never heard of any plans that would flat-out say they deny a certain service categorically, so i'm kind of, like, surprised that this is happening. and, you know, is this something that the office of managed health can mitigate without going legislatively? >> yes, so the vast majority of

these situations is not a circumstance where the insurance is denying that the service was medically necessary, but what has happened over time is a lot of insurance plans have -- we will send a bill, and the insurance plans have slowly started to ratchet down the amount that they pay us against that bill, and this has been a dynamic that we've been facing and there are a whole bunch of reasons around it. so, for example, ten years ago we may have sent out a bill to a private insurance plan, and the plan paid us 98% of the bill, and they disallowed 2%. what's happened increasingly is today insurance plans are paying us in some cases 50, 55, 60% of the bill that we send, and that has -- so they are not denying the claim, but they are paying us less and less, and that's leaving this gap that exposes

patients in cases where they have the type of plan where they are exposed. so it's not so much that the insurance plans aren't paying, it's they are only paying a portion of the bill and then our recourse is, essentially, either to legislate or to take legal action against the plan. >> commissioner chung: so they can reduce the amount that they reimburse us at will, without any -- agreement or anything? it's kind of -- it just bothers me to know it's that kind of unethical practice out there and nobody is doing anything about it. >> yeah, and the framework for it is that under the law there's essentially a provision that says the insurance plan can pay what's called a usual and customary rate, but that is not defined in a formula in the law, it's defined conceptually in the

law, and so insurance companies will make their own calculation of what's usual and customary and we might think that's not very usual and customary, but there's no referee that will judge whether or not they have paid adequately. the only way that you can remedy that is through the courts. and we have, in fact, at the department of public health, we have been actually pretty active on that front, where we have initiated a couple of lawsuits and a couple more potential in the works, where we've actually gone out and said you've ratcheted down your payments to us so much that we now no longer believe you are meeting an acceptable threshold and we've been effective in doing that. we've come to settlements that we've been quite happy with, but that process is time and cost intensive, because it is using the legal system, and so that's not the first choice of how to

resolve. >> commissioner chung: thank you, i really appreciate the effort that you all are making into this, and it's almost like those insurance companies warrant some public shaming, so that people could see that kind of practice exist. thank you. >> president chow: commissioner green? >> commissioner green: thank you. thank you, greg, for sharing the draft plan with us, and i also want to commend you for the swiftness of -- and the comprehensiveness of all of the different aspects, you know, and given that, i want to just kind of caution folks around expectations to come up with the best and right solutions in a 90-day time frame, because what you describe deals with changing sort of revenue-cycle procedures, all the way from

dealing with that and the kind of skills and talent and structures and processes that are required to address that to sort of a legislative or legal sort of remedies to try to do that, and so the whole spectrum in between and being prepared to do all of that in a time when the way that health care is being paid for is changing, right, from fees to values. so i just want to, while i commend you for doing that, i want to make sure that we don't think the first solution that sounds right and looks like is going to be the necessarily the right one, because it will change along with the way that health care delivery's changing, the population in san francisco is changing, and medicare and medicaid policy oversight is going to change. i do want to really endorse the

part of the plan that does speak to the cap on out of pocket, because that to me is a very both pragmatic and appropriate step to take, given that these other solutions and these other things, trying to explore insurance agreements with the insurance industry that acts, as you just described to commissioner chung, we have no leverage in terms of the volume that we can provide to sort of do contracts, so that's not necessarily going to be a great avenue. and so all of the things that we're going to try to do to address this very, very real situation, 1,700 patients a year is still a significant number of folks compared to the 104,000 that we do take financial in many ways a big financial hit already from. so i just want to sort of caution around expectations and to really sort of make sure that we are -- have an opportunity

over time to review the data, because everything comes into play just in terms of any one aspect of something that you're going to implement systemwide. >> thank you, commissioners. great point. will take that feedback, because you're exactly right. we will, at 90 days, come back with something, but a lot of what is required here either is going to be an iterative process over time or is going to take much longer than 90 days to implement. so, as you said, if you look at this list, working on state legislation or contracts with insurance companies, that is a much longer term process, so i appreciate that. that makes absolute sense that we should be thoughtful about expectations about how much we can accomplish in the short term and also that this is an iterative process that we are going to have to constantly review and evaluate, so that we

don't end up back in a situation where our policies are outdated. thank you. >> president chow: commissioner sanchez? >> commissioner sanchez: i -- excellent report. i just wanted to underline one thing that you mentioned in your report that i think is really a very critical variable in the whole process, and you mentioned communication with the patient. this is really a key focus. i think we need to look at, primarily because of not only the diversity of patients, the fact we know -- we know, given our public health area, the diversity of the city, the age factor of so many people, seniors, growing numbers, four generations in the city, three, five, two new ones, you name it, occupational workers who drive in from all over and live in the city while they work, coming

from india, coming from latin america, they used to, coming from ireland, you name it. they cover the waterfront. and if there's an injury or something happening, the majority will probably end up at the general, okay? now, i could think of numerous cases in the past where an elderly person who might live in a given area was brought in, in the trauma center, and ends up, you know, at the general, and because there's no wife anymore, there's no son, but there's a grandchild or a great grandchild who maybe lives across the bay and comes in, and sees a grandpa, whatever, they may not know he's a veteran, perhaps, they may not know that he is covered with insurance or not, and then we've had some cases where -- i'm talking about before, where the information pertaining what may be the outcome and who's going to be responsible for this is given right there with maybe extended

family that have no idea what this is about, you know, and that brings even more trauma. especially when you talk about -- i know many greek families or maltese families or native american families, again, it's a cultural thing, and it's really part of the equation pertaining to if they would even have access to health care, much less when they are brought in because of a situation being hit by a bicycle, being hit by whatever, you name it. but what i'm saying is, that is really the critical part, and i think when we look at the communications part of the protocols we could offer them as patients, that we really constitute maybe a core team, whose sole function is to disseminate these programs, whether it be in the peeves clinic, gerontology clinic, you

name it, but have specialists trained with multiple languages, so this way you could be called in. so if a family comes in and no one in the family speaks english, but they speak a multitude of languages, et cetera, we have staff that could communicate this in a very positive way. one time you have a social worker, one time you have a nurse, one time you have management, even walking down the hall and a patient may have expired, all of a sudden be given a bill for -- and nobody -- people say, how are we going to do this, you know? all i'm saying is, you really underline a very important part that's always been a changing focus at the general, and that is the fact our changing populations over the years, but communication, if we could focus on that communication and the multitude of languages, whether it be retirees or young people

or occupational workers from all these countries, provide them with the baseline, thank you for having your grandfather or your husband, whatever, be brought here, here are some options you may want to talk about or you may want to give to whoever is whatever, but have people who are caring and understand and could speak the dialogue and make sure that it's communicated. otherwise you're going to have some problems we've had before, where people don't want to go, because ems is going to hit them for $400, $600, they don't have $400, they can't afford it. all i'm saying is, we've always been aware of the human variables at the general, so as we take a look at the payment plans and protocols, i think we want to upgrade that focus on communication and patient understanding in a cross cultural linguistic model that makes sense to ensure we always

maintain and provide the highest quality at whatever cost we could serve in order to provide the service we always have and hopefully will in the future. does that make sense? >> that absolutely makes sense. thank you for the comments. we'll certainly take that to heart and think about how we can maximize the ways that we're able to do that really high-quality linguistically sensitive, culturally sensitive communication with patients. >> thank you very much for your report, and i want to echo the comments that commissioner guillermo made, and i also want to suggest that i appreciate the assertiveness in which you take your responsibilities to address this issue. whether or not we get the outcomes that we desire, just know that we're in process and has some periodic updates about where that process is, because it will take a long time. we recognize that. but i like the assertiveness and the position that you have taken

in relationship to addressing this issue, and i think the community will appreciate it, as well. >> thank you, commissioner. >> great way to welcome director colfax also. >> speaking of director colfax, any comments you want to make in relationship to the presentation you just heard? >> well, i just want to reiterate the appreciation for greg and his team for being on top of this so quickly and i'm hopeful short-term resolution will come forward, but also want to reiterate commissioner guillermo's comment, the most immediate solution isn't the best longer term solution, so i think 90 days is a good way to come up with some immediate solution, but i also don't want us to think after 90 days whatever we've done is set in stone. and i know that greg doesn't feel that way, and dr. irlick doesn't feel that way either, but just to reiterate that, thank you.