>> how much? all of i it may not bet back. >> it can be millions. >> for instance last month in the blue shield presentation a lot of information on various aspects of the total claims and fees but within that we show the pharmacy rebates and if i recall correctly approximately $6.2 million in pharmacy rebates paid back to hsf in 2018. if you recall we talked about how the claim persons for pharmacy and -- claim experience increased 7% before rebates were considered. because of substantial increase in 2017 the net increase was only about 2%. those rebates do come back and help support a suppression of

trend for us as hsf is what we saw on the blue shield data. >> after reading of the hearing they were talking about full disclosure of the secret rebates. do we know what the rebates are before they give it to us? >> in aggregates. >> pbm is middleman. that is what the hearings are about. we don't know what they are getting. they keep a percentage of it. that is what all of the hearings are about. there is not transparency here. >> we do know that hsf does the majority of the rebates for the united healthcare city plan and the blue shield access plus plans. the majority of the rebates pass to hsf. we have insight on what those

are. the health plans keep a percentage. >> there is full transparency? >> well, we are not provided information on a drug by drug basis. we do receive aggregate information on the value of the rebates. what passes through to hsf versus what is kept by the uhc for the city plan. >> just to clarify. i think part of the confusion is that there are independent pharmacy benefit manager companies that insurance plans contract with. i mean you see them advertised. they may not be doing the pharmacy benefit management in house but they may be doing it with another player, another party. i guess the question is for hsf

blue shield of you california and kaiser do they manage their own pbms or contract with a third party to do that? >> so my understanding and if i speak incorrectly i ask healthcare representatives to correct me. kaiser is all in house with blue shield. they are contracted with cvs health where blue shield manages the programs, formula, but the purchasing is based on cvs because of the leverage cvs health brings nationally and united healthcare similar arrangement with rx who is part of the broader health group organization. >> part of the concern of the

hearings is what we have read about before. cvs and others may or may not have ordeals with pharmacy manufacturers to actually push their drugs. it makes it sound like they are on the street corners, but push their drugs. >> you are right. there is a piece beyond the rebates. that is where the employers and payers and local governments have big concerns. what do those look like? how do you get to that information? >> that you have not diagrammed that? is that in front of us or not? >> i didn't diagram it because it is opaque. >> that is the point we are concerned about. >> it is fuzzy. >> let's go one click to the

future because the next part of the slide we want to talk about the key trends what is happening and what is going to impact the pharmacy spin going forward. there is something called e scribing because you recall we were talking the patient and physician relationship when they are prescribing medications there is technology to bring this information and cost savings to the clinic in realtime while they are prescribing the medication to a patient. they can look at benefits in realtime and see where the greatest incentive is, meaning least cost share for the member. that could have a real impact. that is actionable information the clinician can call in realtime, that could have an impact on the cost of care. they are driving this in the use

of e scribing for clinicians. >> can we stop there? it would appear then that the pharmaceutical industry knows what each provider who is writing the prescription is prescribing or not. in fact, that is not entirely the case. i think, for example, when i was in the practice, yes, that data was being forwarded by pharmacies to manufacturers. they knew how much drug x and y. they could target their advertising. my understanding having worked at kaiser for 16 years is that kaiser refuses to release the prescribing information of individual practitioners outside of their system to the drug manufacturers so if they tried to detail me on the street

corner, they wouldn't know how much of their drug i was prescribing as opposed to another company's drug with a similar action. there is a line that may not be solid betwee pharma is that trus it now a solid line? >> the only line i want to draw and hope the team will take away with is providers are provided much more information when they prescribe in realtime so the member is not showing up trying to get a prescription filled and there is a $700 could pay and they have to walk away and a lot of red type to get something they can afford. >> i assume that if there are alerts or warnings that the

system can prevent errors. you are prescribing also now it alerts the prescribing provider what the member' member's co--py be? let'spretend there is a patient that has gone through the process. the final diagnosis was rheumatoid arthritis. the doctor wants to spree scribe the latest and the best. the e scriber can point out there is a biosimilar where the member will have the least cost share of all. it makes sense for the member who hasn't been able to work because of the disability associated with the arthritis. on the first try the member is getting the care because the pbm

will give the highest reimbursement to. that is the way to appreciate it, i think. >> thank you. we talked about e prescribing a major trend to change the way how they prescribe. another is and we have read about this in the newspapers. you feel recall on thatgraph that right now the way these rebates work and we are talking about millions of dollars but somehow getting the rebates to go back to the member at the point of sale when the transaction is actually occurring when they fill the education making it much more affordable. that is a new trend. i think certain employers will consider this and some pbms say they will consider this or

potentially do. that would be a flow of the dollars back to the member yielding savings right there. forward one click. the pbms themselves? >> there are recent mergers between pbms and health plans that may allow for more of the point of sale rebate dollars going back to the members and better integration of data for risk scoring. another is this institution called icer which is a watchdog drug pricing industry group. it is the instituted for clinical and economic research. looking at in determining the true value of the drugs are and asserting what the price should be. this is done in europe and rent three introduced by the pbms here as well. in addition to looking at the

published literature about the effect of the drug. this also looking at the quality and cost. and that is there whether it should be covered and what the appropriate price is. >> this has been in place for quite awhile. it is o often involved in europe and canada by the licensing agencies to help decide on the value of introducing the new drug based on dollars per patient year of life or quality of life or whatever parameter. i didn't know how much this has been developed further because it was when it was proposed to our food and drug administration

it is crude and dumb go anywhere. our fda does not look at these issues as they expend education. i didn't know this was going anywhere in our government regulatory agencies. you are saving some of the pbms are asking for this now? >> they are looking at it or saying they add this to the way they look at certain drugs they may put on or take off the formula. the financial incentive you talked about between the manufacturer and the pbm may be one component. another are what are the quality adjusted life engineers? how much does this bring the member. it is financial and quality getting to the center of that, you know. >> will this data de transparent

when they advertise their latest drug. somebody watching their kids play football would they advertise this is $800,000 per month of added quality of life? >> the way my understanding the way the clinical piece works there is a great deal of transparency and a panel of clinicians that serve on the medical necessity committees through the u.s. in that decision is made it is sent to a different group. ir serve as a public watchdog. all information is public and you can review the reports online. i was checking over their work this morning. it was impressive. for the pbms, the opaqueness question i am not sure. i am not a spokesperson for them. i want that to be clear so i get out of here safely today.

>> this red piece is cool. one of the key pieces that is a major trends to follow really closely are the new specialty drugs. they are expanded indications. there may be an original indication for adults and it is so successful at bringing a better quality of life they want to expand to children. maybe it takes care of oneault to immune condition like arthritis maybe it can be expanded to include other conditions. next slide. for this slide here what is really interesting you notice the pie is bigger. that represents the total cost spent on specialty drugs in the u.s. back from 2012, a lot of these drugs were administered in an

infusion site in the outpatient aspect of the hospital or physicians clinic. there is a huge chung that came under the medical carier. there has been this compelling trend that will continue where basically now half of this occur on the pharmacy side. these are specialty drugs that may be where the patient is doing the injection themselves or maybe an oral drug filled under the pharmacy. specialty drug trend is to continue at 17%. we think this trend is going to continue. it will be greater than 50% in pay short period of time. one more click. i will talk more about the example of specialty pharmacy trends and expanding indications. we talked about this earlier. this is humira. in 2002 for those with

rheumatoid arthritis and did not do well on generics. there was a new drug with a profound impact on the quality of life. because it worked on that autoimmune condition there were others they began to do investigations for. originally maybe the vo volume f this drug shipped out every year was small. as the number of indications increased, those approved by the fda, chrohn's disease and then conditions for children. you can see that the spend on this is going to be bigger because there are more indications for which this has been approved. there is a 16% increase per capita in humira use alone from 2016 to 2018.

next. one other big deal here is this example of biosimilars. it is a biological product, it is a large molecule made from another living organism or a plant. when it is biosimilar, it is similar in terms of effect and safety in treating the same conditions for which the original was used to treat. we have snowflakes. at first they look identical. when you look close a few are different. to translate to the biosimilar. that means it is similar. the dialogue activity in suppressing an autoimmune condition. maybe the inactive ingredients in the infusion bag may be different. there is a tiny number today,

only about seven. there are more applied for. they are not in the market yet today. i think one thing to help would be more competition, more biosimilars, more generics. i will head things back over. >> i am sorry to interrupt. if we think that expert opinions and that raises, you know, anxiety among members. i can tell you the number of times i tried to convert someone from a brand to a generic drug made by the same manufacturer who failed the generic. that is the same drug but same manufacturer. now we are talking about biosimilar. what may be similar within the margin of study for allow ever many people these are tested on

-- we will now have a responsibility that will be more intense to convince members to use biosimilars and not object. this may escalate, you know. the object for valid reasons. similar for 100 people may not be equivalent for the 101st person. this is promising in terms of drug costs, it makes the market more complex for the provider who you started with. the provider patient relationship at the bottom left. >> from population health i am interested to see what happens to those grandfathered and be don't need to switch versus new diagnosis. there are power full incentives. these are 15 to 30% cheaper. i will be keen on the researches

for those who decided to change when they are stable and doing great on another medication. it is a keen area of active research. >> thank you, doctor mills. on page 7 we are going to talk about prescription drug retailing initiatives. 85 to 95% of total prescriptions dispensed are generic medications. that helps to both deliver very effective medications to your members and certainly aid and kind of helping to manage the overall cost of the medications across all three plans. two circumstances typically call the generic medications to elevate in price. that is the focus of the retailing initiatives.

first is in your example you sited when a branded medication does lose the patent and there is an exclusive period for that manufacturer to produce a generic equivalent of that drug that launches on the marketplace during 180 day exclusive period. when there is no competition, we find the price of that generic can only be marginally less than those of the brands. when you factor in the fact that brand of drug may have a rebeat, sometimes the met cost of the brand of drug can be less than the new generic during the manufacturer's exclusive period. that is one circumstance. something we have seeing elevated number of circumstances certain older generics who have

manufacturers hugh are deciding to -- that are no longer manufacturing in that space. when the number dwindles there may only be one or two for that generic. that can leave those left to elevate prices in response. these are the two circumstances that drive conversation around retiring or up tiering. some specific generic medications. you can see on page 8 what that can look like so trying to move away from this classic approach of calling drugs generic, preferred, nonpreferred and to more of a 1 through 4 approach. you can see how tier one is

generic but can bring in lower cost branded medications or higher cost generics on page 7 moving to other tiers. >> from is a third scenario not as common as what you outlined. there has been reported of generic companies buying the rights to produce a drug generically when they calculate how much money they can make selling that drug find it is more property annua profitable t company pays them off. to stock holders it is good because they make more money acquiring the rights to the generic and not making the drug and getting more income from

another pharmaceutical company to keep it off the market. i don't know if that is covered. i don't think it is. there is certainly cases of this discussion in the press. >> i would imagine that is also driving retailing generic as well. the final page of the discussion. i want to highlight that on the surface when you have a higher priced generic medication you may not think it impacts overall members but there is a fixed dollar prescription drug co-payment associated with the prescription drug coverage like on the hsf plans. if there is continued use of the higher priced generic cost so that feeds to the under writing

when we produce the rates and when the plans produce calculations for insured plans rates. we have seeing employers with tg strategies to focus on particular diagnostic categories where there are alternatives available. communication of the changes where thewhere they occur you wo have targeted communications to those impacted and our provider community the use of tools to help promote cost traffics

paraphernalia see at the point of prescribing initiatives doctor mills spoke of. >> no further word about medicare getting involved in hsf, is that correct? >> not that i am aware. with this would there be more transparency? >> there would be less? >> pharmacy benefit managers might get a bigger rebate we don't know about? >> the rebates apply to the branded medications, not necessarily to generic. this is really an attempt to increase utilization again within the full framework of wanting to deliver effective medication treatment to patients, but recognize that slight differences in formulation could result in a

medication that is as clinically effective to the member but at a much lower cost. >> my concern it is that it works for the members to their advantage. >> again, you know, the complexity of this. both of you have really highlighted nicely. it is awful for everybody. when i was in service practice one health plan gave me a list of five health plans they covered with the same corporate name. the different formulas for cold and allergy medications. not only was i supposed to know who their provider was. i left that to my girling person. when i -- to my billing person.

i was to figure out which plan they had to figure out what was cost-effective for the member. quite frankly in any practice situation, i didn't have the time to do that for something that was just for a cold or whatever it was for. this e prescribing thing can help if it covering all of the plans with the same blue shield or aetna or kaiser. the provider getting it on the screen. don't use this, use this. the next step is for the member. i will give you an anecdote. my father was dying of cancer and my mother was being discharged from the hospital for a prescription for an antacid not covered by the formula.

there wa was one on the formall. i said talk to the doctor. i was her son the internist telling her there was an equivalent drug. that is what the doctor provided. my mother was a college professor. that is what the doctor prescribed, that is what i am going to play for. the complexity at every level is not just the members. it is the pharmacy who is trying to do the right thing and there are pharmacists doing the right thing and the providers. we can't minimize the impact on anyone. >> i noticed that you ascribed no affirmative behavior to the pbm in this process. i thank you for that. >> any public comment on this

item? come forward. >> my name is erica. i am a current employee. i am covered under blue shield. i have run into several issues in my ability to access insurance. i have spoken with the director yant. i am going to speak on the drug prescription coverage. >> speak into the microphone. >> i will share personal and private information that is a bit uncomfortable. i know i am not the only member that is experiencing this. i have prescribed a litany of drugs that aren't covered under a co-payment. if i go to a specialty pharmacy

the cost is 50% of the negotiated rate. i have copies of this if you need it. that was the price that i was quoted. then i was given the price if i pay 100% out of pocket. 100% out of pocket is 40% less or 40% less than if i used my insurance which is supposed to be 50%. the 50% of the covered rate. my personal question. can i get reimbursed the 50% that is the coverage rate? the real question for you is how many other drugs fall into this category? how many other members are

paying 100% out of pocket because the insurance coverage they pay for, that the city pays for would cost them more. i recognize there is no vote today but i wanted to highlight the great responsibility that you have t to t to to ensure t for our public dollars. theresy tremendou -- there is as impact this will have. i called another one from san francisco. these are from boss t boston. that is the cost. thank you for your time. >> have you talked to our director? >> i do appreciate everybody

coming here to speak out today. it is a challenge. erica has been a fabulous advocate for herself. we have worked alongside of her to uncover some of these difficult situations that our members experience from time to time. i appreciate having the opportunity to work directly with her and the carrier to see where we can intervene in this case or in cases in general. it speaks to and i know that many folks here including our board hear from members on a regular basis. it is so beneficial that we hear directly from them so we can dig deep into the story. that is the most informative we can do. i think it allows us to provide the most support to our membership. i appreciate it and we will continue to work through this situation.

>> thank you for coming. >> i think the one thing we know there is always money in drugs. whatever side of the fence you are on there is a lot of money in drugs. one of the things that occurred to me while listening to this presentation is the level of advertising that is going on. when you are trying to get patients to consider generic, they have been watching ads for name brands for a period of time, number of years, many months. i know actually i had colleagues who said they would still be working if it wasn't for hue hua that helped them on the job and i have watched transition with the colleagues.

then what i notice is the drugs are advertised for other kinds of conditions which is always curious to me. this is a drug that has multi-uses and the diagnosis seem very opposite. i think what we are not looking at, if you are trying to get people to switch to generic there is a psychological issue. this name brand is the best there is. when you are offering me generic it is sub standard. it is a third rate. i know out to buy my benadryl from cost could. i can get a big bottle to last a year from costco versions a regular pharmacy. i think we have to take a look at the bigger picture. as long as the drug

manufacturers understand they can use advertising to influence people, when it comes to what we are looking at is saves money. also the fact we are looking at an exact replica of the original but lower costs because we have passed that threshold where they are not trying to recover all the money on experimentation or whatever it is and advertising. it is the same thing. in our blindses as consumers we -- in our minds as consumers we don't see it as the same. you are offering generic. i don't know how to change that. you can see it in magazines and on tvs and the internet, everywhere you look you see ads for new drugs and the influence it has on consumers. thank you.

>> any other public comment. i want to say a former speaker. it seems like the last couple years i have heard a lot of complaints about expensive drugs people have to take. life saving drugs they have a tough time affording. it seems like there is something more we should be able to do about that as a health plan. i don't know. the whole pharmacy thing is scary. that is just a comment. we are done with the regular rates and benefits section. we are now moving to the regular board meeting matters. that is item 14, please. >> item 14. reports and updates from contracted health plan representatives. >> good afternoon. i am from kaiser.

i would like to introduce a change in account management. for those familiar with a trisha. she has been the account manager or a couple years and has done a wonderful job and has been promoted to management. we are happy for her. as she transitions out we have a new account manager to take her place. that is debbie. sheep has many years of experience -- she has many years of experience working on public sector accounts. i am confident she will fill the big shoes patricia has been wearing. >> any other reports here? public comment? seeing none. item 15. >> item 15. opportunity for the public to comment on matters within the board's jurisdiction.

>> last chance for public comment. seeing none. item number 16. >> opportunity opportunity to place items within the board's jurisdiction on future agendas. >> you are in negotiations still? okay. nutrition counseling from blue shield. they are the only plan that doesn't have that as far as i can tell. i mean if they are not going to do it then we should find somebody else that will. that should be part of the plan. there shouldn't be any question. last reports said go to your primary care doctor. that was like an insult to me. that has to be part of the negotiations. i appreciate that. thank you. anyone else have comments on this item? seeing none. if there is no objection this

>> here we go, with another great announcement today. thank you all so much for being here. thank you all. and welcome to dorhouse. it is a place that serves as an example of how our mental health system is working right here in san francisco. this is a place that people who are in crisis can come and immediately get help and transition to possibly a two-week stay, and, if necessary, a 90-day stay, because we know that someone in crisis who needs help and assistance, it requires a lot of support and a lot of wrap-around services. and this is a great

example of us doing it right in san francisco. but while this is a great facility doing significant work, it is just only one tool. we have to address the challenges that we see playing out on our streets every single day. people who are suffering from mental illness, people who are suffering from addiction, we see the need and we wonder why isn't the city doing more? it is heartbreaking and it is frustrating, and we are investing in more solutions to try and address this issue. we've already opened 50 new mental health stabilization beds, and we plan to open another 100 beds this year. we recently announced a $3 million grant to expand the department of public health efforts to help those suffering from substance use disorder. and we're working to expand our conservatorship

law so we can provide help to those who you, unfortunately, sometimes can't help themselves. but each of these efforts, while important, is just one part of a whole behavioral health system. and that system needs greater coordination, focus, and accountability. because while there are great people doing great work, both in our public agencies and our non non-profit communities, like doorhouse, we know that not everything is working. and that's why in my state of the city address earlier this year, i announced that i will be hiring a director of mental health reform, and that i want one person who is looking at this system so that we can change it. to invest more in solutions that are working and to move away from strategies that aren't working. over the last few months, we have been searching for someone who had the

experience and the expertise and the commitment to take on this issue. and today i am really proud to announce that dr. anton negusa blade will be taking on this critical role. [applause] >> i hope i didn't butcher your name. [laughter] >> dr. negusa blade is currently the medical director for psychiatric emergency services at san francisco general hospital. wherever day he sees those who are most in need, and just as important, where he sees the flaws in our systems that leave those in crisis with nowhere to go, dr. negusa blaine is an addiction and emergency psychiatry, and i know he is ready to take on this challenge. and let's be clear, this is a major effort.

he will be tasked with improving our city's efforts around mental health and substance use disorder, including identifying and understanding the exact population that we're trying to help in creating a system to track services across our entire behavioral health system in the city. he'll be assisting with restructuring and expanding existing services and identifying gaps where improvement is needed. and creating a data system so that we can measure our progress, so that we can measure our success in what we're doing. this won't be easy, but i know that he is up for the task. and he has my full support to achieve this goal. he will report to our new director of the department of public health, dr. grant colfax, and i want to thank dr. colfax

for helping to lead this effort and for his early emphasis on prioritizing behavioral health in our city. i also want to thank ucsf for loaning dr. negusa blaine while he takes on this very important role. ucsf has always been a partner to us in providing health in our city, and we appreciate their leadership and their support in this very difficult task that we have to do. and we know that it won't be easy, but we are prepared to do what is necessary to make sure that we partner, that we make better investments, and that we do everything we can to improve behavioral health in our city and the challenging conditions on our streets. and with that, i'd like to welcome to the podium the new director of mental health reform for the city and county of san francisco, dr. anton

negusa blaine. [applause] >> thank you, madam mayor. i'm anton negusa blaine. as a psychiatrist, i think of my job and work mostly as establishing safety through listening. everyone has a story to tell, and a reason for the problems their experiencing. creating the right environments for people to seek care, to accept help, and also to work on their own behalf to get better, that is in some ways our most basic and our most pressing challenge. in my time at psychiatric emergency services, i have seen people in crisis who are disconnected from care and resources in the community. i often challenge our staff to ask, what are their barriers? what can we do as a system to begin to bend in their direction? i look forward to working with the health department leadership and community partners to figure that out. we have so many dedicated

and talented providers and experts in our system. it is a great basis of strength to begin this work. together we can develop a strategic approach to mental health and substance abuse services for people experiencing homelessness in san francisco. while the system works very well most of the time for most people, we need to focus in on the gaps that leave some of our most vulnerable residents at risk. san francisco has an outstanding track record of problem solving. i'm honored to be asked to serve at this critical time to address the problems of our homeless residents who need mental health and substance abuse care but are not able to access it through our current needs. we're going to examine the data, and we're going to assess the programs that are in place. we will build upon what is working and develop new approaches as well. as a city, we can continue to do better to ensure that all san franciscans have a real opportunity for wellness and recovery.

thank you. [applause] >> thank you. and with that, i'd like to introduce our new department of public health director, dr. grant colfax. >> thank you, madam mayor. this is really an exciting and inspiring day. and it is really great to see some of the key people who make our system work here with us today. and as i reflect on my first month as director of health, i'm struck by how extensive our mental health and substance abuse treatment is throughout the city. just for some numbers, the system already provides care to some 30,000 san franciscans in about 300 programs. we have approximately 2,000 beds in the behavioral health system across the continuum of care, from crisis to acute

in-patient care, to residential treatment and beds and boarding care. we know that recovery is responsible with treatment. today at doorhouse, which is a great example of a part of our system that is working well, to help people recover. we know there are many effective programs in our system to meet individual needs. that's so important because there are individual situations that play out differently for everyone. but we must, and we can do better. we need to lower barriers and make it easier for people to experience recovery and wellness. for many of our most vulnerable residents and their families, the system can be confusing and hard to access. we must collaborate better with community providers, patients, families, and other stakeholders to present a more client-centered model of care. we must have a system that responds better to the mental health and substance abuse treatment

needs, people experiencing homelessness, or those at risk for ending up on the street. we need to implement the most evidence space, tools, op optimizing every dollar for care, delivering culturally efficient care, and demonstrating results. we need to scale what is working and end what is not. i'm grateful that mayor breed has decided to face this issue head-on. with her leadership, i'm positive about moving forward in the right direction. dr. anton negusa blaine comes to us with experience in addiction psychiatry. he has been medical director of the psychiatric services, the emergency services at san francisco general hospital, thereby being on the front lines of mental health and substance abuse crisis. he sees the issues we are facing and trying to solve every day. we're grateful to him and ucsf for making this

integrative new position. he will work with me with mental health and substance abuse services for those in san francisco and those at risk for being on the street. he will help us to assess the system from the patient's perspective and by looking at the data. he will identify successful models of care and opportunities for additional resources or service expansion where things are working. he will ensure that our investments are informed both by science and the people we serve. we are fortunate to be taking this step forward today, and i look forward to working with everyone for more improvements in the futurement thank you. thanfuture.thank you. [applause] >> thank you. and dr. negusa blaine is on loan to the city from our great partner, ucsf. and i want to welcome to the podium dr. matthew state, who is the chair of the department of psychiatry for ucsf.

>> it is wonderful, truly exciting to be here today for this incredibly important announcement. i want to thank mayor breed, director colfax, of course dr. bland, as well as all of our community partners and advocates who are here with us day. i'm matt state, the chair of the department of psychiatry at ucsf. as i said, this is an extraordinairely exciting day for our city. it is incredibly rewarding to have ucsf faculty, like dr. anton bland, to be able to play such an important role in this effort. the city and ucsf have a very long history of highly productive partnership, and as the representative of the ucsf

here today, i can't stress our eagerness to continue working with you, director colfax, and dr. bland. it is particularly rewarding for me personal to be able to help support the remarkable work that is being done as a partnership between the city and ucsf at the general hospital and in our community based programs. our department of psychiatry is the second largest service department, serving more than 13,000 individuals and families annually. the faculty and staff at ucsf are talented and are really on the front lines of national crisis. our doctors, whether thairthey're in psychiatric services, or division of substance abuse, our trauma programs, our

community based wrap-around programs, jail-based psychiatry, are all helping people who are struggling with their issues, and very often are facing homelessness, exposure to violence, marginalization, and stigma. in this department, dr. bland is a resilient and talented leader. he has been a highly affective leader who has a deep, deep understanding of the mental health challenges that the city faces. he brings a remarkable mix of clinical excellence, administrative skill, and very importantly a deep compassion for every patient and family that he interacts with. in taking this position, he will join an already outstanding team, in working throughout the city who are addressing this challenge day and night. and with the active support of the mayor, director colfax, our community partners, and i guarantee every person at ucsf, i'm confident he

will help achieve lasting and sub substantive change that will affect the lives of the most vulnerable in san francisco. thank you again, mayor, thank you, mr. colfax, and congratulations and best wishes to you, dr. bland, as you begin your tenure as the doctor of health reform in san francisco. congratulations. [applause] >> mayor: again, thank you to ucsf for their partnership in this effort. we are truly grateful for their support. and i think that this is going to be absolutely amazing for our city, and it is no -- it is primarily do to our working relationship with ucsf and the resources they continue to provide to support our programs here in san francisco. i would also like to acknowledge and thank the progress foundation and doorhouse for their support and the work that

they continue to do in san francisco, as well as another community partner, positive resource center and brent andrews. thank you so much for all of the work you all do to work with communities and to continue to make sure that san francisco is at the forefront of addressing what we know is a serious crisis. not just with so many people sadly that are suffering on our streets, but people who need help, they need support, and need resources, and it is time that this city has taken a really hard stance around trying to reform mental health in a way that removes the stigma so that we can get people to help and the support that they need. so i'm very honored and grateful to dr. negusa bland, who has stepped up to the plate to take on this incredible responsibility. so thank you all so much for being here today. [applause]

>> i will call the meeting to order. we will start with the pledge of allegiance. >> roll call, please.] [roll call] >> the usual rules for public participation will be applied today. i will limit testimony to three minutes on any particular topic.