upticks in experience. there is a contingency reserve on this plan. we don't talk about it here. the rate stabilization is a third line every serve after the i.b.m. p and contingency reserve. i feel that still having $7 million available for use in 2021 and beyond is adequate but also feel the fiscally responsible action to take is to apply for than one-third per policy. that gets to my recommendation on slide 8. what i would ask you to consider today two approval actions. number one, suspend self underred stabilization reserve on one time bases for del deltal and approve $7 million to be applied towards the buy down

across the active employee ppo plan for plan year 2020. >> i move that we accept the recommendation as outlined on page 8. >> second the motion. >> any public comment? >> i have a question. >> go ahead. the net effect will be to reduce everybody's rates is that correct. >> rates will reduce from 2019 to 2020. we will present those next month. >> for active population? >> for the active population. >> active employees ppo plan. >> we also have dental dental ppo for retirees that is self insured. >> correct those rates are locked in to the end of 2021 daysed on a three year lock in delta dental provided last year for the retiree ppo plan.

>> thank you. any public comment on this item? all those in favor of approving the staff recommendations say aye. opposed. all right. it is unanimous. >> thank you. item 11, please. presentation of dxcg risk scores. presentation of aggregate diagnosis cost group per scores which correlate costs to the underlying illness burden of the sfhss population presented by the enterprise systems analytics manager. >> good afternoon, commissione commissioners.

we do have a presentation. first of all, i would like to acknowledge the assistance of the analyst on my team who has prepared the report i am presenting to you today. she may or may not be joining us. she is held up at the office. we are presenting the diagnostic cost group or risk scores. there were late breaking updates. if you haven't been to the website lately, you might want to go there for the latest version of this. the risk scores, as you know,

are the healthcare measures which measures the illness burden. the group level results help predict future cost of care, measure efficiencies and assess the disease burden of the sfhss population. within the deck, the current period that is defined as october 2017 through september 2018 and previous period will be october 2016 to september 2017, we had that as a rolling period instead of full calendar year to make sure the risk scores are calculated in time for the risk and benefits cycle. pmpm, medical claims are based on full calendar year. we do make adjustments for that. you will see the concurrent and perspective risk scores. those concurrent risk scores are

retrospective looking at the utilization in that time period and our perspective risk scores to predict the future conditions and therefore, the costs of our population because it is hard to know what condition somebody will have at a future point in time, age and gender weight more heavily in terms of calculating perspective risk scores. moving on on page 2 and our executive summary, certainly the big change since we presented the risk scores in the previous year were the introduction of blue shield trio plan which resulted in access plus risk scores increasing so healthier individuals have migrated to trio. the active cco city plan population we see improvements there, very slight, but in the

risk scores as you know from the demographics report we have been seeing increasing population in that plan. that helped. driving risk scores with musculoskeletal positions are number one. we have seen this on the dashboard. diabetes is one of the top three drivers in what is contributing to the risk score. it is the most costly ma man age condition we have in our condition. the other summary is say the risk scores are increasing. the scores increased for active and early retirees and medicare tire res. they have improves due to younger age. we have seen that with the city

hiring. with the demographic report you see the average age down slightly and early retirees have higher scores. we have taken a look at the early retirees 55 to 64 knowing the early retirees really have a higher risk score and there is the cost driver when we look at blended active and early retiree population seeing what is happening with the age group comparing actives to early retirees. we see those early retirees in the age group have almost two times their pmpm claims and much higher risk score than same age people still actively working. let me say i am your enterprise systems and analytics manager.

>> just to make sure. we talk aboutmu about diabetes d muscle scores. the cost is manageable. can you break down where the cost comes from? is it hospitalization, surgery, complications, coronary artery disease, renal failure, these kinds of things? so we have some sense about what we might be able to look at. muscle skeletal for the future, for example? >> we can and it is part of all of our strategic plan to really get the data driven and focus on the population of health. sanity check. what are the conditions to dive

into and look at the various programs and go deeper to see what makes sense. all things i am excited to move in that direction and busy doing that analytical work. thank you. moving on page 3. here is just a trend view of your concurrent risk scores for our four plans we have. of course, blue shield access and trio, kaiser and uhc. medicare and advantage ppo and trending with the active, early retiree and medicare tire res. again early retiree population the risk scores are upwards. for trio when you look at the data. it is based on limited data. it is a baseline, not pulling too many insights off that as

yet. also, just to note when we see the medicare scores we present in this report, they are also a lot higher than you would think. that is because we have the commercial model for genir rating the risk scores so we are using a commercial model on the medicare population. having checked against the medicare model and the watson market scan database for benchmarks. from the u.s. norm our medicare risk scores are lower. working to see if we can get to western or california norm to get a sense how we are looking there. i wasn't able to have that for the board meeting today. we will bring that back. on page 4 you see the same sort of trend. here we are looking at perspective risk scores.

this is a predictive score. again, based on the summary statements this is where we see slight reductions with our city plan score and we have got kaiser having much lower active and early retiree risk scores than in comparison to our other plans. >> i am going to keep asking questions. when you look, for example, at compare populations across the health plans. is it the feeling that it is because certain members choose certain health plans because they have more conditions compared to the average person at age 45 or few error is it something to do with the way that health plans code some of the encounters or even encourage services or discourage services

or even encourage certain medications? in terms of the cost breakdown? is it member driven that differentiates kaiser from blue shield trio? >> i think it is a little of both. we are trying to get to the data. we are trying to analyze people we see moving plans in a given plan year. what are we seeing in terms of utilization and services and procedures. that is the member driven. they want it taken care of with a different provider. that is sort of what people think is one of the drivers. we would like to really look at the data to assess that. also, talking to our members with surveys and outreaches to understand that. there is a coding issue, certainly. some plans are much better and coding than other plans.

my mentor has been that i have the data wait to talk about what we see in trends, what is happening with the population for everything to be perfect or leveled playing field, that is up to the plans to continue to work on inputs to our all payer claims database. it is a claims data base. not everything is in the claims data. maybe some are on the electron cal medical record. we are trying to make sure we understand the drivers. these are great questions, thank you. >> that is very helpful. hypothetical situation. when i was in practice at kaiser i saw a woman who joined was getting an annual colonnos copy in another health plan. when we talked about the utility

of that, it was clear she didn't need the annual o colon os could be. if you were tracking the risk score from one health plan to another. would the risk score, you know, change the individual therefore make the change of the aggregate from health plan a if they all get the test at one year compared to plan b where they are not. >> my senses in thattic case although i think what you bring up could be other cases. it is diagnosis driven. just because they have ordered the procedure if the diagnosis comes up there is no there there that shouldn't affect the risk score, and if it is showing up as preventative it is not

impacting medical claims. in terms of correlating the risk score to financial spin. i will take that back to confirm. that doesn't mean there aren't some level of those occurring which are based on different provider practices how those impact the risk score. >> i would just add i think you are aware that practice patterns vary among the physicians regardless of systems. the kaiser medical group has more control over the practice patterns of the physicians part of that group than hill. there is a wide variation of practice patterns of physicians. some of that is picked up by the claims dated take base. it is not a measure of the practice patterns or protocols. when you look at utilization,

there are so many variables that contribute to the comparison across the plans. i think it is more to your earlier point that it is somewhat over driven why they go to certain plans. we do see a higher risk population choosing other than kaiser. >> continuing on page 5. here is a new presentation of information from what we have brought in previous reports. this is now available to us where we can look at that risk contribution and identify the conditions to driving that risk score. that is the muscle skeletal disorders rating hig highly and diabetes. for older car cardio vascular.

moving on on page 6. here is a look at -- we have taken the risk score and overlaid on the medical pmpm. i would like to be clear that pmpm is very specific to medical and rx claims if you are crosswalking to other data, it doesn't include some nonclaims related data that drives your total spend such as other costs. as we trend this i would like to call out an issue we are addressing is that looking at the medical and rx claims. our blue shield data we have in the claims database is showing larger spend than what we are showing was actual spend in our inchoices. all of that data originates from

blue shield we are working with them to understand what is driving those variances. this is reporting off what is in the data base. we did see a reduction in the blue shield per member per month from the previous period. we have trio on here but baseline. kaiser and city plan pretty consistent year-over-year. dollars dropped off final chart on city plan. 2016 year pmpm was 870, 872 in 2017 and 886 i in 2018. online you will have the proper chart with the data labels. the next page is the same pmpm with living score overlays. looking at early retirees.

higher risk scorin'dicates greater illness building. the pmpm decreased for access plus. some of the trio migration of people is influencing some of that. the next slide is just a different supplies. i will move forward on that. it takes all of the plans you have seen on the previous page and puts them all on one page. to slide 9. this is a view of the risk score by plan and also as a combined risk pool. this is for the nonkaiser plans. top left active and right is early retiree blended at the bottom is how we rate the plans that are blended. overall effect to combine these is that you will see slight increases in the access plus and trio population but from where

your city plan risk score is a dramatic decrease. the bottom your combined risk pooling for concurrent score would be 1.17. perspective a 1.1. then as we talk about not only predicting future costs but we like t to be able to assess performance and measure efficiencies. what we are able to do is take the risk scores and do dynamic justments to act for who has a sicker population potentially driving those costs. these adjustments take into account the risk scores for the population and we are able to do it based on various meted tricks. the way to read this is look at the pmpm spend on outpatient and

blue shield access plus, for example, actual pmpm $472.28. if adieus for the risk score of 1.015, then the algorithm indicates the spend should 443.96 in the active portion. not as efficient. that is 1.1 ratio whereas conversely if you look at the kaiser plan, the spend there was $331.82. their population has the risk score .792 on actives. adjusting for where the risk is. the spend should have been $346. moephish efficient when

adjusting for risk. that is how to read the reports. there are a few in here. i won't speak to all of them unless there is a particular question. >> i have a fact question on te dynamic adjustment created by what set of assumptions? >> it is using the risk score and scaling all of our plans. our plans total they are looking at that in terms of risk. they are accounting for spend in relation to the risk score. those are the main assumptions and more specifics i will have to bring back to you how the calculation works. >> it is like putting your thumb on the scale in a way it seems to me at first blush, and i recognize you could draw a broader conclusion, yes, one plan is more efficient in some

ways than another. i think it would be useful to outline what is embedded in this factor. this is our own calculation here. based on it we are driving to a broader conclusion. i think it would be useful to at least know what that is. >> we will look into that and bring that back to you as well. >> if i could follow up. going back to the discussion on delta dental. if the efficient plans are efficient because access is more difficult or something, wouldn't that possibly show up as efficiency if the members weren't utilizing the health plan for the same condition in one scenario compared to another or am i off base? >> i don't think it would. it is looked at claims

utilization. only those that got the services. it does not speak to who is not getting the services. what is the spend and the risk of those people spending it? i don't think it helps in that scenario. >> we have a diabetic who is utilizing -- same, you know, same score in the two different systems. will this calculation of pmpm would be independent whether they saw their provider three or four times because of differences in practice habits? never if one set of providers says you need to see me every three months and the other one says every four months, this would not show up as efficiency?

that is what i am trying to understand about practice habits. our members willingness to use resources when they should use resourcresource such as diabete. >> i will look into that further. i think we can further. i don't know 23 we will ever get to the specific with provider practice. we can overlay like visits per patient to other things to put it more into context. >> to follow up, i am nervous about the use of the word eyeficiency. it divided health plans into a couple plants. is that what we are saying there is a difference between the health plans. i would like to have a better

understanding before we use terms that look, you know, per jourtive. >> i think we are limited in that since this is based on utilization. it is a fascinating question we cawecan delve into. there are originalsis in the database to get to your question. i don't know that the risk score is the place for that. >> should we use the word efficiency. why. >> is there another word we could use to describe what we are seeing without the analysis? are we making a leap. >> thank you. moving to slide 12. i think you know we don't have the financials for the medicare

population. you didn't see medicare tire res mentioned on the other couple of pages. we can dynamically adjust based on utilization metric. this one is looking at a comparison based on admits per thousand. then just moving to slide 14. you will see in the appendix where we have a lot more detail by all of the age groups and the risk scores and genders. if you would like to see that, that is available. we have summarized it to show per each plan the average age and risk score. as you can see so far the males in kaiser has the lowest and females in the city plan have

highest. females in trio lowest and males in the city plan have highest risk score. that is a quick look on page 15 where we analyze risk scores by relationship. h.h.s. subscriber versus dependents and within the active population the spouses have a higher risk in concurrent and perspective. for the early retiree population. we have a temperature higher risk score. >> this is the finalnal assist on page 16 where we looked at 55 to 64. of course, this was our summary point that the illness burden for those 55 to 64 who are early retirees, much higher

than for the active population. you see in if concurrent risk score a 1.538 is your concurrent risk score versus 2.287. in perspective risk score the active population has 1.665 and early retiree 2.193. earlier with the pmpm to spend on early retiree population was twice as high. that brings the presentation to a conclusion. are there any additional questions? >> once we have completed our analysis, how does this flow back to the plans and negotiations with the plans and working with the actuai the act?

>> as we go through the renewal process a big component of the renewals is experience in previous periods and various trends and risk assumptions. this gives us our viewpoint in terms of where we see the future of the population and the current cost implications. beyond that i invite the actuairrito speak. it gives us the perspective to what is going on. >> i ask that as educational and process question. we have a number of the presentations that come not that they are not valuable, and they are. the question is why do we do all of this if the health plan is over here doing the same thing? i believe the original investment effort here with your arrival and your team analysis

was to validate or find out where there was variance in terms of these broad-based suggestions that lead to some definite motion about what the price is going to be for the following year, and to have invested the time with you and your team qualtaytively over the last few years we have had a more informed discussion as a result of all of this. that is what i am encouraging the public to understand. it is a mind bending exercise to go through this and not see how it relates back to the end game. are the premiums going up like rust that is always with us year in and year out? the answer is yes. do we have other information to help to dampen it down? the answer is yes. >> thank you, commissioner scott. >> i am looking at the medicare population. when you do this coding, where

do you get your statistics from? do they come through the health plan? >> i am referring back to when medicare sued some of the health plans for coding. when you have look at the statistics on medicare from our plans, could you see if something is being up coded? are they all done by you independently of how the plan is in are they showing you the statistics? how does this work? >> we derive the statistics ourselves from the claims data provided by all of the plans. if there is additional coding occurring on the claims, that is coming into our claims database. >> if they were up coding you wouldn't know that? >> that is a separate analysis.

over time we looked at a number of things that have been up in terms of the media or spot slight that we want to make sure we are not seeing that in our population. we did look at that some time ago. >> would you say our paplation -- population is getting less healthy or more stable? certain groups are higher. >> we certainlydency the early retirees and medicare tire res they are getting sicker and older. that is what happens. we know people end up with chronic conditions, more than one and over time what can we do to delay that? that is when we hospital to start see -- hope to start seeing the shifting. >> are they getting sicker than a few years ago? is it more so now? >> i only have our risk scores

for 17 and 18. we went live in 15. that is murky. we have the risk scores in 2014 which i don't remember off the top of my head. i know we had done it a couple times. one was based on rx. when we look at the trend line we are looking at, yes, they are getting sicker. >> this is exactly the approach we are taking when we say population health of being able to understand the health of our population and this of where we looked at early retirees and actives of same age to see that pretty big variation in the health status. >> was it always that way? >> i don't know. we know what it is now. it will help us as we do more

and more analysis to figure out where the levers are to exercise to delay the onset of chronic disease or better manage it once it has taken place. those are big opportunities to explore. >> it makes sepses the early retirees might be higher. they have a lot of disabilities. it would make sense they are reekiering because of -- retiring because of the problems. that is the other side of the coin there. it is obvious with firemen and cops they have a lot of physical problems when they retire. >> right we can help inform the employers and safety and well-being programs. hopefully, there is an intersection there. >> some of it is hazard of the

job. >> true but there are innovations to help us have a healthier work force. >> we know certain jobs have more hazards. there may be other jobs as well, more sedentary. more diabetes. thissal laws us to look at the population. you mentioned early about benchmarks. the question is are there other avenues for the health plan cost and belong to the business group on health. you are not operating in a vacuum do you have access to the same analysis in other employee groups either public or private public. >> we have access to the market

scan database with millions of lives in it. i will follow up to members of the pbgh. i have been in contact with other cities, southern california and washington state to meet to leverage the best packets to compare the data and look at things, certainly trying to take advantage of things like that. >> this is cuttingening t cutti. at the conference board there were two populations of health and using all payers claim databases. one with i.b.m. and uc starting to take a look. we are on target where we need to go and your questions are excellent about what framework and approach we will take to identifying the conditions that

we believe we can change behavior in order to have a healthier population. >> i would say it is all physical work. that might be a separate population. >> they are a small group. we might be able to be innovative with them. >> i want to applaud you and your staff. these reports are detailed and quite daunting. it is a learning curve for me as a board member and for you and for members this will have impact as we see what is happening why health costs are what they are. i think this is superb and i am glad we are on the cutting edge. >> i appreciate the discourse from the members of the board. >> any other comments? any public comment?

>> good afternoon. president every tired employees of the city and county, vice vie president of 1021 still looking at my brothers and sisters in the active world and trades. the trades are among the early retirees. kudos to marina and her staff. these reports are fascinating. what i notice is early retirees seem to be about 10% of the population had when compared to the active at least in the numbers i saw here analyzed. couple things occurred to me. one, looking at some of the data for the actives, i have

maintained when i was on the board that blew shield has over -- blue shield has over rated the risk and kept premiums high. when i look at marina's statistics. that bears those out and i think those rates need adjusted accordingly. we are paying a lot for what they consider a high risk factor that is not there. my concern about the early retirees while they are rated with actives. with only 10% they bear an undue burden for some of the rates. some of that could be adjusted as well. i know we can't get all of claims information or a lot of information with regard to medicare. we have maintained a lot has to do with the choice of plans. it is concerning to the people i represent that we made that

change to only kaiser and uhs to take medicare plans. it seems to me when we did the contracts originally. any plan that buys into the system has to provide the wenfits an -- benefits across the board. blue shield rates were too hard. we need to negotiate harder and adjust them. it am concerned on the previous information report we had with regard again to blue shield rates, i think our active population demonstrates those rates should be lower and we should look harder. when i look attria and access -- trio we can justify in something to work out flex funding we should have greater negotiating room to bring the rates down.

i thank you for these incredible analysis if we look further we will figure out that there are certain populations that may be paying too much and others not enough. i am hoping we can reach the right kind of median for our population and understand when people go out and receive injuries in late 40s and 50s it is hard for them with very firm pt to come back to full work, especially if they are in the trades or in police and fire, especially in the trades. those people just can't get back into shape. we have to acknowledge that. that is a big, i think, cause behind early retirees and the fact that those are th the retis with the higher rates not their spouses. it is their job.

thank you. >> no other public comment. move tom item 12, please. >> item 12. best doctor's annual report presented by best dock important's repsen-- docto docts representative. >> >> good afternoon. trent rainy. client representative with best

doctors. thank you for giving us the opportunity to give you a height of the 2018 utilization. i have been working with hsf, abbey mitchell and the department leaders since late last summer when i joined the best doctors organization. meeting with them monthly through conference call and reb narand in person -- webinar and in person. quarterly we review throughout the year. these are highlights of the culmination of the four quarters in 2018. january through december. we appreciate the opportunity to come out here. we released the full report for 2018. what i am showing today is just some highlights. you have probably reviewed the full report. if you have questions, we can definitely take those as soon as

i touch on the highlights. hopefully this is familiar for some of you on the board last year. our reports are constantly evolving. thanks to you we have been able to bring things together at the annual report. i am working on bringing those quarterly. that was based on the hard work of abbey and her team and commissioner was involved and the clinical details. as far as the agenda for the presentation, some highlighters of did yo did youof th did youo. i want to touch on the member engagement. there is a lot of good things happening. there is a lot more to do to

help in that regard. look at the utilization height highlights of the flagship products or services we offer your membership. we always start a lot of our presentations with a quick somebody story. we don't do that to blow the numbers out of the room. we don't necessarily present the highest cost. we don't look at that most of the time. we try to pull out very common you tillized services, common conditions have when they contact best doctors for a review. this is a 35 to 40-year-old female. female. there was a diagnosis that we didn't consider formal. she had been recommended

treatment. she asked us for review. all of her information was gathered. medical records, testing information, radiology reports, everything available to really have our expert derm what the next steps were or what the possibility of it was. really at the end of the day the diagnosis was clarified. working on the same diagnosis. the expert clarified the diagnosis, recommended different treatment. not that the other treatment was wrong by any means but suggested additional testing to really get to the dermer of the pain this member was causing. the members quote was that the expert had great observation and was very detailed. just another way to look at the services you offer the

membership and we provided through expert medical opinions. look at some high level utilization reports. details are in the report. on the first page here of the presentation, i like to look at a couple of flagship services. tend to be the most often utilized services you provide through best doctors with expert medical servicmedical services. find best doctor is simple. when somebody is looking for a new specialist or just moved to a different area within the same city and they want to find a physician or specialist close. they can contact us. we have a list of best doctors, if you will, based upon our regular polling of physicians. it is polling physicians it is

to find out who would they go to. knowing the medical community is probably one of the best guiders of who we would see in the physician's world. that is very popular. i have shown a two year comparison. in 2017 there were 391 contacts to best doctors for find the best doctor service. slight decrease in 2018, 352. the targets are kind of set based upon your size. we do adjust those over the years. i am not surprised in the second year we saw a slight decrease if not much at all. it is when the program is new people see find a best doctor as something i can do. i can check who are the physicians on the list to see if they are participating in my network and who i might like to

utilize if i need to change doctors. the target we adjust over time depending on the age of the client, not the demographics, but how many years you are with us. weep tend to see that service decrease a little over time. as far as the expert medical opinion. the detailed review for your members when they face a medical situation, diagnosis, surgery, anything in the medical world you want to review. we did see a 27% increase in 2018 over 2017. not a surprise as people hear about us more, see us more in the newsletters. the staff at ffhfs talks about the program more.

we see more people utilizing it. you are below our target. we set those based upon the age of the client. how many years you have been with us and various other factors, engagement that you are participating in, those type of things. nice increase in 2018 over 2017. that is in much greater detail in the full year report. the other services you offer the membership. ask the expert is a service we offer through best doctors. we find this tends to be one of the least utilized services for what it offers. let's say somebody don't have a surgery they are facing but they have a general question about health or possible family

history of certain conditions. maybe they have not been diagnosed. they may not have a case, per se, they may not have had treatment recommended for a condition. they can call best doctors and we will get an expert to review the question and respond to them without the need of opening medical records, that type of thing. sometimes people call, thinking they are calling to ask a question. through our clinical intake we will find out maybe they have a case. they may have called intending to ask the expert something. if we lead them down the correct path we will open an expert medical opinion case because there may be information that we can have that true review of their records and provide that. critical care, again, not an

often utilized service. we want be to assist you in really promoting through so your members are away. if it is a primary member, an active or retire re. we want to make sure they know enough that they can inform friends and loved ones this exist. often times when membership lands in an emergency room, i c.u. resolution in critical care situation people aren't thinking about best doctors. the more we do to educate those people. that is another thing that comes with multiple years with our services they learn more. they realize we are not just expert medical service that is where they see value. we make sure the family knows about critical care to drive the care they are giving.

treatment support is not as commonly used. i will talk a little bit at the very end of the work we are doing with abbey, particularly with marina and her team. they have asked a lot, and we think there is a lot we can do to leverage the all claims payer data base, the analytics in the areas of treatment decision support. this program is focused on certain conditions, about eight of them at last count, to really drive engagement formu for musco skeletal issues. really trying to help drive did youtivelyization for those that might need is service that aren't aware. look at the member engagement piece. this is where we like to present

information on how the member heard about us, how they got to us. i am very happy to report that abbey it wastic it was particule service team have a great understanding. we are doing more activities to get them to drive that. from 2017 to 2018, we increased those that responded. they heard about us through the staff from 18% to 35%. they are doing a ton of work to understand the program and help refer members directly to us. the benefits website has gone from 10% to 19%. various other communications an

listed. people find us through newsletters and things we are doing. i know there is more we can do. abbey and her team asked along with carol for additional assistance at giving people information not to annoy them or put more mail in their mailbox but to target the people who might need some of our services. when you look at the services we provide, almost everybody in your population could benefit from one of our services at one time or another. just increasing the member engagement that way. we like to look particularly for the expert medical opinion. at the reason folks are calls us. most are the same year-over-year when we look at the top few categories why they called us. need help deciding among

multiple treatments? they are diagnosed. they have treatment options but they need help deciding among treatment options they often contact us, have a case reviewed and get that. 50% in 2018 called us for that or contacted us for that. symptom not improving, 21% questioned the need for surgery which is important when somebody is facing a surgery this have an opportunity to ask an expert or they don't understand the diagnosis. that is good to see that number fairly low. we think the medical community does a great job locally at informing people about the diagnosis. another thing we like to point out is member satisfaction. overall satisfaction from the membership who has used our services is 99%. that is on a 40% response rate. believe it or not, that is good.

most of our clients we see in the 20 to 25% response rate. it is maybe driven by the fact they are calling us for a specific need and we usually ask them at the end about their satisfaction. often times when people get services and get taken care of, they are on the road and don't want be to complete the survey. it is great 4% of the pop -- 40% of those that used us. 99% of those that used our services were satisfied. another thing we did or do for you on a quarterly bases definitely annually is break out demographic information so you understand the members utilizing our services specific to the expert medical pick. opinion. that is a lot of impact to

members but also the cost of the plans. the first slide here actually breaks down demographically by main population groups. splitting out the active membership versus the two retiree populations. early retirees and medicare eligible retirees. of the expert medical opinion cases we opened or completed which was 194, we had 114 of those were from the post 65 or medicare population. 64 of those 194 cases were active population. smaller portion of your overall demographics was 16 of those 194 cases from the pro-65 or

recallly retiree population. is there more we could do with all of those populations? most definitely. we think we are just touching a very small peas and assisting a small portion of the population within all of those categories. -- categories. look at a different breakout. we have provided comparison numbers. looking at a couple different things. first of all, breakdown male to female for expert medical opinion service. also looking at the membership being active and retirees primary members, those who came from the position of primary versus dependent. at the top we provided comparison listing hsf first comparing to the education and government