individual deductible for certain elements of the dental plan, which i will talk about in detail later. we also found it would be helpful, as we discuss these recommendations, to understand what the distribution of populations are for both active employees and for retirees. so on slide three, just for background, you see the current number of employees and retirees in each plan aced on information that was presented by the demographic report in february. so i will move to page 5. if you recall, you know, this being a self-funded plan, and last year we also came to you and presented a three year administrative services only the

renewal, and so that the stays flat from 2019 to 2020. we have continued to see favorable claim experiences. we discussed last month. you also approved the use of half of the existing rate stabilization reserve or rating in 2020. that number was $7 million. we followed follow the same methodology of developing our rates for the planned that we are recommending for 2020 as we used last year. page 6 simply outlines the history of the administrative fees, including the $4.62 per employee per month fee, that went into place january 1st, 201943 year period. that fee would sustain for 2020, and it will also sustain for 2021. on slide seven, you will see how the 5.3% reduction is calculated

, and how it plays out into the total cost rates for the active employee dental tpo plan, and this includes an underlining 2% trend assumption in our forecasting for 2020 claims, and includes the use of $7 million unit rate stabilization reserve in 20 twenties. -- in 2020. before i moved to the discussion on the insured plans, any discussion on the self-funded plan? >> the active member doesn't pay anything on the premium, right? >> for most of the employees, it is $5 per month is the single contribution, $10 per month is the employee plus one contribution, $15 per month is the employee plus two or more

contribution. >> thank you. >> you are correct. that is the case for the two dental h.m.o., there are no contributions for each of the two for active employees okay. i will move ahead to slide nine. again, just background on the five fully insured dental plans that are offered, it there is a reminder that the delta dental removals that were presented and improved last year to the effective january 1st 2019 included a three-year lock on fees, and the united healthcare h.m.o. plan is a one-year renewal. based on this year's renewals, active employee rates increase 3%, retirees maintain 2019 levels into 2020. so pictorially, page 10, you see

the rates by active employees and retirees at the bottom of the page for each of the three tiers. 2019 to 2020, same except -- same exact figures in both columns. no change for the delta u.s.a. h.m.o. and on page 11, you will see pictorially how the rates look for active employees at the top, retirees at the bottom. 3% increase on the active employees, no change on the retirees. and the retiree p.p.o. on page 12, again, no change in the rates. so now we want to transition to the topic of looking for ways to increase retiree p.p.o. network utilization, and in the delta

retiree p.p.o. plan. we reviewed information and contained an executive director report this month, you will find information on utilization of delta dental benefits by type of dentist. so we are looking to find ways, without increasing rates, to promote greater utilization of p.p.o. network dentists. >> are you talking about retirees now? >> yes, this is retiree dental p.p.o. if i can take you to page 14, this is the current plan design, and in particular, the focus on the column headings, so there are three different types of dentists and other dental practitioners that a member can

utilize, so p.p.o. dentists, preferred provider organization. these are the dentists that are providing services, generally the highest level of discounts to the member, and one of the benefits to using a p.p.o. dentist is you will see no deductible for use of services. you also have coverage for cleanings and exams, as well as x-rays, where you see that 100% covered. there is tremendous benefit in using a p.p.o. dentist. we have done research with delta dental and virtually all of the retired members do have reasonable access to a p.p.o. dentist. a second level of benefit you see in the middle column called premier dentists. premier is a broader network of delta dental establishments for dentists who are, for whatever reason, choosing not to be in the regular p.p.o., but also

amenable to providing a certain level of discount to delta dental, not as high as if they were p.p.o. dentists, but affording some level of discount for services. and then the third tier is out of network, which is the dentist to isn't participating in either the p.p.o. or the premier networks for delta dental. >> let me ask you a question. in the active dental plan, there's a difference in the coinsurance for premier dentists versus other networks. and it pretty much is the exact same for the retirees. i'm wondering why that is. >> i don't understand -- i don't have that background knowledge on how the plans are developed, i know that in the director's packet, there was also a presentation that they provided us with a history of all the plan design changes in the

program since 2010, so at least to be able to see over the last decade, each of those plans evolved. the retiree dental p.p.o. program is a retiree pay all plan, and so -- >> i understand that. i'm just curious there isn't a distinction in the actives between premier and out of network, and in the retirees where there is in actives. you get a better deal if you are in premier then if you are out of network. i'm just curious why that would be totally different because they're both delta dental. >> one subtle difference is that it was use of a premier dentist, and the cost of the service is generally less. you are paying for the coinsurance portion on your own. you will be paying a lower amount out of your pocket than going to an out-of-network dentist, or the rate for service

would typically be higher than for premier, and you'd be subject to any balance billing requirements of that specific dentist. while you are correct when looking specifically at the way the plan design is portrayed and the retiree guide, and how i have transcribed date here, there are extra charges that someone will pay for the same service out-of-network that are not subject to the number in the premier. >> you can't see it on their. it appears here everything is the exact same. >> can i just follow up that question, then, just to make sure i understand. it is an interesting point. so when you talk about out-of-network coverage, is that of the build service? so let's say, for cleaning and exam -- cleaning and an exam that the p.p.o. dentist and the premier dentist get one -- get

$100, and the out-of-network bills $200. is the 80% coverage of the $200, or is it 100, and then the member gets balanced build $120, basically? does that clarify the question? >> in your example, it would be -- you would receive coverage for 80% of that 100. the remainder would be when i say balance billing, the remainder equals balance billing , that cost would be passed to the members. >> so that would be the $20 that delta dental would not have covered for in plan providers, whether premier or h.m.o., and then the 100 over and above that that an out of plan dentist might charger be 120. >> that's correct. if that happens to be the out-of-network dentist, for

example,. >> and what is the percentage of people in each group? in the p.p.o., premier, or out-of-network. >> if i may direct you, and i will take this in a moment, so in the director's report, and unfortunately we can't display this easily, what towards the back of the director's report we have embedded a chart that shows planet network utilization for each of the past six years, so it is right before this slide. >> i'm just curious, you know, the number of people that are in >> thank you for asking. the network utilization distribution for retirees in 2018, 41% of procedures were in

p.p.o. networks, 54% of procedures were in premier network, 5% of procedures were out-of-network. forty 1% p.p.o., 54% premier, 5% out-of-network. >> okay. >> that is specifically for the retiree group. >> right. >> our design recommendation on page 15, we did ask delta dental to propose ideas that are rate neutral, so by definition, that means something improves design wise, with something has to correspondingly decrease from a

design perspective. and so the idea we are bringing you today is to improve the p.p.o. network coinsurance for services now covered at 50%, to improve that to 60%, and that would include crowns, dentures, bridgework, and endodontic or root canal services. for the coinsurance for these services in premier or out-of-network, they would remain at 50%. and then to pay for this, we are looking at a recommendation to increase the individual number deductible paid for services other than diagnostic and preventive care, delivered by a p.p.o. network dentist, or an out-of-network dentist and $50 annually to $75 annually. if i can take you to slide 16,

what we have done on slide 16 is presented the plan design page that you saw on 14, but then also reflected what the recommended changes are. so when the p.p.o. -- in the p.p.o. dentist column, you could see something that would change to 60%, and then in the premier dentist and out-of-network columns, you can see we would propose the 75-dollar per person annual deductible, noting that we would retain the $150 family deductible that is in place today. again, those deductibles today, and going forward would exclude diagnostic and preventive care services. >> can i ask a question? they are reviewing utilization. the gap in utilization was actually in the preventive services. it was in the cleanings and all

that. so i'm a little -- all -- although i appreciate the increased coverage for people who have problems, one could argue that if it is 60% covered, i will wait until i really need a new crown before i see a dentist. how does this help what our goal -- our goal was to increase utilization of preventive services and routine cleanings. >> sure. so today i would argue that there is as much incentive as can build into a plan design for someone to use preventive services, because if they go to a p.p.o. dentist, the service is completely free to that individual. for someone who really likes their premier dentist, or even like there out-of-network likes there out-of-network dentist, this change doesn't penalize their plan design for preventive care, because the deductible continues to exclude diagnostic and preventive care.

i would say as your actuary, improving the coinsurance for premier dentists or out-of-network or cleanings and exams detracts from trying to promote utilization of p.p.o. dentists. , in fact, we have seen a nice increase since 2013, 35% of all services for the retiree pdo plan were administered by dentists, and that is now 40 1%. so we have seen a nice five-year progression from 2013 to 2018 of a continued increase in p.p.o. dentist utilization. this particular plan design recommendation, in my opinion, aims at those who are, to appoint, where they must obtain one of these major services, a crown, endodontic root canal,

encouraging to consider obtaining that service in a p.p.o. dentist environment, to perhaps then have the members think through, should i continue to utilize the p.p.o. dentist going forward, rather then, perhaps, staying with a premier dentist or staying within out-of-network dentist. so the bottom line is we are trying to produce a recommendation that doesn't increase the retiree costs cost out of their pocket for the contribution -- increase the retiree cost out of their pocket for the contribution. this is an idea that we felt could benefit certain members who were in highest need of dental services to make that more affordable, if they are obtained through a p.p.o. dentist environment. >> can i just respond?

i think that's great, and i guess if we were to accept this, then it would still be upon delta dental and our patients and staff as we roll this out, to remind people that preventive services actually may be the most cost effective. a ten% improvement in your deductible may not amount to much if you just get an extra cleaning or two, or one, at least, because majority of our members are not even getting one >> i have a comment on this. i disagree with any increase for the single person as well. right now, they pay $550 a year for 1,200-dollar a year benefit. if you go two or three years with this cleaning, you are way ahead of the game. that is why some people don't even sign up for this, and i mean, it is just expensive already. why are we trying to direct people out of the p.p.o. plans?

because i know how it is as a dentist, i have seen some bad dentists and heard some nightmare stories, and they are still dentists. so there are reasons why people go to other plans. not just because of the cost, they are going there because they care about their teeth, and i disagree with trying to direct them, because i don't think -- i mean it is obvious right now that it is cheaper to go to the p.p.o., but trying to up the price for an individual who is in a premier, i don't like the idea at all. i just think the whole plan is not that affordable to begin with, and so now we are just adding on another cost, even though you say, we're not increasing the premiums, but you're increasing something. anyways, i am against it for that reason. >> thank you for the commentary. i will stress this particular recommendation. it again does not affect the rate approval, because the rates

are the same whether this is the design, or page 14 is the design , so when we ask for your votes, i will ask for this particular recommendation last. but mindful that what you choose to decide on this specific topic does not affect the rate approval for 2020. >> no, but it affects the single individual in the plan. >> it might not be the premium, but every time they go to the dentist, it is a different story , so it definitely changes it. >> so this is an option we are presenting as an idea that we were given a suggestion to look at ways we could improve the plan design and certain aspects

of the plan, but still not change the rates from what they otherwise would be in 2020, and certainly we respect the decision of the board when it comes time to vote on whether to adopt this specific change or not. >> you know, i'm not against p.p.o. section, we do need the 60% coverage, if you could just do that without the $75 increase , at 25-dollar increase, that would be fine, but i just don't see why you want to add on another cost to it to a person in this retiree plan who is already, you know, these co-pays are all the reasons why people don't pick up these plans. >> and to improve the coinsurance on p.p.o. dentist for 50% to 60% on the p.p.o. plan design for those highlighted items. without the corresponding deductible increase would require a premium increase on

the retiree dental p.p.o. plan. >> thank you. but you don't have a choice, basically. okay. >> with that -- >> actually, not the newest, but as a relatively new guy, just so i understand the p.p.o. plan, how broad or robust, how easy is it for it to find other dentists if you don't like the one -- is it like you have one choice, you have many choices? how does that work. >> sure, certainly it will vary by geography, there's no question about that. in more urban, suburban areas, there is a wide choice. in very rural areas, it could be more limited choice, but we have worked with delta dental to understand what the reasonable access standard for dentist availability in the p.p.o. network is, and virtually for

all retirees who have reasonable access to a p.p.o. network dentist. >> is there any way to explain what reasonable access is in a way i would understand? >> it is usually defined in a two dentist per 10-mile radius standard. >> in an urban area? >> urban area is typically two in 5 miles or two in 8 miles, and then very rural areas would be more like two in 15 miles, two and 20 miles. >> does that mean two in san francisco? [laughter]. >> minimum standard. we can certainly work with delta dental to understand, for instance, by county how many p.p.o. network dentist there are and counties that serve retirees >> could i anecdotally comment? from my own experience, my out-of-network provider was

overcharging me for routine care , and when i found that out, i decided to look at the delta dental p.p.o. network, and at least a nine for 127. i had a number of options, i had at least five options within walking distance almost, certainly two within walking distance of my home, and about five within, you know, that to .5-mile radius. it was all online, and i could go back and review, you know, member satisfaction with that. i actually found it quite convenient for my own personal experience. >> and again, new guy question, but so when you are saying improving plans, what are the measures of an improved plan design? you are aiming at something with this, which i assume -- i mean

it is an improvement to the plan designed to encourage more people to sign up for a p.p.o., and that is because, why? control of cost? >> a couple reasons. the p.p.o. dentist total cost structure, based on negotiations from delta dental, so the coinsurance remains for the member and it will be a percentage times a dollar amount , that is lowest of the three options, so the member will pay the lowest cost for their coinsurance portion to a p.p.o. dentist versus a premier out-of-network dentist, and also , you know, delta dental's process of removing p.p.o. dentists will be stronger than it is in any of the other categories, so it's an idea

aimed at trying to provide more financial benefit to the member who meets those specific service -- needs those specific services , where we are increasing coinsurance paid by the plans, 50% to 60%, but also with the hope that it will also make those members, by definition of paying those services, perhaps more in need of ongoing -- the importance of ongoing, regular, routine dental care, to be more receptive to considering a p.p.o. dentist to deliver those services. >> thank you. >> anything else? >> i have questions. the new person question. so when you mentioned that the p.p.o. population is at 41%, and you had talked about retirees previously being in the thirties , did you see which category services they were utilizing the most, and is that why you chose those three to

change the plan design for? >> so there were a couple different alternatives that were discussed with us by delta dental. we chose -- as an example, those who are using at least one of these services is almost 24% of the population in 2018. so fully acknowledge that if 24 people are using one of the services that are captured in this 50 to 60% migration, that means there 76% who aren't, but we selected this particular one for recommendation because of how we believe it is very important. one out of four members are utilizing one of these services in the given year. the need for proper dental care does not stop just because the

crown is serviced, the bridge is serviced, this is a high need population from a dental standpoint, we felt. if they are seeking a service in this category of the 60% that we are presenting today. so that was the rationale to selecting this particular plan design recommendation to migrate these services from 50% to 60%. >> what percentage change in migration from premier or out-of-network to p.p.o. do you anticipate with this change? >> that is a good question. candidly we did not ask delta dental to estimate what that would be. we have had a pretty consistent progression of about a 1% increase overall.

p.p.o. dentist utilization every year since 2013 through 2018 has had an increase. certainly our goal would be to increase that perhaps in the first year it would be another two or 3% increase. at the end of the day, member choice is still critical, and the beauty of this plan is it does allow the member to decide which dentist is their preferred dentist. there are obviously financial considerations in their choice. we just believe in trying to present a design alternative that helps to better support the net payment for a major service by further incentivizing p.p.o. dentists.

it is a choice. what we are driving. they are moving to a ppo dentist would save the most by getting the coverage moving up to 60%. i like this recommendation. >> i am not concerned about access. i am concerned about quality of care. you can have a crown and two years later, it is not good. there is a huge difference in dentists. that is my main concern. if i recall, it was the actives not getting the preventative care that they were having a big problem with? isn't that the report? it was a large percentage of cleanings that they were doing. >> the statistics for 2018 active employee who did not have

a cleaning procedure, 32%, retiree plan members who did not have a cleaning procedure 29%. >> i wonder why we are not doing something to get the actives to have more cleanings. it is their percentage that was higher, right? 30% were not. yoyou know, anyway i am against any increases at this point in the plan because of the cost already and i don't know the percentage of people that take the health plan. that is one of the reasons they don't. go ahead. anybody else? >> okay. are you asking for a motion? >> go on page 18.

do you want to do the motion individually or in total? >> finish the representation in page 18 here. >> recommendation number one on the active employee dental ppo plan to accept the recommended 2020 rates as presented in the document with 5.3% reduction from 2019 to 2020 as well as holding the 2019aso fee for the 2020 plan year. >> i was enter training the possibility of moving recommendations 1, 2, 3, 4 and leaving 5 separate. if you feel we should take them individually, we can. maybe we can deal 1 through 4 together. i would recommend that we approve recommendations 1, 2, 3 and 4.

>> i second the motion. >> any public comment on this item? >> i would really like to. >> please state your name. >> gail ow is my last name. i would like to give stories to what karen has brought up. as a retired person, i went to the doctor and found out i needed a crown right then and there. there is no time to switch. often times if you are going to switch, you have to have an agreement with the dentist ahead of time. it looks like this is coming down the line and it is going to

cost this much. you know, plan for it. having these differences in costs is something that a person can't really use that in making the decision because you find you have to have a root canal. usually you are in pain. that is an issue. also, when you do need that person, then you have to find another doctor in a different program, a ppo, that is accepting you and wanting to do the work and it would entail x-rays. i think it is much more complex than the difference in the rates. thank you. >> any other public comment on this item? please come forward. >> .

>> diane with the u.s. f retired division. i have a question. i got a phone call from my dentist that they are no longer in the delta dental network. am i still eligible if i am out of network provider. i would like to keep the same paiperiperi dentist. >> sharon with delta dental.

smile away is for in and out of network dentists. you can still be in the smile away program. >> any other public comment on this item? the motion would you please state the motion. >> to approve recommendations one, two, three, four as presented in the minutes. >> that was seconded. >> i seconded it. >>ault those i -- all those in . opposed. it is unanimous. >> i asked for recommendation number five on page 19 except the plan design changes as in the document for the retiree ppo. move the retiree p po co-insurance from 50 to 60% as outlined on page 16 and move the

premier and out of network individual deductible from $50 annually to $75 annually. >> i would like to make a motion to accept the plan design changes as presented in this document. >> second for number five, right? >> number five. >> any public comment? >> one comment. we approved the rates the delta dental ppo. these are the design changes within retirees on premier or out of network will have a increase in deductibles. for those retirees that will be going to the ppo, there is an

increase in the coverage it would be from 50%. the share would be from 50% to 40% for the crown and for the procedures. i am going for that one. this is purely the design changes. >> may i absolutely clarify what i am asking you to vote on. item four you approved page 12. these are the rates for 2020. no change in rates for 2020 regardless of whether you approve number 5 or not. if you choose to approve number five, the plan design for the retiree p po for the 2020 plan year will be what is listed on page 16. if you choose not to approve number five, the current design listed on page 14 will remain

for 2020 plan year. >> how about for item number four three year to the end of 2021. would that apply also if you approve the design change number five? >> the rates pulled through december 21, 2021. >> are you making an item number four? >> number five. we passed four. >> i'm sorry, yes. >> could i comment as well. i want to make sure we tease out the concern about quality of delta dental ppo providers. if that is an issue i think we need to address that separately with delta dental or any of the providers. i don't think the board is in a position to be recommending a panel of providers that we find inadequate. some of the comments that say

assume that ppo dentists are not as good as other dentists, i think it is not something that we have had evidence presented to us. if we have concerns about that based on member complaints or whatever, then that needs to be addressed in a separate discussion. >> i understand the comment. we are not recommending retire wrist to move -- retirees to move that is their choice. i will remain on premier dentist will assume my deductible will be increased, but we are not recommending the retirees to move. they still have the choice if they want to remain out of network premier or ppo.

all we are doing is making the planned design changes to benefit those that would go to a ppo dentist. >> any public comment on this item? >> you know, it is kind of a tough call because most people love their dentists probably more than they like their primary care physician. i used to say when i was on the board our dentists are more important than gynecologists. we were having a little discussion in the back there. this is a tough one. i think we like the improvement of any benefit. it is always a plus. one of the things i looked at, if i am getting a crown from $600 to $1,500 depends what kind

of crown you need. it is a lot of money. this additional $25 for the year is from 50 to 75 annual deduction. that 25 bucks is nothing compared to my 60% coverage and 40% i am picking up for the crown. i don't see this as really impacting retirees all of that much. it is a high expense. if i go to a ppo dentist for 60% for the crown it saves more than 25 bucks for the year. i think this is a better deal and you should consider it. we watch every penny. in this case when it is a matter of annual deductible and the biggest expense is for the

service, let's keep urging preventative care and hope weault keep our teeth in good shape. i have a beautiful set of crowns that kept me going for year. consider this option and vote positively. thank you. >> any other public comment. all those in favor of item number 5. aye. opposed. motion passes. 4-1. now we are on to item number 11. >> review and approof staff recommends to not renew best doctor second opinion services presented by mike clark aon.

>> on page one of the document we started a recommendation summary. we offered expert medical case review, expert medical pip services through the best doctors organization since january 1, 2017. this is available for all members enrolled in sfhsf medical plans and retirees. this serviced commenced under a three year service agreement that ran january 2017 through 2019. after careful consideration of the services rendered under this agreement and review and also looking at the services that they provide to members that seek expert medical opinions which we will hear from the health plans to further describe

approaches. we recommend today to the health service board that they not proceed with the third-party medical opinion service to the 2020 plan year. that means allowing this agreement with best doctors to expire on december 31, 2019 as it is scheduled to. on page 2, we recommend the focus be placed on increasing knowledge and promotion how members can seek expert medical opinions within their health plan environments. we provide information in this material on that. this recommendation including a provision to include evaluation of expert opinion services and further marketing activities on

behalf of sfhsf. page 3 lists one of the contributing factors behind today's recommendation. that is low utilization of the service during the past two years it has been offered to members. less than one-half percent has engauged the best doctor service during the period of availability. we present a table where down at the left side are particular services that are available through best doctors that have been discussed by best doctors representatives at prior meetings. you will see data so you have an active member column and retiree and the sum total members. to the left is 2017 data. to the right is 2018 data.

these are the number of members utilizing the various services available through best doctors each of the past two years. keeping in mind your overall base is over 120,000. though best doctors proposed a reduction of the per month fees for 2019, you will see that in the. i should say 2020. you will see that in the appendix for details. that was on top of the reduction for 2019. there is an underlying question whether paying for the third party to deliver the services not integrated with the healthcare provider is prudent. we will talk about what they are to deliver for members. we know the plans have

mechanisms. from is regular recognition that can be increased. posting the procedures of the plans on the website, on pages 5 and 6, we have listed out information that each of the plans have provided us so the uhc city plan for non-medicare active employee and members for the ppo medicare advantage ppo for the blue shield access and trail plans and the kaiser plans that cover the non-medicare population and the medicare plan. you will see that on pages 5 and 6. rather than me readings through the tables, what i would like to

do on page 7 is ask for comments from each health plan to comment to allow members to seek expert opinions. we also have fliers illustrate these for members. i did this alphabetically. i will ask a representative from california to discuss their approach to expert medical opinions within the plan. >> . >> good afternoon. paul brown, director of account management for blue shield of california. i want to say first that all of our members are always entitled to a second opinion for any course of treatment or surgical

proceed ush. any member with any question about a diagnosis they receive or they believe that they just need additional information regarding any condition this they have learned about, entitled to a second opinion. you generally go through your primary care physician as you would for any course of treatment. your primary care physician can refer you for a second opinion. >> if it is a specialist with a second opinion that surgeon or specialist can give you a second referral or you can go through blue shield for that. for a surgical procedure, the common question is can i be referred outside of my medical

group. implying if it is within the medical group you may get a rubber tamp opinion from your first opinion ag and we allow people to go out said of their medical group to seek a second opinion from any blue shield specialist. >> any question on the blue shield policy? >> do you need a referral? >> yes, you need a referral from your primary, specialist or blue shield. >> can a person use a doctor in access plus? >> that is a good question. i don't believe they can. that would be in the providers in their plan. a trio provider would be access to any provider that is not

exclusive to their group. it could be any group in the trio plan. >> they couldn't switched. >> so that was my concern. they may want to go out of, you know, in both it is a delegated product, it has to be within the network configuration of your plan but you are not, you know, limited to in the case of a second opinion the medical you are involved in? check. >> in the bay area we have a number of medical groups. they could go to any one of those for the second opinion.

>> they could pick a doctor and ask the doctor to refer to them aas lockas long as they were ine group. >> say that again. >> they know a doctor they would like to be referred to. >> that is why we allow the members to go outside of the medical group to give them the feeling of a second opinion that doesn't have a relationship with the first opinion. >> any questions? >> board members? no. >> i want to ask you a question. you talked about th the customer service team for the trio here.

>> this would not be for access plus. part of the configuration is a combination of customer service and clinical. there are pharmacy techs and medical directors on that team so they, too, with medical background could assist in helps navigate that individual to a second opinion. they are used to this and can help guide people to another specialist. >> it is just access plus, just trio. >> yes in the trio design. >> concierge has been broadened to include all kinds of

services. in san francisco and in many urban areas, concierge service was add on. individual members might pay to their preferred divider for additional access. if it is e-mail or phone access. there are a couple doctors who charge $25,000 per person per year. those providers accompany them to every sub specialist examination and interview. it runs the gamut. it is a world that blew shield used in a different context than we may be hearing from neighbors and friends and shouldn't be equated with $1,000 or $12,000 a year for additional access. >> i would agree. it used to be the guy in the

front of the hotel, now it is everything, includes primary care, food charge. thank you. >> i will ask for representation from kaiser. >> area vice president for kaiser. as blue shield said kaiser supports second opinions. the process of this would be that any member can talk to a specialist, primary care physician or if they are not comfortable about the second opinion they can go through member services and choose from 9,000 physicians to get a second opinion. the beauty of the delivery system is that information will go right to their medical record which sets them up with the

physician along with the person who gave them the second opinion. can somebody go outside of the network? there will be times that we may not have a specialist that treats a certain condition, and there may be authorization to go outside of the network. in general we find our members find with 9,000 physicians an opportunity to see someone else within the network. if we have somebody who wants to go outside of the network and pays for that, our physicians are open to discussing any opinions they get from other physicians. i will too questions at this point. >> i want to be clear. you have to find a person in the network. >> they can find them themselves. >> the tests are the same tests

that came from the original doctor and the same everything? >> not necessarily. each doctor practices independently and may choose different tests to order. it would be a new visit like going to any other physician. >> that is my concern they are using the same information from the original doctor since it is all in the same system. >> i had a visit with a physician. that is what people feel. he said physicians arepletety determined what they want to do in their practice. if you would have asked many. they would go. there is no one directing kaiser physicians to do anything. >> i thought the doctor could should light on this. he has a lot of practice in

this. that is my concern about kaiser. >> i am a retired physician. i have had contracts with everyone of our providers. 16 years forser his and 16 years for kaiser. as a physician i found myself recommending to members they get another opinion. for example, a pathology report. i would talk to the pathologist. i have sent this to stanford. second and third opinions can come from the provider community. that is sometimes transparent to review the lab result to the member. i was in a position for 33 years to refer to out of plan specialists who had