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 more area

expertise than i did. i don't think i had denial from the health plan aing, no, you are our boy. you have got to do this. i do think we need to recognize providers should be accountability for thee decisions and recommendations and be open to new suggestions and all of that. i could order tests as a kaiser doctor or blue shield doctor that were not on the normal menu sent to specialty labs that got covered and were done as i had ordered. >> the member paid normal laboratory fee. they weren't charged for a test within the contracted lab with

blue shield. with the specialty labs they didn't pay more than normal lab co-pay. >> any other questions here? thank you. we have one more. >> we will ask for representation of united healthcare on this topic. >> good afternoon, heather with united healthcare. there are differences on how the plans work. i will talk about city plan for early retirees. city plan is ppo and the members have in and out of network benefits, they can see any provider for second, third, fourth opinion. the only thing that will differ is the cost share. based on plan design they are

responsible for their could insurance. they can seem another opinion both through customer service, talk to them and they will find another provider to see that is available. >> shannon with united healthcare. it works same with the medicare advantage ppo. the provider does need to participate in the plan. >> i think your plan is ideal. thank you. any questions? no. the thing i was concerned about is when people are not feeling well, they can't do things themselves. they can't goat denied for an

appealna asking that didn't work. it should be easy to get a second opinion. >> i will take you to the recommendation page. to note in the appendix we have contained rate and financial information on the fees for best doctors. for you to know that it is here to round out the information we are presenting on this topic today. with that i will take you on page 8. today we are making the recommendation that the healthser chris board approval allowing the agreement with best doctors to expire on december 21, 2019 with the 2020 plan year. again in recognition this

recommendation comes with the understandinunderstanding the pl increase awareness how to seek expert medical opinions within the framework of the health plans including posting information on the hs.org website and the evaluation of the expert opinion services will continue as part of any future vending activities. >> any further questions? i think i need a motion here. >> i move that we accept the recommendation to allow the best doctors contract to expire as indicated in our recommendation. >> i second the motion. >> any public comment first as a member of the board.

i want to say that i reviewed all 336 consultations provided in 2017 and 2018. there was a summary. i didn't review the data but reviewed the summaries. i want to thank best doctors. they were very complete. they did not include identifier other than gender. it didn't include age, race, religious preference. i was blinded to look at the health the than. the expert opinions were comprehensive and very expert. despite some initial concerns the first time i reviewed the

first set. the recommendations were interesconsidered a change. they seem to have cleaned that up. i really think they did provide a valuable review and accurate review. the members who repond ponded to evaluate their reaction it was very high by the members lieu utilized this service. it was a tribute to their expert opinion and time spent. there was one treating physician who showed up and 336. he seemed to appreciate the consultations.

there were snow mather respect. i -- i would congratulate any discussion about cost savings. that was bogus. over and over the cost associated with the recommendations, there were cost savings but they were all sort of fabricated because it made a lot of assumptions. saying you saved $17,000 by recommendations the bilateral cataracts that he could avoid the surgery if he stopped driving at night was not the $17,000 cost saving to avoid the procedure if they didn't drive at night, they could drive in the day. iowa president to point out the

-- i want to point out the issue early on there was no quality assurance plan. when there seemed to be a question about accuracy of diagnosis. there was no way best doctors got back to providers to where this interpretation mate have happened and the resolution. that is a serious concern i have. best doctors clearly is correct in saying they have no doctor patient relationship. this is a review of records. there is no personal contact. then have more response built any other provider would have in care of our members. they have not come up with a resolution of the issue

regarding when there were concerns about diagnosis how that information was handed. were they correct or incorrect or whatever? i feel very strongly that we as a board need to hold our health plans accountable for the quality of care. that includes not only accuracy of diagnosis and cost benefit analysis. we make sure they are getting timely and comprehensive discussions about the care presented. there were cases where it was a first opinion. the member was asking about surgery when he or she hadn't seen a surgeon. the provider would say esophageal surgery but they had

never seen the second opinion. those are not the kinds of situations on which we should allow. members need to know that they need to trust to some extent the providers we are offering and get their opinions upfront. if the they have questions whate mechanisms are and they should include treatment and surgical options. they need to start with using our health plan providers. it was a lot of cases that showed ability to communicate with providekers. you want me to have a surgeon,

maybe i should see my surgeon. they are saying experience with best doctors, i think the challenge is to us as the board to provide optimal care and i support the recommendations aree accounareaccountable for that c. >> public comment. >> catherine guy, retiree. i reviewed the best doctor's report from last month. the discussion recorded in the minutes expressed concern about utilization. it does not address what you just mentioned in the minutes. how do you increase?

>> yesterday i discovered a staff recommendation to not renew the best doctor's contract. in the reports on rates and benefits they note that best doctor's services is eliminated. i oppose this. second, because it is a valuable benefit. members have expressed gratitude for it. when i was diagnosed with him wh lymphoma. i wanted to know what the physician who was going to do the bone-marrow transplant was best route to go. i made a big deal at kaiser and

at the time i was director of health services that might have had something to do with it. maybe not. i was permitted t to have a secd opinion it was the choice i wassent going to take that ensured i would get into renation with a bone-marrow transplant. with the second choice i might not be standing here today. if the cost is too high negotiate down. if there are concerns about quality work with best doctors to have that quality issue conversation. when directorian directoriant mr statement. if you had an opportunity to have a second opinion, would you take that. urge no or vote to delay until those occurred. lastly i would just say i didn't

have the benefit of second bin. i was within kaiser until i made a big deal. in i hadn't made a big deal they could have flipped a coin. i urge you to vote no on this. thank you. >> i am representing sciu10-1 retirees and the csf. the feedback from members that utilized this service has been positive. what i found when i speak to pre-retirees, they are not aware of 24 benefit. this is an option and benefit. the other thing that occurred to us most people who are going to utilize best doctors are getting the kind of diagnosis that might

be unusual. it is not the go to the doctor with the flu. they are not calling to find out if they have the flu or allergy. it is something much more serious and meads something. i think it is not going to be something that is minor and we are only going to fix your wrist as i did for tendonitis. when it is more major they are utilizing this. utilization needs to be in context. i am understanding what you mean and i think it is up to our providers to be forthcoming about the options within the plans. when i have listened toy

retirees includes one who used it for himself. his father is a retired police officer and used it for his father as well. his father is almost 100 years old. this was impressive. this was a benefit they were grateful to have. i don't think we expect high utilization. then we have a lot of high claims and dealing with rates higher what this provides. it is that option. when people hear they haveited those who used it and this is overwhelming to me, they all have had very positive responses

on you it worked for them. please reconsider your vote. thank you. >> usf retired division. i would like to second. i would like to ask a question about kaiser. the kaiser representative said if we want a second opinion outside of kaiser like at sanford we could do it at our expense. if we chose to do that and that second opinion brought us information which would lead to a different treatment or more effective treatment than what kaiser had wanted, would kaiser pay for that? we need, i think, in the united healthcare people can go anywhere in the conduct tree. we need the opportunity even if

we pay for it upfront of getting the second opinion and if it leads to new information kaiser needs to cover the cost or provide those with cancer, heart disease, i have paid to go outside of kaiser several times. twice they agreed with what kaiser said. it made me feel better. it made me more accepting. i used best doctors twice and found it immensely valuable. thank you. >> i can address the issue you raise generically and say that obviously every treating provider has to be comfortable with the recommendation because they have to sign off on the prescription.

as the infection disease doctor i saw several with lymes disease and went outside of kaiser to doctors who recommended a host of therapies which i was not comfortable prescribing. most of those individuals found somebody in kaiser to do that. it wasn't an infection disease doctor but they found somebody more kind than i was or whatever. they did take those recommendations. i don't think that kaiser practices medicine just like blue shield doesn't practice medicine sin more united health care. they are providers independently licensed in the state of california. in their best judgment they

would give any member the feedback of where those recommendations fall. at least one physician who was included was very appreciative of the recommendations that came from the best doctors expert. i think he did that to prescribe that. there were probably a lot more examples of that. everyone wants the best thing. the question is it done only at mayo clinic or someone advertising in the paper or handout or who is that? at least our health plans are accountable to their own providers and monitoring the quality and recommendations and should get the feedback one way or the other about that so they can take actions that they need to.

>> withkaiser the way to get action is to file a grievance. if you are not well that is not the easiest thing. i had an experience with kaiser where a specific doctor recommended something to me but the doctor at kaiser to get it i had to file a grievance with kaiser. i filed the grievance and won. if you are really sick it is not easy to go through. >> any others? >> well, i guess i am a little

confused that the best doctors isn't here. it would be interesting to hear from them sort of their take on all of this. i would be more comfortable given the public comment about how potentially use full this service is actually hearing or giving best doctors the opportunity to explain their service. i would be inclined to continue be this item and give them an opportunity to respond. >> i believe they were here at the last meeting, weren't they? >> yes, and i would comment they did not -- we encouraged them not to present the cost savings data because we felt it was not contributing to the conversation. i wanted to calm that out.

we also as part of the strategic plan did a request for information on a number of services available out there with 200 plus startups a day in healthcare. i am not sure this was the case when best doctors was selected. there are several other entities shifting the model. the model best doctor has was their best effort to provide this extern expert opinions that they provided us with. helping members find a doctor abother services. the up take in the utilization everyone i have spoken to including those entities with employers who are having the same struggle with both low uptick of services, they are not

budging on the price. we have gone at them several different ways wanting to have a case rate for the most highest level of consultation but there is no -- it is not a pal littable number and they didn't present a way to manage it. so they knew, i spoke to them myself this week we were having the hearing and made it clear the recommendation and they chose not to attend. i think it is a state of the market more than anything. i don't know that the current model has these cumbersome aspects to it.

for the plans neverred and institutions and let alone the practicing physician. those are the things as i said we did build it into the request for information. we are seeing several different models including i understand this week or maybe the week before if you go on the main home page for ucsf you will see ground round for a service availability for a cash price anyone can purchase we will see different coul configurations evolving in the near future. >> other comments?

>> even before going to best doctors, they could get a second

opinion. >> okay. , any other comments? there is a motion on the floor to approve allowing the existing service agreement with best doctors to expire as scheduled on december 31st, 2019. with this continuation of third-party expert medical opinion service by the 2020 plan year. all those in favour? >> aye. >> opposed? >> no. >> it is unanimous, not unanimous, 4-1. four in favour, one against. okay. we have been at this for two hours. do we need a ten minute break? is everybody happy for that? a ten minute break.

>> we decided we stand appear and talk individually about health plans. for this year's cycle, without a be helpful to start the conversation that we will have about each of the three individual nonmedicare plans by a short presentation that provides an overview of what is happening with the renewals across the plans, what total right member -- rate contributions that we will be looking at, and other information that spans each of the active employee and non medicare retiree health plans on page 2, i described that is the purpose of this material, and you'll focus for the cycle 20 plan is what other plan costs will be, how are they impacting 2020 rating actions, whether

they be a self-funded plan like united healthcare, flex flaunted -- funded plan, blue shield plans, or fully insured kaiser permanente plans. and then baked into our recommendations include a few plan design change suggestions that we believe will be beneficial to members on the united healthcare plans. will be talking about those individual presentations and what those are. so everybody can see the total rate increases that we are going to present today that are shown at the bottom of page 1. both on a before rate stabilization adjustment basis, just purely based on the experience of the plan, and then for those plans were rate stabilization applies, blue shield plans and the u.h.c. p.p.o., what the adjustment is after stabilization.

kaiser does not have stabilization adjustment because it is fully insured. you will also note the asterisk footnote at the bottom of the page. the five-point 9% increase from kaiser, 1% is due to the return of the federal affordable care act help ensure tax for 2020 after was suspended by the federal government for 2019. some commentary on the specific rate actions that i discussed on page 1, for the blue shield plans, to .3% increase, 0.9% for kaiser. they were higher increases in 2019, approximately 90% overall. what we are finding that is especially with the plan, now that we have one full year of actual experience, that the plan is doing well. and so our increases are substantially lower than just

general trust -- trend cost expectations for good news on the blue shield plans. for kaiser, we do want to remind everybody that we have a 0.3% rate decrease for 2019, and that followed two years of approximately 5% increases for 2017 and 2018, so the underlying 5.9% rate increase which is really 4.9% on actual cost because the extra 1% is due to a federal tax that is outside of kaiser permanente's control. it does meet national trend expectations. and then with the u.h.c. p.p.o., the underlying increase from the experience matches national trend expectations, and then as we will talk more and more about in that presentation, we had some rate stabilization reserves

that we applied 22019 rates that were not available for 2020. there's a slight deficit in rate stabilization now, so 5% of this increase is the rate stabilization change year-over-year, 5% is underlying experience. saw the next page, we have a look at the planned distributions. like i showed earlier, this gives everybody an indication of how active employees elect by plan, where the percentage is for each individual column. for instance, 22.8% of access plus active employees or access plus represents 22.8% of all active enrolled employees. you can see distribution, early retiree distribution, just to give you a framework for when we

talk about the plans how the population distributes across each of the four plans. page 4, again, is the summary chart, now for this purpose, it is illustrative, showing to the nearest dollar. actual rates we will ask -- ask you to approve during the rest of the presentations, but just for illustrative purposes, you can see how each of the health plans' rates are projected to play out on a monthly basis. so three sets of columns, so the active employees who fall under the 93-93, 83 contributions strategy, active -- active employees who fall into the 19683 strategy, so we typically show both of those in our presentations, and then the early retirees or the full

employer contribution are also shown. i have some shading that helps you see the association of plans , and especially for, you know, labelled here see the cna, city plan choice not available. that was designed last year to help those individuals who live in a location where they don't have a choice of plans to result in a lower paying contribution for those members, and so you can see where the associations are in the shading of city plan choice not available to other plans. and then i will also direct you to the second footnote that is effective january 1st, 2020. they will be a super -- suit -- a service fee of 2.2% of the value of a minimum of $2.49 to be charged on credit card transactions that pay for member health plan contributions, but

there is no service charge for each x. and my final page talks about plan design changes that we will be talking through four united healthcare p.t.o. we received feedback, as we did the bench working presentation back in march about the fact that the network family out-of-pocket maximum relative to single is much higher versus the other plans. so we have a recommendation to lower the out-of-pocket maximum today to twice the single amount so that ratio holds today for blue shield and kaiser permanente plans. we are proposing that for united healthcare. we will talk about that in that presentation for blue shield. expand access for certain vaccinations to selected retail pharmacies, as well a similar to

what was done last year for united healthcare plans, offer up to 40 personal counciling visits per member annually without a specific diagnosis. today they are generally available to those with diabetic diagnosis only. and then with kaiser, it is a required change, implementing a change in the infertility benefit coverage and we will specify that in detail when we have a kaiser presentation. and then finally, coming back to the conversation we had with you in april around prescription drug retearing. we talked about this as a possibility that we would perhaps evaluate for the 2020 plan year in the united healthcare and blue shield. we are not recommending those changes today, so a lot of work has transpired in the last four weeks since our last health service board meeting.

granted, it would generate cost savings for the plan, but there was substantial concern as we really dug into the numbers, and i will specifically credit william from the san francisco health services system. he was instrumental in doing very deep analysis almost drug by drug analysis, and we feel, as a result of that evaluation, there would be concerned about possible tearing changes on member medications and the impact. so we do believe that more education on prescription drug alternatives is needed. there is immense change, as noted by a doctor on one topic. the awareness of the cost of medications and advertisement. so that any medications and those high-cost ones we focused on in april, are prescribed less , in favour of alternative and effective medications in the same treatment classes.

>> i just have a comment about page 4, monthly rates. when you look at blue shield retiree plus two, you know, they are higher then the city plan by $700 or something on each tier, which amazes me because when i see how expensive the city plan is, but blue shield appears to be more expensive then the city plan. when you get down to then -- when you get down to the member contribution, it is more for the city plan, even though the total cost is less, so how does that work? >> there is a historical basis for how total cost rates have been set, established long before i personally became

involved with the san francisco health services system. as a refresher, one of the things that we are working towards with 2020 being year two of the three-year transition, is to migrate city plan total cost rate relationships between the single tier coverage and the family tears for early retirees to be consistent with the relationships that are in place today with blue shield and kaiser. with respect to the employer contribution, the city charter defines the elements of the formula that we utilized to calculate the employer contributions, and then by definition, subtracting those from the total planned rates to generate member contributions, and the employer contributions are the same for those in retiree plus one dependent, and retiree plus two or more

dependence. essentially the number is the full increment of contributions for the second and higher dependence. >> in the city plan? >> actually, that phenomenon is all plans. for instance, in the middle of this chart on page 4, the employer contribution, if you look at the right two columns in the middle of that chart, is an example you will see 1,716 in both the retiree plus one and retiree plus two more dependent columns. you will see the same phenomenon with the same numbers in each of those two last columns. >> it appears that blue shield is every bit as expensive or costly as the city plan, and yet we keep saying how costly the city plan is.

>> thank you for that acknowledgement. we certainly recognized it last year and thank the board for approving the action that is now having his as migrate over a three-year period, the reading relationships between the family levels for city plan for early retirees, and the single tier for retirees. >> thank you. all right. any comments on this item? seeing none, we will move to item number 13, please. >> item 13, review and approve blue shield in california flex contributions presented by mike clark from aon. >> mike clark. you will see on the content page we presented a renewal summary,

we recommended design changes for 2020, and the resulting rate cards, and ultimately asked for your action on a recommendation. you also see in the appendix for reference, there are footnotes to help define terms in the rate cards, glossary of terms, and then to the extent it helps to view the 2019 current year for trio. so today i will present recommendations that include, first of all, approving a renewal proposal of what will be a combined rate increase across the two plans, very specifically to .3% for access plus, and 0.9% for trio. as well as the resulting rate cards that include two recommended plan design enhancements. so the first is based on a blue

shield recommendation, which we thank them for bringing to us during the renewal process. the expansion of the availability of certain vaccinations and retail pharmacies, i will describe in detail what those are, and this is expected to deliver about 125,000 annual savings, and then also to be consistent with the united healthcare plan and introduce availability of up to four counciling visits per member. we expect this to have some nominal aggregate financial impact. certainly additional service cost from the counciling business themselves, within then we would expect some modest reaction that result from members utilizing what they gain through the nutritional counciling visits. >> i'm not sure this is the right time to ask the question, but the expansion of available

vaccinations at other institutions, does that -- is that because the providers, there is a provider charge for the flu vaccine and their offices, and so you are now limiting that information, and i guess the question is, how did these outside organizations integrate that message into the health record of our members so that we can look to see how our members are doing with regard to the vaccinations that are listed pneumococcal vaccine, flu vaccine, et cetera. is that built into the hundred $25,000 savings, is a transparent interaction, or is there some loss of interaction? >> i can speak to the savings assumption, and then a

representative from blue shield has additional information to share, i would welcome that individual to come forward. the savings is estimated based on a savings in terms of the cost of delivering the vaccine, and an alternative site of care, and also some presumption that a member who may not have obtained a vaccine, but if you are making it more readily accessible, perhaps through a retail pharmacy, that could have some nominal impact and avoidance of certain conditions that could lead to additional costs. i will remind that 125,0004 this is a baseline of about $300 million in this plan, so that is a relatively nominal figure. >> this doesn't illuminate someone going to their dr. and

getting a shot. >> no, this is simply expanding the accessibility but does not change any current approach for someone obtaining a vaccine. i will share that specific table of the specific vaccine shortly. page 3, just to remind that, these rate cards in the presentation are shown for two common strategies, but there are multiple employer contribution strategies for active employees across the entire system. so please note that the total rates apply in all situations and we are simply showing two of the most common employer contribution strategies for the city and county of san francisco >> paul brown, blue shield. good question. i don'tno