we have these unique neighborhoods with so much cultural presence and learnings, that we want to preserve. [♪] >> the health services systems board will come to order. please stand for the pledge. [pledge of allegiance]

>> madam secretary, roll call, please. [roll call] >> item number 3, roll call, please. >> approval of possible modifications of the minutes of the meeting set forth below, regular meeting minutes from april 11th, 2019. >> are there any corrections to the minutes? seeing none. wait a minute, i have to open

for public comment. any public comment on this item? >> you need a motion. >> i need a motion. >> i moved to approve the minutes of the april meeting as presented. >> second. >> okay. i asked for public comment already. all those in favor? >> aye. >> any opposed? it is unanimous. all right. item number 5, please. >> item five, general public comment on matters within the board's jurisdiction. >> please come forward. >> good afternoon, commissioners i'm actually here to request that in future agenda items that aren't posted, can you please put some way that the public can

communicate with you? these are posted on monday or tuesday, and it is hard to write a letter and have it arrive at 11:45 a.m. by thursday, and there is no e-mail address or phone number for people to call and leave comments who aren't able to take time off to come here. it is just a request. thank you. >> thank you. any other public comment on this item? seeing none, we will move on to item number -- >> item six is the president's report. >> all right. i would like to welcome mary how to the board. she was appointed by the mayor, and she is presently the director of human resources in run county, and has prior experience in san francisco. she was at the human resources department for san francisco

juvenile probation, and prior to that at san francisco human resources department for the employment division. she comes to us with a lot of experience. thank you. >> thank you. >> any public comment on this item? seeing none, item number 7. >> item seven is the director's report. this report is given by the executive director. >> good afternoon, commissioners i wanted to start off my report by recognizing that may ease mental health awareness month, and we have given you all green ribbons that you may where this month in recognition of that, and i wanted to use this opportunity to call out the services and the individuals who provide employee assistance to employees of san francisco.

we have three employee assistance councilors that are under our purview, and they do an excellent job. two of them are able to join us today, and i wanted to recognize cathy newsom and jeanette who have been with the organization for quite a while and provide an extraordinary amount of services both on an individual counciling basis, as well as departmental consultation and training so that we can reach more individuals. i personally have had a lot of interactions with them, and they do provide a really excellent service, and more recently, we have been meeting with our health plans and they have been helping us look at the mental health services that are provided by our health plans and that bridge between our employees in the services that our plans have. it has been a really excellent in-house consultation that we have available.

i would like to ask jeanette and , to step forward, please. [applause] >> i also wanted to comment on the fact that natalie helped us put together a really robust orientation for our new commissioners and i wanted to thank her for doing that. members of the management team

participated, but boy, she pulled it together any quick period of time. the only comment is we needed more time. that was great. i hope that it is given a good footing to new folks. i recognize we didn't do that for you, supervisor madeleine when you came onboard, but we can figure that one out for you if you'd like. it was very helpful to put all the materials together and i emphasize throughout the process that we put this together and it was indeed an orientation. it was not a training and education, that would have taken much, much longer. we hope we have provided you with the know-how know how to find information that you may need in the ensuing months ahead the third thing i wanted to call out that is not included in the director's report because we were just meeting on this matter this morning, but h.s.h.

leadership team. as you know, we have been in the extended blackout period due to the current rights and benefits cycle for much of what you will learn today, and approve today in june for the health plans for plan year 2020, and we have been in the process internally of constructing a proposal to bid out the system to resolve a number of challenges that we face for the year beginning in 2021. am i getting my years straight? okay. and what we have ascertained is that the marketplace is pretty unstable and there's a lot of change underfoot, and some of it may be resolved sooner than later, some of it maybe never,

but i feel it is our obligation to inform the board of what we know about the marketplace and to have a better understanding of the problems that we are trying to solve four. what i would like to recommend to the board is that we have a hold on your calendars for a may 30th meeting. that is a placeholder should be run into delays with the rates and benefits cycle. assuming we don't run into any delays in the agenda today, i would ask we use that meeting to bring in a board education on the marketplace, and to help inform the board of what we are understanding and seeing, and the questions that it raises. the second thing that i will have together to present at that meeting is a stakeholder process in which we will involve our members in really doing some deep listening, and to understand the wants and needs

and desires of our memberships so that is taken into consideration as we then conduct a request for proposal, which would not be had until january of next year. we are slowing down the process in order to get better educated. the better we get -- and to ensure that we have a process that understands the huge variation in it needs that we have from our memberships so that we can you well advised when you go into selecting and designing the services that are needed. so we can visit, and i would like to assume that at the conclusion of this meeting, should we not need the may 30th meeting for rates and benefits, that we would keep that meeting on the calendar for the special meeting of the board , of which we are required to give a ten day notice, which is part of the reason why i

wanted to bring it to your attention now. we would put out the ten day notice on the 20th, and orchestrate that meeting on the marketplace at the time. any questions regarding that or anything else in my report? >> so that's going to be a board of education meeting? >> correct. >> in october we usually have a board of education. >> right, that would be a little late in the process for this. this would be -- yeah, at least i have tried to use any time that we don't have action items on the agenda to educate the board, but this meeting would be solely for that. >> okay. >> i know i can't make the may 30th meeting that was held months ago, but i had already made plans. i think we will be welcoming a new board member on may 15th.

>> yes. >> that person, presumably would be able to come. i am saying we need to make sure that the schedule is inclusive of all board members. i'm certainly dispensable, so i don't need to request that we look at it, but i would appreciate consideration to postponing it until another date >> thank you for bringing that to our attention. we will do some polling and determine a date that is suitable for all members. i do think it will be worthwhile to do that. >> i just wanted to thank you for your hard work. the employee assistance program is one of the programs that gets barely noticed, but i think it is one of the programs that is very employee -- very important to employees. thank you. and to the director, could you just give us a synopsis of the

enrolment for the benefits, and i think we need to reach out to the unions, most likely to let them know. >> yes, would you like to step forward and explain what we're doing with the voluntary benefits this month? >> i'm the chief operating officer of the health services system. the voluntary benefits that we rolled out to the city workers, all city and county employees, a couple years ago, and, you know, these are benefits like supplemental life insurance, pet insurance, et cetera. so we were working with a company to do a mid year enrolment post tax benefits. they're not like your medical and dental and vision benefits, which are pretax. that can only be held in october so we're doing this mid year because they are very popular.

to give an opportunity so they don't get buried in the whole message of october enrolment. we notified everyone, not only some of the labor organizations, but directors of departments and h.r. people. >> thank you. >> any other questions? is that the conclusion of your report? >> that's all for today. >> very good. any public comment on this item? >> good afternoon, commissioners welcome to mary how, and congratulations. e.a.p. was very special to me for all the years i worked in the city, and i know jeff very well and his predecessor jeanne. this is really exciting.

congratulations. i'm representing claire, and i'm representing a p.u.b. protector benefits question. we are getting calls from members who want to know about finding mental health councilors , and i guess some of the calls came in and they were told to call member services and health service, and i didn't know if that was the way to go, or if they should be calling their own hmo to find out what those contract relationships are , and with the lists are so that they can find a marriage councilors, or mental health therapists, and this is specifically in the mental health world. since it is mental health month, we would like some guidance in what to tell our members when they call us, because we are not going to do any referrals. thank you. >> we actually are developing some materials that we will distribute to other departments,

and we can distribute them to the associations as well, and to have access through mental health services. i think that is a fabulous suggestion. i see jeanette nodding her head. great. >> hi, i'm so happy that there is an and open enrolment program for voluntary benefits. i'm rather new to looking at this, so i'm wondering if there was a vetting process that the department went through so that we can trust, and i'm sure we could, that these are suggestions, but that they are also, kind of, like beneficial for the workers who will have the opportunity to join. for example, i would like to know that what is offered by the

organization is comparable to what my credit union offers me in terms of certain types of programs. do you know what i am trying to say? >> yes. the voluntary benefits are for active employees. there was a vetting process, a contractual relationship has been in place now for three years or longer. >> the work tara relationship originally was ebs, and it has been going on for a very long time, well over a decade. they are the ones who set of these benefits. we work with them on the particular carriers and the type of benefits. two years ago when we rolled them all out to the city and county, we did a survey of employees to see if they would be interested in these kinds of benefits before we took on that kind of work.

>> right. and we don't do comparables to other employers. thank you. >> any other public comment on this item? seeing none, public comment is closed. item number 8, please. >> item eight is the financial report as of march 31st, 2019. this presentation is given by pamela leven 11, the chief financial officer. -- pamela 11 -- pamela will even the chief financial officer. >> that report you have in front of you act as expenditures and revenue through march 31st, as well as a projection through the end of this fiscal year. i will first address the trust. the trust fund balance, as of june 30th, 2018 was $77.4 million, based on activity

through march 31st. we are projecting the fund balance to be $84.3 million at the end of this fiscal year, which is an increase of $6.9 million. overall, we are seeing unfavourable claims of experience for both u.h.c. plan and access plus. for the blue shield trio plan and the delta dental self-funded plan, the claims experience continues to be favorable. we received $1.7 million in pharmacy rebates from blue shield in march, at a total received year-to-date of $3.8 million. we still have a projection of ending the year at $6.9 million. the healthcare sustainability fund is expected to have a year and balance of approximately $1.4 million. a total of 500 up -- $500,000 in performance guarantees payments have been received as of march 31st.

as of today, we spent $105,000 this fiscal year for the adoption and serves as an assistance plan, which totals about $200,000 for when we first started it in 2017. i remember hearing that we might have a scene on me of adoptions and this just proves that we have not. it is a benefit that many employees are very appreciative, and then the amount of shares for the benefit accounts won't be known until june. we continue with having the grass for each plot -- graphs for each plant showing cumulative expenses compared to the budget premium. as a summary, the cumulative expenses are tracking greater

then the cumulative revenues for the other plan, and the cumulative expenses are charging lasts for both blue shield, access plus, and trio, as well as delta dental. based on the financial results through march 31st, we are projecting to end the year within the general fund administration budget at $334,000, primarily due to salaries associated with delays not in our control. are there any questions? thank you. >> i don't thank you can answer this question, but i heard today that the government has decided that all advertising for pharmaceuticals on a per month

basis or above a certain minimum level will now include the cost of that medication. the pharmaceutical industry, of course, as opposed to this because they say does not reflect the actual cost to health plans, and part of this is through the pharmacy rebates system. i'm wondering if you, or anyone has any thoughts about whether this move, which i think is a very positive move, may actually impact some of our balance in terms of pharmacy rebates in the future, or is it all just speculation? >> if you are referring to the legislation, or the rulemaking that c.m.s. is making for medicare for the point of sale, it is the other one. okay. >> it is too soon to tell, probably. >> it is really complicated. i don't know that it's going to help anybody because what they

may advertise as their price may not be what is negotiated with your plan, and it may not be what you pay as a member, so i think as we mentioned, we talked extensively in the last meeting with about the whole pharmaceutical situation. >> that was hitting the newswires first thing this morning. there was certainly a lot of emphasis on price transparency coming out of washington right now for pharmaceutical ways. in this particular instance, all that i know from what i have read is $35 is the minimum

threshold for a price to be disclosed and advertised i think we will all be very interested on what other specifics come out of the amounts in the coming days. thank you for raising the question. we will all have our eyes on what exactly this means. >> any other questions? any public comment on this item? seeing none, public comment is closed. now we will move into our rates and benefits section of the meeting, and that will be item number 9, please. >> item nine, revised recent benefits calendar as of april 16 th, 2019, presented by the executive director. >> i think the rates and benefits calendar is discussed

previously, and we may indeed be cancelling the may 30th meeting should we make it through this completed agenda. >> any public comment on this item? any comment from the board? seeing none, item number 10, please. >> item ten, review and approve the 2020 delta dental plan rates and administrative fees. >> mike clark from aon. good afternoon, everyone. i am going to present to you our plan year 2020 renewals recommendations for all of the dental plans that are sponsored through the san francisco health services system. as an introduction, this has rating recommendations for both active employees and retirees

with the demo plans. i will start with the delta dental of california active plan it is the one plan that is self-funded among the dental plans offered, so our recommendation will improve administrative fees and our calculated total plan cost rates the other dental plans are fully insured, and so the recommendations include those insured rates, and then finally, we also have a design change recommendation we are making on the retiree dental p.t.o., that is rate neutral, that is designed to encourage and increase the availability of dentists. bottom line on top, obviously getting through the details next on page 2. there are five different recommendations i will be presenting to you today for approval. first with the delta dental active employee p.t.o., no change in administrative fees,

at a five-point 3% decrease in the self-funded total cost rates for the delta care u.s.a. fully insured dental h.m.o. for active employees and retirees, no change in those rates. for the united healthcare interdental united healthcare interdental h.m.o. plan, a three % increase for active employees, no change in rates for retirees. for the delta dental retiree p.t.o., no change in rates. as he mentioned before, a recommended plan design change on our rate neutral basis that would increase certain aspects of the p.t.o. network benefits in return for an increase in the 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