state hio or h.i.v., and national networks, which will really speak to largely, is that is the paradigm where we are now that it will give us the scalability of really transforming care. and then there is consumer mediated. that is where patients, you know , a common example is through a portal, they can aggregate and assemble their own information and direct it. i do want to call out, i'm not being an apple fan here, but apple kicked the door open in terms of patient engagement and patient control of their own information with the apple health records. what they did, by using -- emerging and new standards, they made it so that the patient has control of all their information that they get through the portals, which is independent or agnostic of the platform, it is being used in the care setting, so if you are being seen at dignity at ucsf and stanford and sutter and kaiser and you are enrolled in all their portals,

as well as independent practitioners who may be using a variety of other systems, and you have their portal, and their systems are subscribed or have an a.p.i. enabled, this gets pushed to apple health records and on your phone, on your smart device in an encrypted manner and secure manner, the patient has control over their information. i'm spending a lot of time on this, but the reason that this is important is his large tech companies have engaged in the healthcare business or tried to get into the 48 many times over the last 25 years, in particular , with the bend on patient records. the reason they failed is because they say it is the patient record, we will put it in our system, on our servers. this is not on apple servers, this is the patient controlling their own information. i heard a great comment about navigating through kaiser's site and going through questionnaire, having to answer your own data, but this does is not unlike if

you have had google photos or any other app in which you can take the information that is on your device and actually have it interact with an application of your choice. if i'm tracking, you know, blood pressure or heart failure, diabetes or copd or any other myriad of chronic disease conditions, you can control that data, have it interact with an up in a secure and seamless, without special effort on part of the user, who is the patient, direct that through your care settings. i will get into later, just at the very end, some of the legislation that has come down the pipe with this. so the onc, which is the office of national coordinator for health i.t., which is part of hhs, ten years ago, in 2015, they set a tenure interoperability roadmap. the first phase was really just the start of exchanging data across domains, having these different systems exchange data, and then -- the ultimate goal is

really improved efficiency, higher-quality, lower cost, and improved outcomes, as well as enabling knowledge and public health. so there was a comment when i sent the draft out about what we call the interoperable health i.t. ecosystem. it is a biologic term that is making its way into the healthcare space. that is really all the participants, and that is including patients, payers, pharmacies, labs, clinics, physicians, nurses, everybody who is involved in the whole environment of healthcare, and all the technology that comprises of it is what they call -- so you will hear health ecosystem, or health i.t. ecosystem. and then, the end goal is nationwide interoperability that is patient centred, and that it

is enabled -- from individual patient scaled up to how we manage and care and improve the health of our communities and populations, and really use that data to go from data to knowledge and knowledge to wisdom, insight insight and real , true predictors. so it is just a map of where we are in terms of nationwide health information exchange. in 2004, the onc was formed and set up a national network, and that was really meant to give people access to the v.a., and social security administration. over time, is a technology got more advanced, and the user became more advance, through standard based exchange, which make it possible for information to really be portable across the continuum electronically, that has morphed into a national network called the health exchange. at the time that the e. health

exchange was stood up and really what is happening with the majority of healthcare organizations across the country , they exchange information, care summaries, and other clinical data. some other networks popped up. one is the common well alliance which is a gender participation alliance, which they created their own network to exchange information with each other. then i will get into the care quality which is our network, but also a framework. the sequoia project became -- is a private public partnership that oversees and manages the national network, it is really important the work that the sequoia project is doing because they are joint hip and hip with o.n.c. just blowing through some of the data that we have, it really is -- our current capability from our hospitals, exchanging care summaries at about 80% now.

finding data is about 60% now. the ambulatory providers, sharing data outside of the organizations, is probably at 40 or 50% now. when we talk about the methods of health exchange, there's multiple methods, and i went through that, and this many more , those are the high-level methods. the mooring more methods of electronic health exchange that you use, the more robust your activity in terms of determining how to best care for your patience and population. this is just some data about those who were using multiple methods across the continuum. a breakdown on the hospital side about the availability and use. we have a lot of distance to travel, even though the technology is there. as you see, it is not surprising in the larger urban and suburban areas. it is more widely used in

critical acts -- active hospitals and rural hospitals. when we talk about the domains of the building, that is to find , send, receive, and integrate. the integration is really the end game, and you need to use all four domains. there has been some advancement, but not tremendous. and the ambulatory setting, conducting off for domains is not really improved that much over the last few years. in terms of sharing information outside, and the different settings, it has not advanced that much. when you look at those who are conducting all four domains of interoperability, it is still heartening to see that the response is often -- the way that they are using the information.

if you look at the barriers to adoption, it really has to do with the five rights which are the right information at the right place, at the right time. the integration of this information into intuitive, native workflow, with a platform that the provider is using is key with the successful use and integration of this data. so just to point out, i believe at dignity, this is a passion of mine and one of my responsibilities as the system from a clinical and, across dignity health, which is now called spirit health spirit health, but within our markets that were predominantly california and southern nevada and arizona, we have 87,000 users, and community view is our main platform. we deployed the solution, and i will show you a screenshot of it , of an integrated view of all

data sources for the patients that we see and data coming from external exchange partners or other system such as centre and kaiser and the v.a. we have 40,000 active users in the system across the system. we are connected to the community, 320 connections. we are doing about a million queries a month. so if a patient, each time a patient has a scheduled appointment and is being seen in any encounter, it triggers a? to go out to our exchange partners, and if there is a positive match, then it returns information to the patient. we have 9 million patients, what we call -- those are 9 million covered lives, basically. this is expanding rapidly. this is primarily through a national network called the e. health exchange. this is what it looks like.

this screenshot, i know it is very busy, but it gives usm his of, so i am their provider and this is a patient that i'm looking at within context, and this is a page that i click on that actually brings in data like medications, encounters a bad, notes, diagnostic reports, labs, meds, pathology reports, all the data i would generally be looking for, including and probably most importantly, care summaries and care coordination. and this is a logo of all the different organizations that we are at the care with. when i look at these pages, these are all the organizations that i will be seeing. some of them are nationwide. the v.a. is a national connection. i'm also proud to say locally that we just connected with the san francisco department of public health, which i will get to in a little bit about why that kind of data is still important. other efforts that we did -- the

healthcare continuum is really in the community. so there are four walls of our care settings. the clinics, the centres, the diagnostic centres, the procedural centres, and you look at things like e.m.s. or ambulances. how do we effectively connect what is happening in the field, and the prehospital or precare setting where patients are actually seen a lot, and is the primary mode of transit or entry into our system. so not surprisingly, the ambulances and what we call the e.m.s. services, they brought their own version of electronic health records and they have a whole different electronic standard. we were able to map those standards together so that if a patient is seen by an ambulance

in the field, they are able to connect and do the same kind of korey about patient formation and transmit that to the hospital or anywhere they want and pilots that we have done that came out of some initial successful pilots out of southern california, we did one in sacramento with the county fire to reduce unnecessary transfers for high utilizers who generally are not, because they are not connected to community providers, or they have had behavioral health needs, and this is where we actually put an advanced practice practitioner in the van or in the ambulance, and it they were to respond to a call and add it and get the patient coordinated right in the field without a transfer to the emergency department, saving millions of dollars per year. another thing that we have

activated that i am proud to say really helped with some of the devastating fires that we have had, is an emergency disaster response. we're trying to figure out, is there a way we can effectively connect first responders in the setting of a natural disaster or a major epidemic outbreak, and this is just how it works that if you are a designated first responder or have that kind of access in these settings, you will be able to access and identify patients and really get them the care they need. other cases about interoperability, there is an opioid crisis in this country. all of the states have their own version of a registry of controlled substances that the patients are getting, and this is a way so right within the platform you are using, you can send out a? to the state registry and see they the history for the control substances -- for the controlled

substances. you're exchanging all this data, we see it as being underutilized , and we are really still not at the point where it is truly seamless, liquid data interchanged with the patient at the centre. so there's a couple ways how we get there. one is, how do we scale this up? i'm going to use the cell phone analogy. i don't know if you remember back in the early days of cell phones, i had to pay a lot of money. and so these were separate networks that connected to each other. that is where we are now in terms of health information exchange. there's a framework of networks now that basically connect those networks together so let's say from a point-to-point connection you're on a network and you get six clinics, you get a few dozen

visit -- few dozen physicians and a couple hundred patients, if you connect six networks, that exponentially increases and you get thousands of physicians and tens of thousands of patients. getting that data and managing populations is really the only way you will be able to get to that kind of scale. as an example, if you look at just our e. health, our internal , our local facilities, testing california, and then what we call federated sources, there was another question about federated sources. if we federated things and the information is not centrally controlled, so there is one method called a centralized hie where, for instance, your dignity, you are set or, you argue c.s.f. data, all those with a central repository, and then it is requested that way, that is not the standard space model that exist today. federated means that the information is that dignity, and

they respond to incoming? that is managed or federated through those networks. we're on the e. health exchange. if you look at the map here, if we just go to that framework of care quality, we start to really extend -- expands the connections in the community that we have. if you look at adding the common well alliance there, then we see just in california how much that expands our capabilities. i am going to actually skip over a lot of this stuff. i think i'm really passionate about this, but i'm taking a lot of time, but this is really about community-based population care which is what we're talking about with care coordination, which we have heard about. the other aspect of how we get true interoperability that is meaningful from a clinical standpoint that is really transforming care. we need to talk about what the meaningful data is. yes, there are data points when

the patient enters a healthcare setting that is important, and things like medications and problems and procedure history and allergies are really important, but the majority of care are out in the community. there are other data factors and variables that contribute to people's overall health and how they respond to treatment in the tape -- and the type of interventions that should be thought about carefully when health plans and healthcare organizations are determining how best to improve the quality of their care, and that is the real continuum. a lot of you have heard about social determinants of health, and health disparities in social determinants of health are the most single impactful variables that determine how a patient is going to respond to their care. what if the patient doesn't have a home or they are transient or they don't have stability in their home? what if their local supermarket

doesn't really look like this with lots of healthy options and fruits and vegetables? what if they are like an island and we have local convenience store that has a local don't -- a bunch of junk food? this is not isolated to underinsured or not insured or medi-cal patients, medicaid patients, these are all of our patients in all of our communities. do they have transportation? and even more importantly, what are their community resources to engage in care? do they have support centres, what kind of resources do they have to engage in their care? what is the level of engagement -- it doesn't have to be high-tech. there's a very low-tech versions of engagement that patients can be empowered to use to really help with their care. and again, the type of

information needs are changing over time and our traditional thinking is that information is expanding to the larger kinds of data sets and information to help with predictions. going from a population down to an individual patient. so you see the importance of this kind of data in coordinating care and it being liquid and seamless, or the whole person care initiative with some of the initial cases to identify at-risk homeless populations and engage and share that dynamic care coordination as they traverse the care settings. here in san francisco, the department of public health is engaged in healthy cities initiative which really is to show that the largest proportion of disease burden is preventable and not well-managed. so had we partner with communities and get data out of

our systems to devise and create truly meaningful strategies and interventions in the communities to give the resources across the continuum first at the hands of the patients, but connecting them with the care providers? by doing things like extracting this data and doing what we call geocoding which is spot mapping it throughout the communities, you can identify those who are at the most need for resources and give the resource information to the patient's and then measure those outcomes. it goes to show that at scale, what we're talking about with interoperability is not just sending my chair summary from one emergency department to my primary care provider. it extends and is much more important to that. so some really great initiatives that are coming out of legislation that will drive the

meaningful advancement of the use of technologies, which is really meant for foster research , improve the opioid crisis, coordination of care, but there's a huge emphasis on interoperability and the use of healthcare and information technologies. and then there's legislation around information blocking. providers, health plans, it is not just the vendors. locking of information related to patients has been used as a competitive advantage both the health plans, healthcare

providers, and the vendors. those days are over and there's actually legislation being informed in terms of defining that, and putting large penalties and enforcement on those actors who are engaging in that bad behavior. considerations, when i think about that truth of health plans and the contracts that they have , so we are getting into a lot of these value-based care systems. they really -- that cannot be done without the use of interoperability as being foundational. the way that they enable their patient populations -- and this goes to what we are getting at here. it is beyond administrative claims data. it is largely what has existed in these databases for least 30 years. we need to move beyond that because those are not correlated highly. those are correlated highly with being able to report metrics,

but they're they are not correlated highly with outcomes. so these plans need to be driving strategies that address the communities and populations, and i mean real populations. not population health as a means from a managed-care standpoint, the managing populations in their care. adopting and employing the emerging standards that the technology enables, because it will really get to the point where the patients are going to be able to have all the information at their fingertips and directed all around using different technology, and all of the peers, all the pharmacy databases, all the different type of administrative data and clinical data will be held to the burden of being able to use those standards to improve the care of patients. i think, finally, but the most important, is the degree to which these plans are focusing and incentivizing consumer and patient engagement.

the patient needs to be at the centre of all this conductivity, and the degree to which the networks connect needs to be seamless for data liquidity. sorry if i took up too much time i could talk about this for days thank you. >> thank you. any questions? >> this is herculean. and i applaud your enthusiasm and the information you have put together, which is quite amazing and i guess, i don't think there's any way to understate the complexity.

the data was sometime summaries, but not the primary data, and when he talk about 11%, people don't trust the accuracy of what they are getting. they don't trust the accuracy of the reports they are getting, and they're not seeing the lab results. so i just trying tried to integrate all this. the v.a. tried to give away its health information system to any user to try and encourage this decades ago, into my understanding, no one took them up on it. so we have a married of systems. and i know all of my colleagues in private practice who bought systems through incentives had to then buy another 12 years later because it was deemed inadequate or whatever. i think this is great, i'm just curious to know if you have any sense about when we will achieve this. >> right.

meaningful use, the incentive programs to help information technology, the huge vendors really got -- really became billion-dollar corporations from this and the patient's and their care providers were left last, because really, the promise at the end of meaningful use, because we are in stage iii, is just that. we have come a long way, and i do think that when i look at the legislation, the burden is shifting from the healthcare provider and here -- healthcare organization to the vendor in terms of saying, you know, not only does our technology deliver this, but we deliver it in a meaningful way and a usable way. the other thing is, we are we orienting ourselves and just being able to say, you know, we've got from faxes and papers, and we are getting the data, but

the data doesn't mean anything in the context. we are not getting the data we need and the way we need it. that pushes happening. i think the emergent standards that we are seeing is really driving this. i'm optimistic. there's a long way to go. i think that the incentives are well-positioned, and i am engaged in this and we learned the lessons of the past, lessons learned, meaningful use, we found a use of technology, costs will go down, quality will go up , neither happened. and the legislation put around it. we have learned the lessons of the pastor frame how we will drive interoperability. i think that this drives towards the patient at the centre who is also really essential and going to facilitate that. >> i will be brief.

we have heard today that they focused on a single payer in california. i would like to remind ourselves in the audience of the single-payer bill got hung up in committee. the providers did not need to use electronic medical record. it actually allowed them the luxury of not using that, and so i don't think the single-payer -- the way it can work its way through and we will answer these problems because there are lots of forces trying to prevent this >> right. >> thank you. any other questions? any public comment? thank you, doctor. >> i greatly appreciate this presentation. i like the sharing of information and i like the accessibility of the patient to

all this information. the only thing i request is this system be simple and be comprehensible, because i went to a war with my printer today, and if it wasn't for canon, a customer support, i would have been lost and probably wouldn't have attended this meeting today , i would still be at my printer. it should be simple, it should be usable by everyone. thank you. >> any other public comment? seeing non, public comment is closed. we will go back to item number 11. >> item 11 is approval of the infertility benefit policy statement presented by anne thompson. >> thank you.

we have several documents that we posted as part of this item. i'm primarily going to walk you through the powerpoint presentation, in addition, there is a policy statement and a summary of the 2020 benefits coverage for the three health plans related to infertility benefits. >> just do the highlights, please and what the change is that will be voting on. >> yes. with that, on page 1, just to say that we continued dialogue as part -- as far as the rationale, a couple of changes from the june presentation that we looked at, which was the second item, adherence to current state-of-the-art professional standards, and looking to ensure equal access to infertility services, the second to last bullet. we are new -- there are new additions as we did our research that we felt needed to be stated

as part of the rationale of the coverage provisions under the health plan. on the next slide, i mentioned that separate handout of the benefit coverage, primarily a 50 % coinsurance. there is a deductible under the plan, and not on the other two because there's not a deductible on page 3, just an overview of the evaluation process. we had spoken to this previously , but again, we spoke with many different folks in the area, health plan partners, really to evaluate the infertility benefits covered under each health plan to ensure the programs were generally consistent and available to all members who wish to build a family, regardless of partnership status, sexual orientation, or gender identity. this included discussions with each health plan accounting, leadership, and clinical experts , as well as a review of

coverage language, clinical guidelines, clean processes, network credentialing, and member support programs. from those -- from this evaluation process, the findings on page 4, we determined that the overall infertility benefit coverage is available to all members who meet the clinical criteria regardless of partnership status, sexual orientation or gender identity. another finding was that there was an opportunity for the plans to better assist and educate the population on the pharmacy benefit for prescription drugs used for the treatment of infertility. that would include dedicated care coordination, assistance with locating competitively priced prescriptions, and clarification about the estimated share of cost for all services related to treatment. throughout the discussion, it became clear that kaiser has practices that providers follow

and that are inclusive. and further follow the professional standards included in oversight committees and organizations listed at the bottom of page 4. on page 5, for next steps, we are requiring the health plan provide a response to the vendor performance annual report out which is contained in the appendix of this presentation. this would be to identify any service gaps and commitment to corrective action when needed. second, offer advocacy and enhanced care coordination to members seeking infertility services pick this could be providing either in-house through the health planner through a third party, and then lastly, to provide concurrent reporting to the board of any new infertility policies, programs, or services that are implemented so we have better oversight and to the changes, the impact, and any corrections, updates, modifications that need to be made through the process.

to get to the point, page 6 is the recommendation from us to adopt the following policy. that is that it shall be the policy of the san francisco health service system and the health service board to apply a 50% coinsurance benefit for insemination services for all members regardless of partnership status, sexual orientation, or gender identity as part of the full scope of benefits offered. >> thank you. >> that is what is also outlined in the policy statement, in addition to some other information, with background information on data that is available and not available, that we did make some modifications to the benefit in 2017, and that inclusion of these benefits is recognized today as paving the way for

other large employers to think critically about infertility treatment options beyond traditional heterosexual partnerships, and to promote inclusion and access for all. the second page of the top has the policy objective, which is really looking at the needs of the total population, and ensuring equal access to infertility services. section three is a policy statement that i just read to you that is on the table for your consideration, and the effective date to be upon approval by this board. >> thank you. looks like we need a motion. >> we need a motion before we discuss? >> we have a motion then we have a discussion. >> i move we accept the recommendation as outlined. >> i second that. >> okay. now we can have discussion. >> we got an e-mail this morning from a member who particularly

raised several good points, and i'm just curious to know about the response. i didn't have a chance to address each one, but the first one started with use of the word infertility, and we keep talking about infertility, which has a certain diagnosis associated with it, and the problems that may arise when implementing a policy that is open to all members. so from your perspective, what is the issue around the use of the word infertility instead of infertility? >> director, would you care -- >> we have referred to this set of benefits is infertility benefits. this situation i came to our attention is a precursor to a meeting -- to meeting the definition of infertility, and that is that these insemination services are now available to

same-sex and unpartnered women so that they would be able to receive those services and either become pregnant, conceive a child, or not, and upon not conceiving a child through insemination services, would proceed with the other diagnostic and treatment services that are covered by our current benefit. >> so is it more appropriate to call it a fertility policy? >> this policy statement, i don't know what we call it, but the services are available to everyone. >> okay. >> i hear what you are saying. >> if there are diagnoses that are required for certain services -- >> and we are declaring that it does not. >> okay. >> it is a precursor, so i think

there's some semantics here that we can work on as we describe our different benefits as being the benefit for conception or some other word, because you are right, you are not there yet, you haven't gone to the gate yet in determining infertility. >> semantics matter. >> it does matter. >> you know, i also don't want to get into a long issue about coding and how these things are described, i know we do have a subject matter expert in the room from kaiser who navigates this space pretty successfully to talk perhaps about how they'd recognize this and what they turn almond -- what their terminology is and what the nomenclature is around coding and the naming of the services and the diagnoses. there between the health plan

and the providers. we are sending a policy on what is allowable for our benefits to be paid. there is a little nuance there. >> i think we could try and come up with a different name. i don't know whether fertility benefits policy would be closer or something that takes out the word infertility from the name of the policy. >> in some of the issues were addressing, it seemed important to me. i'm a little uncomfortable voting on a policy were think some of the issues, even though it is? what we call policy, it is not clearly stated up front, and so that is just where i am at. >> would you like to amend the statement at his -- as it is currently written? clearly i think we are on the same page as the intent for the policy. >> okay. , then i will start there. i would like to amend the policy to call it a fertility policy

that infertility benefit policy. >> i would second that with a provision that we stated this way and we are putting quotations around it so we can get clear that that is what we are doing. >> i guess the question is, based on issues that have been raised this morning, which i am not in a position to compare side-by-side, do we have enough information to vote on this policy, and if so, what is the necessity of the timing? can be deferred until we get some -- raise all the questions and address them in another setting? >> we could vote on the policy today and come up with the name at the next session. whether you call insemination policy, i think there are other names that people can come up

with. >> what is important to recognize, and i would urge the board to consider accepting this today, is this is a shift that recognizes that these services were not readily available to all members and now, with this shift, will be more inclusive, i think that is a very important policy statement for the board to act upon and we have had literally hundreds of hours internally working on this and any related questions, and some of the other ones that were raised in that e-mail, and i believe that members just that members here she would like to speak to them, we have addressed , as well because it is this procedure that can take place now, the insemination procedure can take place to help a woman conceive. it was not for a covered benefit i would urge the board to take

action on including that covered benefit. >> that is fine, as a board i guess i just pointed out the issue of the diagnoses and the use of the term infertility was not newly raised today. i think i had heard it, you can correct me if i'm wrong in previous testimonies, as well. it is so basic, and yet, i guess whoever devised all this decided that that wasn't really an issue to be addressed, even though it had been raised. >> the separate issue of what constitutes a diagnosis of fertility and a past practice of requiring heterosexual couples to have had sexual relations for up to 12 months was written out of the policy in 2017. there have been instances where practitioners and providers and health plans have tried to exercise that past practice, which is a problem.

the problem is not with their policy, it is problem with the practice. with this particular case, i know we have worked very closely with blue shield to uncover the problems that occurred in this particular case, and there are practice issues, not policy issues. and shaughnessy from blue shield to speak to what blue shield has learned from this and how they are working to ensure that the practice meets the policy. >> i appreciate that. i appreciate the changes. i think that change me be enhanced by changing the name of policy of fertility. >> to be want to vote as this as is today with the requirements that the next meeting we will perhaps change the name of the benefit? >> we could change it today. >> we can always change it later if we come up with a better name

>> okay, so the amended motion is what again? >> we change the name of the policy from infertility to fertility benefit policy. >> and the motion stands. >> yeah,. >> the motion has been seconded and we change the name of this policy from infertility benefit policy to fertility benefit policy, every time the word in for to -- infertility appeals in the title and the policy. >> okay. do you have that, natalie? okay. is there any public comment on this site and? -- is there any public comment on this item? >> hi, there. name is erica and i am a city employee. i work as a legislative aide to president norman he who has

stated publicly his concerns about access issues of -- along with other supervisors, as well, however because of information that was just posted, he has not had the opportunity to review this. i'm speaking today as erica, city employee. i wanted to thank the director and her staff are there work. i know they have spent a lot of time on this and i want to humbly thank you, commissioners, for listening and taking my concerns seriously. although we hoped that what i experienced, the denial services was isolated, it is not. we all want the same thing, to ensure all members have equal access to benefits without unfair barriers. for this reason, i would like to propose a friendly but necessary amendment. i have four points to make. i hope you give me the time to make them. if the goal is for people to have access, it is critical to remove the word required

diagnosis of infertility, otherwise members will continue to have the same access issues on the proposed policy change will have little actual impact. the diagnosis of infertility recognizes the needs of couples are uncoupled females. this is not accurate. requiring a diagnosis of infertility is exactly the problem. it is precisely the issue i ran into, as would all lesbian couples. requiring a diagnosis unspecified or otherwise does not address the fact that lesbian couples or those single by choice may not have a qualifying medical diagnosis of infertility, but still require reproductive assistance in order to have a family. if this language remains, insurance can and will continue to deny the population. changing the policy statement without changing this part of the policy does not get to the

root of the issue. this can be fixed with a policy offering fertility benefits rather than infertility benefits if you are not willing to do that at this time, please do so with the r.f.p. number 2, the powerpoint mentions that kaiser has a progressive policy that has not denied patients. what is it? is it a checklist, is that kaiser allows not having access to sperm as a qualifying condition? whatever it is, as commissioners , you should incorporate this methodology is a policy and add language to the policy so that it is abundantly clear for both members and contracted providers. my doctor, my physician suggested a code, which is encounter for procreative management unspecified with work , but i am not an expert in don't know if this code would qualify as medically necessary.

number 3, the policy statement. this talks about insemination services. i believe the intent is to cover all fertility related procedures , however, the language of insemination services is very specific as a medical term and does not include ivf, it does not include assisted hatching, genetic screening, retrieval, transfer, and all the other bulleted points listed on the front of this paper. a friendly amendment could be insemination services, i.v.f., and other related procedures. lastly, this would have to do with the findings on page 4. the opportunity to better assist and educate members on pharmacy benefits and restriction services. i was pretty insulted or bothered by this statement.

i don't need a better education, any of the cost of the drugs to not be 40% more if i use my insurance than if i pay 100% out-of-pocket at a pharmacy that is covered by my plan. please know that if there was any other way, no one would choose i.v.f. it is awful, physically, emotionally, financially, even with coverage. commissioners, might ask of you today is to take time to ensure that members who have no other choice have access to benefits without burdensome barriers. again, i truly appreciate the work of the department and the thoughtful space that the commissioners and you have given to this issue, but it is a policy change that is being considered, they should fully address the issue. if more time is needed to find -- finding the language to ensure that it is clear and without room for interpretation, please consider postponing the

vote until your next meeting although the department has been aware of this issue since december, tely has made public statement been verified as a systematic issue. we all want a policy that is equitable and friendly to all families. please take the time to ensure that the language is clear so that the department and as commissioners, you can confidently know that the changes you are voting on will have a measurable impact to members. thank you for your time and consideration. >> any other public comment on this item? >> i am with kaiser. i just want to make a comment to clarify on what kaiser does here , and if you want to come up , and if there's anything that i don't have the answer to, you

can help me with that. we have had a practice in place for as long as we have had the fertility program and infertility program and we do talk about for sale -- fertility and infertility with our benefits. we do not distinguish whether it is a same-sex, heterosexual, single-parent who is trying to become pregnant. we cover all of that and there is no different -- differencing coverage according to each of those cases. and so it is important, i understand talking about fertility, we do talk about fertility within the benefits department and we do not see a change coming to the way that we manage these cases at all. i don't know if there is any other questions about how kaiser handles this, but i'm happy to take those at this time.

>> any other public comment? >> we undertook an extensive review with our partners around infertility and how members access care. we did identify gaps, and some of those gaps were with authorization and denials and authorizations and timing around those. the timing doesn't fit our standard timing practices around standard medical procedures. infertility has a very different timeline for treatment, and so we've adjusted those timelines. in her case, we discovered that it was a physician who inappropriately asked her to get her own drugs. our partners are supposed to get

the drugs for their member and pay for them and then get reimbursed by blue shield. she should not have had to go and find those drugs. the physician should have gotten those checks for her and given them to her. we have addressed that, and we are actively putting in place specialized clinicians that will handle any infertility or fertility authorizations access for service and then we also looked at having one point of contact that will handle any appeals so that we can ensure that we are accurately following the medical policy put in place by the board. thank you. >> any other public comment on this item? okay, we have a motion on the

floor here. does anybody want to add to it or do you want to continue this matter to look at it further? >> a couple comments. i know this is not -- it is borderline legal advice here, so first, it might be better just to call it an insemination policy so we can get away from the fertility issue one way or the other. it is my understanding that this current draft of the policy, there is no required diagnosis for infertility. secondly, we are here to sit our policy for our benefits. we're not here to vote on internal billing codes for kaiser or blue shield. i understand that is an issue, and we have control over our policy, so i think we can take a

look at the document. calling it an insemination policy will hopefully be a reasonable compromise. finally, would be worthwhile if we could get a clarification by insemination services. i think we should maybe try to answer that without question. should clarify what the insemination services include. my understanding is -- do we want to clarify that? >> are those codes different for insemination services? >> again, it gets into a coding discussion. i think what is really important here is the discussion of what services are needed for a particular woman conceiving

between the provider and the patient, and so i am wanting to not get in the middle of that discussion. that is where that decision gets made. >> absolutely. when we talk about insemination, it would not include for sale it -- fertility for males, i believe. we maybe excluding some things that we don't want to exclude, just as a thought. you are absolutely right. there are different codes that are being used, i don't know if you have any more comments. >> there is the female infertility code and there is the mail infertility code.

>> i am getting increasingly uncomfortable that we are trying to draft this policy in an open forum today and i am therefore going to withdraw my second to a motion of changing the title and withdraw the original motion to move for the adoption. i would rather think that we would like to take a moment and go back and given the level of these issues today, assure that we are clear about what is included or excluded in the policy as we are grafting it. so we start with the name and be clear about that, and also the provisions that are being outlined or described in the policy itself. i withdraw my original motion and my second. >> i believe we should continue this matter if we have this much discussion on it. it is almost 4:00 p.m. now.

>> i move that we do for this to another session with a more robust response to the issues and a policy that we can vote on at the time. >> i was second that. >> i don't think we even need a motion, so we will continue this matter to the next meeting or whenever it is possible to get this ironed out. >> we're drafting a policy for our system and not micromanaging their codes. correct? >> all right. >> it sounds like we're trying to borderline micromanage their codes. >> at this point, we are not doing anything, any motion today , we're just deferring this item. all right. okay. now we are on to item number 13.

>> item 13 reports and updates on the contract health plan or representative. >> would anybody like to come forward here? does anyone have any comments? seeing none, any public comment on this item? public comment is closed. item number 14. >> item 14 is opportunity for the public to comment on matters within the board's jurisdiction. >> does anyone from the public of and anything they would like to say? >> i apologize. i missed my opportunity on 13. is it okay for me to give an update now. >> sure. >> i have two updates for the organization. and the first is about a contract that we have reached with c.b.s. minute clinics in states where we are not located. this is an enhancement of our travel benefit. so effective immediately, you can travel.

if you are travelling to nevada, we do not have a health plan in the state of nevada. you could go to a clinic, pay your copayment, they would have accessed all access to all that information, gave prescription related to that visit, and you no longer would have to pay out of pocket and be reimbursed. we've always have coverage for urgent and emergent care anywhere in the world. that has not changed. this is just an added benefit. financially members can go to the clinic and only pay the co-pay and not have to worry about being reimbursed later on. >> thank you. >> say a member loses sir her prescription for medication, is this already coverage, is it included,. >> under that scenario, they would call kaiser and we would coordinate getting them a prescription