what we did here, as we looked at the daily rate for psychiatric emergency services, hospitalization at general hospital, and also jail contact. this does not take into account any reimbursement that we had from medi-cal or other insurance , but we wanted to look at the overall impact of this through our system, not just for san francisco, but at the state level. and this first graph is for psychiatric emergency services, second just for psychiatric hospitalization, and third is for incarceration. as you can see, because of the significant reductions that we have, there are also significant savings associated with them. in toto, there is an 80 3% reduction in monthly costs, which accounts for $430,000 each month. which is a great outcome to have we are hopeful that as we continue to work with individuals and continue the program, we will see this long lasting effects. this is something that we will continue to look at while the state only requires that we submit a report to them on court ordered individuals, it is because we have been so successful in engaging individuals in voluntary services, that as

one is we only have one psych ward in the hospitals, and that's at general hospital. we need more psych wards to take care of these problems. two, if somebody gets arrested and goes to court, and they say yes i will go to a rehab or a center, we don't have enough in san francisco because they case gets dismissed because they agree to go to rehab, and their case gets dismissed, and it just happens over and over and over again. if we want to help the homeless, we need to get more psych wards and more rehab. i really think we need to look into those areas. thank you. >> thank you, dave. >> hello. my name is bob abassi, and i'm a south beach resident. i don't have a whole lot to say, but it boils down to this. we all want the same point, we all want the same thing, but i think all san franciscans have to sacrifice equally. somebody just said it would be courageous to build a shelter here, but i think it would be courageous to build a shelter in the marina. i haven't seen anyone do anything like that. this district has disproportionately carried the load. i just want to se

hospital. robert mueller ordered fbi agents at the hospital to not allow comey to be removed from the attorney general's hospital room under any circumstances. but after that hospital room confrontation, president bush initially decided he would just go ahead with this warrantless surveillance program without justice department approval. it was only when comey and mueller and a whole bunch of other doj senior people threatened they would resign. they actually drafted their resignation letters that bush finally backed down and the program was changed to account for the legal objections to it at the justice department. and that story about the hospital room confrontation, it's a story you may have heard. it has resurfaced in recent years because the players from that drama have come back into the public eye. in one way or the other. james comey went on to succeed robert mueller as fbi director. after comey was fired robert mueller was appointed. special counsel to investigate comey's firing among other things. regardless of your feelings about robert mueller, regardless of your feelings about james comey, i know y

discharge from laguna honda hospital hospital, zuckerberg san francisco general hospital and other san francisco skilled nursing facilities. the target also includes individuals who are at imminent risk of institutional placement, but are willing and able to remain in the community with appropriate support. institute on aging and its subcontractors will provide coordinated case management with a culturally diverse staff of social workers or managers who will conduct the assessment, care planning, care plan implementation, monitoring, reassessment, and discharge. case management is an integral part and a component of long-term care service delivery, and essential to accessing additional services through the community living fund. the program's purchase of services component can fill the gaps for goods and services that are deemed necessary by care managers but are not available through other means. the purchase of service funds are used as a last resort when all other payment options have been exhausted. these purchases can include homecare, home modification, assistive devices, and housing for similar other things. the program's goal is to support community living and r

general diverted 65% of the time. the city has to pay full price for those same people to be treated at other hospitals. 130% of the time last month and the month before, san francisco general hospitalran above capacity. 130% of the time. that means that patients could not be adequately treated in the units they're supposed to be seen in. i.c.u. patients had to be boarded in the wrong area. if we leave money sitting on the table because we want to attract workers, how can we take care of the people that are already here? let's not lose sight of the fact that san francisco exists and will exist. do the right thing. >> supervisor mar: thank you. next speaker, please. >> i'm a resident of san francisco for close to 45 years. i couldn't help but notice that in presentations that the corporations, and the city, what we get from them, is millions, so i wonder -- the huge gap there. i wonder, could there be a hearing that explains to all of us what the community benefit of that growth or that stability of having those companies in the city? what are we actually getting when we can't tax these property taxes compared to what we have lost and will continue to lose? our community, the diversi

at san francisco general. this is our rates. we are looking at a number of other hospitals to benchmark where we are in comparison to those other hospitals to look at whether our pricing is in line with standards. i will note that from a practical purpose, once we put the patient protections into effect, the rates that we adopt will have very little bearing on the individual patient because we set the out-of-pocket maximums. we set a cap on what to bill the patient based on insurance coverage, and because of that the rates really become essentially the primary function of the rates is relationship between the hospital and insurance companies. out of our due diligence we are going to go through with the study to determine if there are areas where our pricing is out of line with the industry. lastly, big category what we are doing, and i won't go into all of these individuals, but we have a number of actions underway to improve the way we communicate with and engage with patients around financial issues. this is one of the things we have noticed through this process. there are a number of situations where a patient receives financial state

hospitals can get from 1 to 5 stars. and generally you see hospitals in the united states falling into a bell curve. so of course we are at the tail end of the bell curve. it is true that safety net hospitals, those serving disproportionate share of medicaid and uninsured patients, tend to be shifted to the left on that bell curve. if you looked at the bell curve of safety net hospitals, instead of the hump being a three, it's closer to a two or below. so, it's not that safety net hospitals could not be 3, 4 and 5, it's just much more rare. so, that's the circumstance. the reason is that the data going into those reports is not adequately risk adjusted. meaning that we have in addition to serving disproportionate numbers of medicaid and uninsured patients, that includes more people who are homeless, more people who have mental illness, more people for whom it's difficult to do well on some of these measures. so, that is, that has been recognized as you correctly state, it's been recognized by the federal government, it's just that c.m.s. has not adequately factored into its rating that that risk adjustment. that being said, it does not mean we can't improvement. and there are measures that

general fund. if our client ends up in the hospital at jones with disco general, stabilizes for a couple of days and then the care manager has a close relationship , visits a client in the hospital that is unfunded. we promoted because it is good care, but it is -- it draws into our general fund for sure. that general fund covers those services and cover services for people who actually are based on eligibility, recent immigrants, for example, would be unfunded and we would cover those services. this next slide to specs -- pixar expenditures. this is a fiscal year 17-18. it is on the slide. we're looking at the total expenditures. the bulk of the services which they call nonpersonal services, 95% of those are our contracts with our community-based organizations, there are some other slices in there within their for our lease payment for city clinics that are not in city-owned buildings, things like that. the salaries and benefits are our civil service positions that i described earlier. material and supplies, pharmaceutical sit in the material and supplies get. you can see our work is such a sliver, the work orders interesting. the new work order with other departments, but most

hospitals who do most of the indigent care. so one of the things we did when we rebuilt our county hospital, i was a swing vote. l.a. at the time, their general fund contributions with five hospitals and with an increasing indigent care population was up to 23, 24%. ours was going in the same direction. so we have tried in california to help the counties and say you've got to cap your cost, be more efficient. my point is, when we get down to 10%, that extra 15% we spend on libraries, sheriff's department, economic development. so that's sort of the color of money. in your experience as a point of sale person, in different emergency rooms, you see people coming in the door, but their costs are all absorbed differently. but the consequences for who pays and subsidizes those costs are also different. could you speak to that on a personal level and then i'd ask ms. collins to also talk to that. >> sure. i think that if you go to different hospitals, people will be paying differently. and the interesting thing about new york, we have a lot of hospitals that are right next door to each other that accept different types of insurance and different types of payments. so there's two hospita

hospitalization, which reflect prevalence, but other factors like access to care. looking at hospitalizations for diabetes, heart failure and hypertension, we see that in general, [inaudible] start to eke pa up when people are 30 or 40. however, against black african americans, rates soar early in the 30s and 40s and rates for black african americans in their 30s or 40s are compared to those -- others who are 30 years older. in fact for diabetes, rates are higher amongst young black african americans than they are for anyone else. at any age. [please stand by] -- it's lower than the rates seen in california overall or the healthy people 2020 goal, young adults, low-income residents and people of color and men are disproportionately affected and have not seen the same gains. low-income residents are twice as likely to smoke and men three times as likely. and a survey of new moms reveal while rates have decreased and the rates are relatively low, black mothers are more likely to smoke before or during pregnancy. and while the rate of cigarette use amongst san francisco high school students as well as is 4%, there's a risk of nicotine addiction as 27% have used electronic smoking devices. overall the rate of binge drinking among high school students is 8%, however, the rates vary and 25% of white students binge drink. marijuana is very prevalent with more than a quarter of the students reporting smoking and, again, that rate varies based with 40% of latin and almost 60% of black african american students smoking marijuana. and 11% of high school students report using -- abusing prescription drugs and 8% report using methamphetamines and other drugs. again, similarly, the students most at risk are black african american, latin and white. mental health including substance use is come know and help may be hard to get. 23% of adults report needing help. 7% of adults report psychological distress and that number is three times higher for low-income residents. depression is the most common mental health condition with the number of hospitalizationseeding that seen for hypertension or asthma. and the rate of hospitalization increased 20% between 2012 and 2016. rates of hospitalization are highest among young adults and black african americans and the tenderloin and sonoma neighborhoods. and depression with pregnant women have consequences for both the mother and baby and 14% of pregnant women report depression. and women with only a high school education are three times more likely to report depression than are women with a college degree and 25% of the lower income mothers experience depression. and among sfdu high school students, 26% report prolonged sadness and 10% report suicide ideaization. rates are higher amongst the middle school students with filipino and latin students having especially high rates. while not shown here the rates are elevated amongst students identifying as bisexual, gay or lesbian. violent crime rates are high in san francisco and rates exceed those seen in california. crime rates and emergency room vi

general hospital. the higher than anticipated census, which has been an issue that we had last year and this year as well. more patients at the hospital than were anticipated in the budget, as well as more payments under the maddock -- medi-cal waiver. they are pay for performance kind of programs where it is the hospital meets the performance targets in terms of preventive care and patient outcomes and patient satisfaction that may become eligible to receive money from the school. the hospital has just been better on the metrics than they anticipated they would, and they were able to drive more of that revenue. that is what is really driving the revenue increase in public health, which is really the other, the biggest news that we have in this report. human services, there are expenditure statements. a lot of it is caseloads being lower than they anticipated, under spending on contracts, and a couple of other things, and just the third item i would note is the war memorial. this is an unusual surplus for them. they have sold transferable development rights to a product developer that means that they have the rights to develop higher

i have trained at san francisco general and the standard was we work on the tough circumstances and we get better care for these hospitals. when you sentiment out of the hospital or an emergency room, great fear is you are making the mistake and they are going to come to harm or die. i don't think when a patient just says i'm ready to go they accept that. these doctors are too good. they are here, they care too much. the real solution to this, i think, is in intensive outpatient case management. it was distressing to hear that 24 -- 20% of the slots are vacant. you need to raise their pay, you need to double their number, and you need to make a real effort to implement this program. get on the street and help those people, and that will bring them home, and you've given us great examples. thank you. >> thank you. >> next speaker. >> hello supervisors, i'm a mental health advocate in san francisco and also a mental health client. i would like to say yes when the police do 5150, they do handcuff you because i have been a victim of the handcuffs and i also would like to say, i have been that person who has gone and been that revolving door going back and forth, b

at that time was not what it is today. it was more of a caregiver. they did less technical medical things. workers wereal hospital stewards, cooks, general laborers and matrons. when the hospital was first established in 1862, most of the andks, the laundresses nurses were african-american. while the majority of those in positions of authority were white. this was typical of most black-on the hospitals. black-only hospitals. there are not very many photographs that identify these were nurses and contraband hospital. some of the imagery you see are there to represent other african-americans worked for the army in similar capacities. edward was the white surgeon in charge in alexandria virginia, that was specifically to treat black-only patients. the appointment of alexander augusta, he was the first african-american surgeon in , 1863. appointed in may when he was appointed, it began a shift in the racial makeup of the hospital staff. with blacks taking over leadership positions from , african-american surgeons and assistant surgeons were either commissioned military officers or private physicians under contract with the army. their appointments represented the first time that a

hospital. >> but i'm -- i'm not talking about a state hospital. i'm talking about where melanie would go first. so that, i'm assuming, are either the healing center at st. mary's or the 7th ward at general. right? >> well, we have more than just the healing center as a lock sub acute. we have contracts with behavioral health and they have them throughout the state. we place people at crestwood vallejo and the healing center. we have another one in movado. each of the different programs have different sort of a focus. so we try and match up the person's presenting need and trajectory for wellness with the facilities. >> so okay. i didn't realize they go out of county. >> we have the san francisco behavioral health center and we have rehab as well. >> i didn't realize we're sending people out of county. that's a whole other issue. so we're saying for someone like melanie that there's anywhere -- you said anywhere from a two-day to a three-month wait? >> i would say for somebody like melanie, it would not necessarily be a long wait simply because melanie's trajectory is straightforward. for her to be accepted would be streamline because of who she is and how she is currently presenting. >> so she would have a space at one of the san francisco based locked facilities? >> yes. >> but that takes away a stays someone else who needs it and has to wait three months. >> the people waiting three months, are they waiting for the healing center? >> they are probably waiting for any lock sub acute bed that's able to accept them. for many people waiting three months, it may be they had a recent assault and so it makes their list shorter because now they can't go back. >> they assaulted someone so they are a harder person to place and melanie is not one of those -- >> exactly. >> she's not hard to place. >> right. thank you, kelly. under sb-40, it's -- what would happen is that immediately there would be a temporary conservatorship, and melanie would be placed under potentially up to 28 days in a locked facility. is that correct? >> during that time, once the conservator is in place, we would have the authority to move her to an appropriate facility. >> okay. so under sd40, but not under 1045 before getting her before a judge? >> during that time, she would have -- actually, i think captain pang was referring to dr. -- and dr. bland referred to the hearings in the court. she would also have the ability to work with her public defender and there's a probable cause hearing that occurs at sf general. >> okay. and so -- >> during that time, the conservator's office di is not - we don't have a role in those hearings. my understanding, the treating psychiatrist presents evidence as to why an individual -- it will mirror lps and the treating psychiatrist would need to demonstrate how whoever is on the hold meets the criteria that's set out in sb-40. >> so sorry. the way we get around getting melanie to court, which is a big problem under 1045, is that the treating psychiatrist puts her on a temporary conservatorship under 1045. >> this is under sb-40. >> so to be clear, the idea is to mimic pretty much exactly how it works today under lps. someone, on th seventh 5150, thy would be eligible. within that 72-hour hold period on the 8th 5150, they would have a probable cause hearing that would make the determination as to whether to grant a 28-day conservatorship. so today, under 1045, that procedure doesn't exist. sb-40 mimics the procedure that is well tested as part of lps. so that's the -- >> gravely disabled procedure? >> so it's a probable cause hearing. so basically, the judge determines based on the criteria established in 1045 whether or not an individual qualifies for that temporary 28-day conservatorship which then allows for the actual court proceeding on the underlying conservatorship to happen within that same period of time. >> okay. what i'll just say about this part and then i'll move on is that i really am worried about capacity in the system because if sb-40 passes, we're talking about a significant number of people. i know that pes is on divergence 37% of the time or it was in april because it is at capacity. i know that the ward at general was at capacity in april. mostly because we can't transfer people with a lower level of care was we don't have capacity in the rest of the system. this is a comment. i have a lot of concern about capacity in the system. >> they're in the system already to be clear, and then today, one of the reasons the mayor announced that she is investing in the 30 dual diagnosis beds is really to unlock that flow. so this is -- that is the investment that can best target and create space across the entire portfolio. >> i would just say that i do feel like you're offering contradictory assertions quite often, and i saw it in your report as well. you're saying they're in the system and using the services, but then you're saying they won't use the services. so it is an inte an ininherent contradiction. they're using ems services. i don't dispute that. they're not using the services that lots of people voluntarily want to use and can't use because there's not enough in the system. so that is a major, major concern of mine as well. just a few more questions before i open it up to public comment. now, most people admit this is about meth users, that 1045 was designed specifically for meth users. i know that supervisor men treated a task force and it's met one time. i'm wondering why we're creating an intervention for meth users, why we're not letting this task force do a very important job, which i really appreciate it and maybe this is a question for supervisor mandelman of coming up with interventions that might work with this population before jumping to this intervention. >> whicwell. >> well, we have a crisis. there is an emergency. i've done an tour of our system and talked to folks in our public health system and providers with our community based nonprofit partners, and it felt to me i was having one-on-one with them, that it would be useful to have them in a room talking to each other about ways to streamline processes, work together, ensure they're the right hand-off when people are leaving psychiatric emergency services, that there was a lot that could be done. this is a task force that's going to meet four or five times over the next couple of months. it's not going to be a permanent part of our infrastructure, but i'm hoping that it will be useful in coming up with better ways for the system to work. i don't think that has any necessary bearing on whether this particular intervention, this creation of this additional type of conservatorship is a good idea or bad idea. >> okay. i have a few -- just a couple more quick questions. i want to understand a little bit more on what's been offered to people that they have refused. this comes from two experiences. my own experience that i talked about with alice where she refused to accept any services we got a housing placement for her with the help of barbara garcia. she didn't want to come inside. we got her inside using a volunteer in my office, ann, became friends with her and started taking her under her wing. she visited her every day. she developed trust with her. she knew her favorite foods. she knew her whole family history. she knew what motivated her, et cetera, et cetera. and so after getting to know and developing trust between annn ad alice over a month, alice agreed to come inside. we got alice inside, and she was diagnosed with breast cancer that was stage 4 because she hadn't gotten medical treatment. she died about a month later. right? what worked with alice wasn't the conservatorship. what worked is someone taking the time to care about alice, taking the time to get to know alice, and taking the time to understand what makes alice tick and convince her to come inside. that was a huge learning experience to me about people who are very, very, very, ill like the people we're talking about here which are a relatively small number of people. that worked. now i want to tell a story of another individual. this was actually told to me by a social worker at st. mary's who works with conserved individuals. this individual was someone that everyone knew, spent time on van ness from pacific heights to the chinatown area. he's a melt user. he's someone who drove everyone crazy. you will a the neighbors complained about him constantly. there was a twitter feed about him. there was a blog of frustrated neighbors. probably because the city and the supervisors and the dph and the police and the department of homelessness were so -- got so many complaints about this individual, once again, in an attempt, a case manager, including a former director of behavioral health took this person under their wing and got to know him and convinced him, without a conservatorship to come inside and get into treatment and get into services. when we're talking about such a few amount of individuals that are so sick, i'm wondering, have we really ever tried what we tried with this individual who drove the neighbors crazy in pacific heights and what ann tried with alice to get them inside, or have we said, high,,, very sick person, you can get treatment and case management, et cetera, and then they just refuse. i want to understand the flavor of what we've offered these individuals. >> supervisor, i really appreciate that because i think the importance of the relationship is incredibly important, and it's exactly what we do in assisted outpatient in building those relationships and trust. you know, i could talk to you about melanie's case in particular, but i want to share in my experience with assisted outpatient treatment that we engage individuals for a minimum of 30 days before we consider filing a court petition and, again, we have clinical and peer navigators. it's that whatever it takes and whatever it takes approach and meeting people where they're comfortable, finding out the foods or coffee they like and really building that personal relationship for them. a lot of ways, that's really successful. then there are individuals where despite that were still unsuccessful. although that is a really important part of our system, it's something that we know is important, that we have increasing dollars dedicated to peer-based services to accomplish that and navigate peer specialists to do that. for somebody like melanie, i can share that she has been engaged -- not only offered case management everybody social socd for a period of time. that attempt to build that relationship outside of placements that she's been at, which we would talk about that also. she's also been somebody who we've worked with through assisted outpatient treatment. we've had the opportunity and the flexibility to engage her in that way. but unfortunately, despite those efforts and building those relationships, we're still unable to engage her in voluntary services. >> okay. okay. thank you. i appreciate that. two more questions, and i swear i will end and open this up to public comment. maybe this is a question for director krasinski. i was just wondering, i know that there are about -- the statistic i've heard and -- tell me if i'm right -- is about 150 homeless people die on the street every year. is that correct. >> it's higher than that. it's closer to 200. >> closer to 200. okay. and of those 200 people, how many of them would fit the criteria under under 1045. >> i don't have that data. dph gathers that data. i'm not sure they would know with the data they've collected. >> okay. the reason that i'm making this point is because we have a crisis. we've a major crisis in san francisco. if 200 homeless people are dying in the streets and they can't get voluntary placements because we don't have enough in the system, i don't know if we can say that some people are more grave than others given that there are 200 people dying in the streets every year. so the fact that we don't have enough capacity in the system, i'm not trying to be difficult at all because i want these people to get help as much as you do, supervisor mannedle man and as much as you do mayor breed and all of our city staff. i just -- i have to know that someone else that's critically ill isn't going to get bumped or taken off the list, and if 200 people are dying in the streets, that's something that is deeply, deeply concerning to me. anyway, that, i think, is just a very, very important point. thank you so much. >> thank you. >> okay. and with that, there might be more questions at the end, but i'm going to open this up to public comment. if any member of the public would like to speak, please do so. you can line up over here. i will call -- i will call some names. sasha bitner, george bachi, sidney wright, kevin o 'shae. feel free to line up. >> ever.every speaker will haveo minutes. mr. wright, did yo can you stars off? >> i'm going to be her interpreter. >> i'm speaking ohi. i'm -- can you hear me? she says hi, i'm sasha bitner and i'm speaking on behalf of senior disability action. she says, i'm in opposition to sb 1045. she says, and implementation in san francisco. she's opposed for a couple reasons. one is because it's a civil rights issue and you can't take away someone's civil rights without a very, very good reason. she's afraid that it will go down a slippery slope. she says it's unclear as to how it will be implemented and if it will be effective and they're lacking basic information. she says finally, she doesn't think police officers should be making these decisions and determining whether they're eligible for conservatorship in the 5150 context. she says there's so many issues with police officers. we don't need them more involved than they already are. thank you very much, and now you get to hear from me. i'm representing independent living resource center, san francisco, as the community organizer there. we are proud members of the voluntary services first coalition led by senior disability action and the coalition on homelessness. you'll hear today from many of our colleagues in the voluntary services coalition, and we stand in strong opposition to the implementation of the bill as when we echo many of the concerns brought up by supervisors on the committee and we appreciate your very thoughtful deliberation on this issue. as sasha said, we're concerned that it may change the interi action between folks with -- that would fall under this and police officers given that they now have this involvement and the power to 5150 folks. also, it's just a basic self cil rights issue that one shouldn't take away basic civil rights from folks and make independent decisions instead of focusing on this very narrow population. we feel that we should be expanding voluntary services and give more choice to folks. thank you. [ applause ] >> thank you so much. >> thank you to my colleagues for letting me go ahead of them. my name is claudia. i'm with the disability rights program. i'm here to speak in opposition to the proposal. i want to make three points. first, i want to say that people referenced earlier today the closure of the state psychiatric hospitals. i want to make clear that the closure of the state psychiatric hospitals decades ago did not lead to or cause our current homeless population. those are different populations. the state hospitals housed a different population similar to our nursing home population today. it's sort of a trope that the closure of the hospitals caused our situation today. that's not accurate. our situation today is caused in large part by drastic cuts to the federal government support for housing, the fact that ssi has not increased at all with inflation and regional and global trends around income and ennuyee quality. that's my first point. secondly, i think we offer reliable intervention services. what we don't reliably voluntarily offer is a bridge into long-term supports such as a path to step down beds or to long-term permanent supported housing. we have a bridge to nowhere, and that's going to cause people not to be engaged with services. my third point is that the state law as well as the america

hospital. >> but i'm -- i'm not talking about a state hospital. i'm talking about where melanie would go first. so that, i'm assuming, are either the healing center at st. mary's or the 7th ward at general. right? >> well, we have more than just the healing center as a lock sub acute. we have contracts with behavioral health and they have them throughout the state. we place people at crestwood vallejo and the healing center. we have another one in movado. each of the different programs have different sort of a focus. so we try and match up the person's presenting need and trajectory for wellness with the facilities. >> so okay. i didn't realize they go out of county. >> we have the san francisco behavioral health center and we have rehab as well. >> i didn't realize we're sending people out of county. that's a whole other issue. so we're saying for someone like melanie that there's anywhere -- you said anywhere from a two-day to a three-month wait? >> i would say for somebody like melanie, it would not necessarily be a long wait simply because melanie's trajectory is straightforward. for her to be accepted would be streamline because of who she is and how she is currently presenting. >>

hospitals who do most of the indigent care. so one of the things we did when we rebuilt our county hospital, i was a swing vote. l.a. at the time, their general fund contributions with five hospitals and with an increasing indigent care population was up to 23, 24%. ours was going in the same direction. so we have tried in california to help the counties and say you've got to cap your cost, be more efficient. my point is, when we get down to 10%, that extra 15% we spend on libraries, sheriff's department, economic development. so that's sort of the color of money. in your experience as a point of sale person, in different emergency rooms, you see people coming in the door, but their costs are all absorbed differently. but the consequences for who pays and subsidizes those costs are also different. could you speak to that on a personal level and then i'd ask ms. collins to also talk to that. >> sure. i think that if you go to different hospitals, people will be paying differently. and the interesting thing about new york, we have a lot of hospitals that are right next door to each other that accept different types of insurance and different types of payments. so there's two hospita