Transcripts For SFGTV Government Access Programming 20171215

They worked in h. S. S. As far as an outsideer could see. There was an additional robocall that did cause further confusion and the noise hit the target, there was definitely confusion and reaction to the letters as well as the robo calling and dis enrollment during this period from the trio plan. At the same time, we need to recognize that sutter is a partner as well, just not in the trio product at this time and we appreciate what they provide on the access plus. We do have some lessons around communications and our letters really predominantly focused on primary care physicians and they could have focused for the hill and all the other trio providers , it was going to be the same. We really focused on p. C. P. Because that was the logic to develop the letter list so thats a Lesson Learned for next year. As a result of that, not identifying that we did lose 800 members that theres no reason that they would be in access plus because theres no difference between what access plus and trio for them and as far as network the only difference is that they have a look contribution out of the paycheck but they elected access plus still so thats an opportunity for the future and it would have been nice to have better control over sutter it was amazing control over sutter but the city was able to perform and perhaps we should talk to them earlier next year. We need to better understand in the future the complex relationships our provider partners have with other partners and that could there could be more that we havent thought of so i just wanted to be honest about that and we dont think there is but we didnt think these were coming up. I just want to be honest and transparent and where we would like to continue this to be very flexible and collaborative and working with the provider partners and h. S. S. In the event something ups and another observation is do we do auto enrollment again for those people for which the only difference would be a lower contribution so its just a thought. Its a question that they wait and explore all kinds of autoen roll and not discovered and whether we want to engage in that process again its really i think something that prolonged discussion and i would expect there would be some necessitys to bring forward if we decide to mh370 of this that direction and some engagement of this board before we make the final decision and. I wasnt look forgeron a decision. Thank you. Does anyone have any questions . Commission commission sheehy. I did find it confusion and i know a lot and i think identifying a specialist problem i still havent figured that out and the web sites are not very good on a i wasnt clear whether my primary care physician was in the network or not and i was one of those who was delighted because ive had trouble, i was at ucsf before here and shes been my doctor for 20 plus years and so at one point i was paying her out of pocket because when you create those relationships you want to keep them but so i think really a lot more clarity and a lot more ability to identify whether the various providers if you are like me and you have complex heath needs that would be helpful. If you are thinking about the ucsf fees was under sold and a lot of people, i know myself i was excited to be able to really be able to have my doctor and uc sf access so you might start earlier and work with ucsf talking about that relationship and again i have a buy as because i worked at ucsf but i think a lot of people in town recognize the excellence of that institution and so that is the main thing. I just these things, i mean i know a lot, ive been doing this for years and i really found it a couple of times i was completely confused and almost slipped back because i thought i lost my primary care physician because the information wasnt able to be accessed and like even when you go to soy went to get my flu shot as people have identified and also to do the enrollment and talk about trio and it wasnt really easy to get the information like one person looked on the screen and said my doctor was not in trio and another person looked on their screen and said that my doctor was in trio and so that level of confusion i didnt talk you are reminding me. We had another there were lots of nuances i didnt mention but i recall there was a lot of provider confusion at the open enrollment meetings and so brown and toll around again, they customize this network and protocols just for h. S. S. And they had representatives at the open enrollment meetings who didnt fully understand it and we did hear about that because fortunately they are right next door to each other so we mitigate it but it did impact some people so that was a huge lesson to learn as well. Thank you. Other comments from commissioners . Yeah, from members i very much exactly what is said. And especially there was a meeting over here at the hotel, there were two meetings there i believe and people i know and the members said they were more confused after they left than when they got there because they did get a different story from brown and tollhappened than they did with blue shield and i dont like the auto enrollment at all and i wonder who is going to take the burden of putting these people back in when they go to their doctors and find they cant access them. Will blue shield be doing that work or will it all be on you . So, after we end open enrollment and we send out a confirmation letters changes permitted are Administrative Changes and administrative errors . People can appeal anything and we do handle those appeals in open enrollment and we always get a lot of appeals after open enrollment so theres an appeal process if someone wants to move back in to access. The reasons that we would do it outside of appeal for some reason we demonstrated an address issue, a Mailing Address issue because that was one of our Key Communication is the mailing, a second one would be an issue about continuity of care if someone is in the middle of treatment. Other than that they would need to send an appeal and it would be reviewed by h. S. S. First and according to our member rules after that if we up hold the denial they can appeal to the board. What was the last thing you said director griggs . The first level appeal is handled by h. S. S. And if we up hold the denial, our own denial then the member can request to appeal to the board at the second level appeal . All right. There shouldnt be a lot of communication putting people back to the access plus because a lot of members did not opt for this and they find this out and otherwise the board here is going to be inundated with appeals there was an appeal letter already here from a member who said it appears compulsory as i did not effect to make the change nor was it clear i would need to check the blue shield access so that the enrollment wasnt clear and i cant imagine how timeconsuming its going to be for staff and everyone if you would have to take these back to the board and i mean, if these are honest mistakes, and theyre not gaming the system, i just dont think it should put a lot of extra work on anybody and it should just happen because, i had two other people that were automatically enrolled and each one of them, their husbands and children had ten different providers and i dont know how you can plus infusions and they were automatically put in to this trio also so i mean, it seems to me like its going to be a lot of this issue. Right. As far as the provider 5,000 have no change and this is more than 5,000 so half of them have no change at all and the other half would be the brown and toll en and they have a change in hospitals so for that reason there was a robust marketing and Education Campaign around that including multiple phone calls to every member and of course we had a lot of members call us and custom mailedings whether theyre enrollment resulted in a Network Hospital change or not and then informational sessions as well as open enrollment meetings so there were significant attempts to and that doesnt again to talk about the Electronic Communications so there were significant attempts to educate all members on what the changes meant. As far as infusions, transfusion s, now theyre going to go for an infusion and they wont accept you, now you have this date set up and thats a big deal. Yeah, that is if people are in the midst of treatment they would continue on with those same providers for that treatment. Commissioner. I mean i was just having been trained at ucsf and attempted to practice there early in my career and then having my career in fee for Service Practice with myriad contracts my medical group had multiple contracts with every provider in the city and then half of the time at kaiser i think i have some experience with this and im saying the complexity overwhelming, i mean i know my own former colleagues what kind of contracts they have with sub specialists and its just amazing to me that this could be navigateed easily or quickly and im surprised that any Sutter Foundation primary care provider had any contracts because they have because they have control if theyre not foundation documents, that said, the percentage of what you call missed opportunities switched backout and speaks the fact that members were alerted to what was happening and had the had sometimes people see the glass as 10 full and they sent out letters further pulled members what was happening and should have raised some red flags for those individuals so it seems to me that i had a major concern about auto enrollment and i think that actually the result was encouraging despite some individual experiences and really i do think the sub specialist issue was predictable and we talked about it here and hopefully you can navigate through some of that. Its always difficult. I like your perspective. If i could add anything, im glad you brought up sutters robocalls and that letter, i spoke about it in the report. The one issue that we definitely made sutter agree on is the only people that would get this communication are patients of the Sutter Medical Foundation so werent auto enrolled to begin with. The 10 that we didnt agree with was one word in there that they were giving members direction to select access plus and so when that i think what went wrong is people had that letter and came to the office and talked to their coworkers and that word the mouth and the word spread, emails spread but the commercial communication between sutter, as far as my knowledge, because i agreed on with sutter to the Sutter Medical Foundation patients and we didnt autoen roll those. I was consulted as part of that process and pushed it in the letter as well. So, whether we do this like process like this next year or not, to me its a subject that needs to engage us early and so that we can get some sensing about the results of this year because were right now just doing it and weve made the journey across the bridge and we have not traveled further so the consequence is ahead of us so thank you for your report and are there any other comments or observations from the board . Well expect follow on reports as we go forward. Is there Public Comment on this item . No Public Comment well go to the action item 6. Clerk item 6, action item. Presentation of audited Financial Statements for fiscal year 20162017 and 2016 and kpmg director levin good afternoon good afternoon, pamela levin Financial Officer, we had to make sure everything was set right. Who do you have in your company . We have a presentation. I want to first turn the presentation over to the kpmg auditor, this is gi walee and we worked with them for several years and shell talk about the audit process and i will quickly give a overview of the Financial Statement. You might find it for someone to sit in the chair and assist you so you can maintain eye contact with us here. Ok, yeah. Thank you. Ok. Good afternoon, everyone. My name is key wa lee and im an auto manager for kpmg so im here to present the Financial Statement auto results for the fiscal yearending june 30th, 2017. So i have in front of us the presentation so lets go down the first slide. The most important slide is the auto results and you can see that there is a result of our audit and there are no uncorrected or corrected misstatements and weve issued a unqualified opinion with a clean opinion and there are no issues and control noted during our ought i had. Im going to add emphasis to this. Its always an audit speak and i just wanted to be on the record that you found nothing outside of the audit expanders that would cause a question about how the funds been disbursed, managed or controlled during the course of this year is that not correct . That is correct. Theres nothing that we found. That is deemed to be report able to the board. Thank you. Ok. Ok and going through the next couple of slides these are required communications that presenting to the board so the first one called the management over of controls so this is a re but the able and this is the fact that across all entities theres some risks associated with the management override of controls so its part of our audit procedures and we are required to have procedures in place to evaluate from the control of substantive area if theres anything that deems to be a warrant that there is control and as a result you can see on the presentation that theres nothing that came about that everything resulted from a procedures that warrant any type of communications to the board. Ok, moving onto the next slide, this is also a, what we call a significant risk and this is basically just that we as auditors have to do more diligence to make sure that the significant risk has been mitigate. This is related to the blue claims reserve. It is a significant risk because its an estimate with judgment involved coming up with a liability for the june 30th and from our procedures, we have from a control and substantive area we have looked at their liability with involved our own kpmg action so look at the methodology and what goes in to the liability and nothing there were no exceptions noted at the end of the day. All right, moving on next slide, the significant account practice s so its been very consistent year over year and these are actually presented in the Financial Statements under note 2 where management has actually reported like all of their significant counter policies and as a result of our task work, they are in accordance with general accepted counter principles and consistent with our practices. Ok. Onto the next slide, these are the required communications and other matters that we as auditor s are required to report so no concerns from management and i know there was a change in some management but nothing that can warrant any problems. Management has been helpful and cooperative so you can see on this wonder wonderful slide theres nothing that needed to be worrisome or any concerns at this point. All right, the next couple of slides very worry but its basically to kind of communicate what management is responsible for and so managements responsibility for the presentation and preparing the Financial Statements and making sure that there are controls in place when theyre preparing these financials. And then the next slide is just kind of more responsibilities making sure that the Health Service board your responsible really for the oversight of the controls over Financial Reports and that is the proper tone at the top and because we do the audit financials it doesnt release the management or the board of the responsibilities when prepared these Financial Statements. Last couple slides are our kpmg responsibilities so better responsible for doing, planning and performing the audit, conducting our audits in accordance with professional standards as well as forming and expressing opinions over the financials. And a communicating to management and the board of any significance issues and concerns very last page this is also just responsibilities over over the m dna and its something that we dont issue opinion on but we do perform limited procedures and it is a required supplement in addition to the Financial Statements. And mdna is the Management Discussion and analysis. Thank you. Yes. And that is all for my presentation. Were you the partner that led the process a year ago. I was the manager. Did you find the same high degree of professionalism and cooperation you found the year before present this year . Yes, yes, management consistently performed really well and very cooperative. All right. Thank you. I just wanted that to be on the record as well. Thank you. Just one quick question. Yes. Some adjustments that were passed from kpmg . No pass auto adjustments. Thank you. And now i will give a high level overview of the Financial Statements theres a lot of detail theres provided and both in the notes at the beginning and the Management Discussions so i will just give a real quick high level because i know we have a tight time line so the trust began 20162017 with a balance of 68. 6 million in net assets and end of the year with a balance of 72. 5 million. So thats a 3. 9 million increase and the primary reasons for that is a 9. 2 million decrease in City Health Plan net position as you know, we continue to subsidize the rates in order to bring them down and make them affordable. And then theres 13. 1 million increase in the net position that 6. 9 million for the blue shield and 3. 7 million for the dental plans and . 8 million for the healthcare sustain ability fund as we know as the 3 and. 5 for flexible spending and 1. 2 as the Interest Income performance penalty and forfeitures. There is a outline in the presentations towards the back that item eyess for the performance guarantees and penalties and forfeitures and there are obligations as weve discussed and reserves against the net assets and they are 45. 3 million against the 72. 5 million and theres a explanation in the report but essentially its 22 million in contingency reserve, 19 million in stabilization reserves, 3 million for the healthcare sustain ability fund and as i mentioned, theres 1. 2 million for adoption benefits basically its im looking at the timeframe from 2008 to 2021 and as you know weve been funding the adoption benefit through the performance guarantees. And i provided some other information in the report for and i the first thing is at the end of calender year 2016 there was a combined total of 14. 1 million in the stabilization reserves for the city plan and delta dental. We have used 7. 7 million of that for 2018 rates and what is available for the future years is 6. 4 million and that is in delta dental so essentially we have a decision by the board to buy down rates using the complete amount in the stabilization reserve. Theres also a comparison of the investment earnings performance guarantees and forfeitures between the two years and so there was a total decrease there the total decreased from 1. 18 million in 1516 to 1. 16 in 16 and 17 and that was a lot of increases and a few decrease so the increase 113,000 and forfeitures 263,000 and while the performance guarantees decreased 396,000 and that reason of that decrease is not because were not collecting performance guarantees and its not due to inadequate controls that we have in our contracts, we got, in 1516 we received two years of performance guarantees and 1617 we received one year so its very strange comparison so i wouldnt be concerned about that. The next steps are Financial Statements were issued in october and we have hard copies at the office, soft copies are Available Online and then the comprehensive annual Financial Report that contains us as a portion for the citywide report is due out some time in december and as we expected as i expected the going between the Financial Systems has resulted in some additional work that needs to be done by the controllers office. That ends my are there questions regarding the audit from cfo or the Financial Statements . Any questions . I would like to recognize my staff who worked very hard on this. We have uri, he is our guru in the finance areas working with the audits and Elizabeth Salazar who is back in the office continuing to work providing a lot of work in terms of pulling up the financial information, its a team effort between my whole team and were to get this done and maintain the proper controls. Again to you and to your team on behalf of the board i want to express my great appreciation for the consistency, thoroughness and professionalism you brought to your work this year and its continuation of what youve been doing in the past. We thank you for that. Thank you. Is there any Public Comment on the audit or Financial Reporting . If not well now move to our next item. Clerk item 7, discussion item, hss Financial Reporting as of september 30th, 2017. Pamela levin. Chief Financial Officer Health Service system. The report that is presented to you today goes through the trust fund and the general fund through september 30th, and then does a projection through june 30th, 2018. Again, any projection that is done in for throw months and annualizeing it has the opportunity of having large swings during the year we do our best for little data, the trust balance at the end of june 30th, 2017, going in to this year, it was 72. 5 million based on the activity through september 2017, the fund balance is projected to be at 67. 3 million as of june 30th, 2018. This 5. 2 projected decrease in the trust is primarily caused by subsidizeing the rates for city plan and unfavorable experience for most city plan and blue shield flex, the use of the healthcare sustain ability fund to fund the budget of expenditures and the use of performance guarantees to fund the adoption sur gough see assistance plan and pharmacy rebates for blue shield and favorable for delta dental self funded plan. New performance guarantees have been received for this fiscal year and as i mentioned, we had the 113,000 for the last fiscal year and no pharmacy rebates have been received this year and i just wanted to let you know the status of the adoption surrogacy adoption plan, we have paid out 47,000 since its inception of january of 2017 and theres one application that should be out the door in the year near future and the feedback we have gotten on that plan is really good. In terms of the general fund, at this point with three months of data we are projecting well end the year on budget. Questions. On the Financial Statement thank you s. There any Public Comments on this idea . Thank you again director levin. Hearing and seeing no Public Comments well now at the risk of all that is sacred, we are going to take a recess of about 10 minutes so if you please mark that clock on the wall, it will say 322 when you should return. Well stand well take a discussion item number 8 and as a prelude to this discussion item this is our crystal ball session at best. So please. Thank you, item 8, discussion item legislative item and excise tax, juan anderson, good afternoon. So i who do you have with you . Ive got mike clark and he will present half of the report and i will start us off and i cant read a crystal ball and you may be following its changing hour by hour and our deck is outdated already and one is just a legislative update on the items that we really do know about and then the second piece is as it relates to aca the things that we think are still in play today and has a shorter term horizon which is the cadillac excise tax mike will review so based on just this morning news, we know that there is a new tax bill, theres broad agreement on the tax bill and we do not have the details of it but we do know that one component is repealing the individual mandate and so i will talk about the potential implications to employers sponsored plans because of this repeal and as you may already know on tuesday the house proposed a new bill which is outside of the tax bill its linked to the government funding bill theyre going to vote on on december 22nd and they are proposing several delays and suspensions of taxes so one would be delaying of the cadillac tax and another year so right now its supposed to go in to effect in 2020 that would push back to 2021 and there are medical device taxes being suspended. I will make a note though because of what is happening in the senate if you were watching the alabama races on tuesday as i was glued to the tv, we do obviously have change in potential power and voting in the senate and as we know today, senator rubio is a no on the new tax bill and theres controversy that senator collins made and that puts that that puts it in play as well and senator mccain is in the hospital so who knows is basically what i am going to say today so with that, im not going to go through each of these in detail but hits the highlights so on page 2 clerk we have a presentation. On page 2, just looking at the senate currently 5246 that will change to 51 and 47 once doug jones is sworn in to office after the new year. I do want to move to page 4 so this is the house bill before they came up with the broad agreement that was Just Announced earlier today and obviously the individual mandate penalty was in play under the house bill and that is off the table now given that we do know theyre going to repeal the individual mandate and then the h. R. Bill also holds the cadillac tax in play so far and then theres a number of other changes to tax treatments that we dont know if theyre part of the ultimate tax bill so im going to skip through that and well move to page 6 the senate bill. And so the first bullet is repealing of the individual mandate that would be after december 31st, 2018 and so this essentially zeros out the tax penalties and there is potential implication to planned sponsor program so we anticipate that there would be more uninsured of people under this program they have destabilized the individual and it cody stabilize and continue to destabilize the market increasing premiums and people would be uninsured so the uncompensated care cost would go up and generally when we see that happening theres a shifting of those costs to other payers like employersponsored programs. We do anticipate should this be in play that there may be increase enrollment in things like cobra under Employer Sponsored Programs and there may be situations where planned sponsored have to look at their strategy around part time employees or pre 65 retirees that were relying on the individual market that they will bring in to an Employer Sponsored Program so those are the major implications of the individual mandate being repealed. There are a number of other tax treatment changes under the senate bill but again, we dont know if thats going to be in play for the final rules so i wont go in to any of the details there. This one does theyre silent on the excise tax so were assuming the excise tax is in play for 2020. So if we can then move on to slide 11 which is Trump Administration and some of the executive order and then the potential impact so on page 11 is ending the costsharing reduction and that would obviously have some impact on the individual markets and that is the deal that senator collins had worked through with mitch m cconnell in terms of delaying or paying for the next two years of the c. S. R. So we dont know what will happen there. Just to clarify again, this is a wire educational moment. These are payments that are made to the states or to individuals . Individuals. Individuals who are covered under the a. C. A. In terms of buffeting them from the actual costs increases that they would find in the individual market or going to the exchange or what have you . Thats correct. So they have an income level of x and if its x and therefore you qualified to have moneys paid on your behalf. The costsharing. So you can attain coverage. That is correct. All right. So we do know enrollment is open right now and the enrollment has been robust but the Enrollment Period is narrower this year than in the past so ultimately it may be lower than it has been in past years it closes this friday. State exchanges have a longer Enrollment Period so for example , california has a robust state exchange and we may still see enrollment there so we dont know what will happen there but its been robust so far. Then i want to move to page 13 so as part of aca there were specific employer requirements which are listed on page 13, 14, and 15 and i just want to make note that sfhss is compliant with these requirements from an Employer Perspective and weve considered all of these components in the 2018 rates as they are impacted. And im going to turn it over to mike starting on page 16. Good afternoon, mike clark. Im going to speak with current state of the excise tax, it is due to be implemented in 2020 but theres uncertainty as to whether it will go in to place whether the i. R. S. Will release the guidance that we need to support understanding whether a particular employer has exposure to the excise tax and we offer guidance to employers to start thinking ahead on modelings and weve done that and we have early modeling to present to you today on behalf of the system plans and also just some understanding of where we think it is today but understand that there is a lot to be clarified here. So, real quickly on page 17, the excise tax was original ledue to the implemented in 2018 and the way the a. C. A. Was written and certain thresh held for cost that would apply in 2018 and direction on indexing so lets flip ahead a couple pages to talk about where things stand today based on on the december 15th legislative update so page 19. So late in 2015, there was a tax cut in spending package that deferred the excise tax to 2020 and didnt necessarily change the presumption toward a plan would have be subject excise tax and there were indexing adjusted and we can see her on the bottom of page and the line that which if a plan is more expensive than that, for an active employee it could trigger tax and just a hair over 29,000 for family coverage. Were going to show here on in just a bit the specific forecast ing that weve put together for one year and ten year for the systems plans and there are some assumptions here, the cac does outline the option to blend similar situated pre medicare and medicare retirees and so at this point weve interpreted that as blending within a specific administrator s plans so this will come in to play when we look at the differentials between lets say united heath care versus kaiser versus blue shield plans going ford. So slide 21, a lot of numbers here on the page, what you will see in the first column are the various plans. And the second column to go with that, whether theyre for active employees, pre 65 or early retirees, or post 65 retirees, you can see your tier structure but for purposes of the a. C. A. They look at single and family coverage so you see the estimated enrollment based on what we knew for 2017 this is not reflective of 2018 open enrollment results. You can see our projected 2020 estimated coverage cost for each of these programs and then as you move farther to the right, weve projected for each program the year that based on the assumptions we know now, that particular plan may cross the threshold and its different forgiven plan between single and family just based on the cost of those programs. The bottom line is, there could be excise tax exposure as soon as the first year this is implemented if it remains in place for 2020, specifically for the blue shield pre 65 plan but again we may see guidance that comes out that allows us to blend completely across pre 65 and post 65 coverages so we would certainly incorporate that and you will see from a tenyear present value, so factoring in rates of discounting that there could be as much as 190 million of exposure over a 10year period from 2020 to 2029. Again, i please caution that the bullets here at the bottom of the page show here are for purposes only these estimates are subject to change based on pending guidance and regulations we have anna appendix but it contains further assumptions if you are interested in reviewing. So at the end of the day, there is exposure for the system but were tracking carefully the progression of what could happen , legislative leon the excise tax and at this point in time, this is our best forecast. Questions from the board . You know, when this came out a few years ago, i dont know who presented but i was under the impression every plan would go over the threshold except paper it was kaiser but this looks different, not the same to me. I cant speak to the projections from a couple of years ago but i know that we are blending pre 65 and post 65 programs for like carriers and this analysis that could be a source of difference from the projection a couple of years ago ok. And you have nothing that tells you in your own professional network how this tends to be trending at this point . This issue . I think the general thinking is a delay could happen and we certainly know that at the time where these were last presented a couple years ago, that particular point in time there was the thinking that no matter how things turned out on the 2016 national elections, there was a consensus that excise tax was something all parties wanted to see deferred and its been attached to various healthcare repeal and replace bills over the last several months in 2016 and just nothing has passed that contains and as juan spoke about , theres a new piece of legislation in the house that could defer at one year. So either 2020 or 2021 the current environment, something will happen and for us it will cost 7. 5 million based on the assumption that you are making . And again, that is correct and i would caution theres a lot we need a lot of Regulatory Guidance to actually perform the real calculations. Understand. Understand. All right. Director levin, did you have something to add . I just wanted to point out that the decisions youve been making over the years looking at how to make things more affordable, to reduced rates to try to i mean any of the decisions weve made in the last three or four years has brought this down and has had an impact so i would like to congratulate you guys in terms of decisions that are trying to limit the exposure. Thats duely noted, thank you for that. If i might add, we are being proactive with aeon and looking at potential solutions for this if it comes to fruition as early as 2021. Were having regular meetings and theyve been very good meetings so were proactive and we will bring you and the board some things to look at as action items for 2020. Other questions from members of the board regarding any of this . Again, thank you for the headsup and look in the crystal ball. Any Public Comment . Hearing none and seeing none, thank you very much. Well go on to discussion item 9 clerk item 9 discussion item summary of wellbeing program data stephanie fisher. Hi, i have a presentation. All right. And do i understand that theres representative from kaiser to present a portion of the diabetess program . I asked for some back up just in case you had questions that were above my head. Would you bring that person forward and introduce them, please. Certainly. Jennifer kristen son earns from Kaiser Office of innovation im going to say. All right. So i just wanted to have you at hand, ok. Please. All right, this is a long presentation and it has two parts. The first part summarizes the general well being data and request to a previous meeting goes in to the Kaiser Research study would you like me to briefly give an overview of the first part of the presentation or skip. Is that presentation in the directors report. Its all one report. Its all in this item. Ok, all right. So ill go briefly through the first part and then spend the majority of the time on the diabetess research and prevention study. Fine. So slides two and three take you back to the research that we started with. So when we started this program we looked at research for how can we see how wellbeing impact s our cost and productivity and that was how we laded on the wellbeing because there was research that said if this well being score was higher your costs reduced performance improved and absenteeism is improved and what is exciting when you get to slide 4, that is our data so for the first time we have our data showing that folks who took the wellbeing assessment, those that had higher scores had significantly lower claims than those who had lower scores so if you are wellbeing is low costs are higher and if your wellbeing was higher, your costs were lower. That is what you are seeing in slide 4. We talk a lot about what can wellbeing do for us and the original wellness plan talked about costs and it talked about quality of life and productivity and performance and when we talk about costs, there are certainly costs impacts that wellbeing can have but cost impacts that wellbeing cant this and this board certainly is presented with issues all of the time that increasing your physical activity, being a healthy weight , things related to your wellbeing arent going to change the cost of drugs and the cost of products at certain hospitals and things along those lines so theres some things we can do and some we cant. What you see on slide 5 is really looking at how much of our cost comes from those risk bands and 72 and a half percent of our population is stable and they account for about 14 of the cost and then you have two percent of our members who are accounting for 40 of our costs so we can work to keep the people in those low areas low risk through well being, and keep that 73 of our population in that low cost area we can definitely keep that there and help there and in terms of offering wellbeing programs but that 1. 9 of the population that is driving 40 of your cost the odds of increasing their physical activity are improving their diet or getting them tie healthy weight probably isnt going to have a huge impact object those costs so its important you understand where wellbeing can impact and where it isnt as effective so that is the point of slide 5. Again, going back to our data just to show you that this hypothetical researchbased project that we started is actually seeing that in our data so here with you those in our population who have higher wellbeing scores theyre more likely to get their preventative screenings unless theyre super high on the wellbeing and they start off again so those folks might have a little bit of a untouchable concern so its that just before that highest range where theyre accessing their Preventative Care at the highest rate. On slide 7, this is self reported days off so this is someone who is off a lot could say theyre not off a lot but you say the same exact thing and as the wellbeing score goes down the days off goes up, right , so that is what the research said would happen and thats what were seeing in our population. Slide 8, slide 8 is a little harder to read and so there were questions at the end of the wellbeing assessment that asked folks of the following factors which impacted your ability to be productive at work so it wasnt actually taken in to account in to the wellbeing score so you can look at their wellbeing score on the productivity measures so what you see is that people who are reporting that they are less productive because of these factors have a lower wellbeing and it differenters so a lot of people are saying that they have too much to do and that is impacting their ability to be productive. And that does have a detrimental effect on their wellbeing bringing it down to an average of 67 points, our over all average is 74 so it brings it down a bit. So there are other factors like depression, problems with your supervisor that when people report those their wellbeing decreases substantially more to 53 or 54 so lots of different factors impacting productivity but they impact over all wellbeing a different level so lots going on on that slide and its very interesting. A lot of opportunities there for us. Slide 9, just dont look at it for a second, just listen. Its a little bit of a mess but basically theres research that looked at is there a single cut point. So theres the score out of 100. Is there like hey if you get over this one point all of a sudden theres a big increase and that research showed that that one point was 7 a or higher so what i looked at was in 2014 what percentage of our population was at 75 or higher and then how did that change in 2015 and we went from 50 at 75 or higher in 14 to 15 and that is a big jump because it has significant i am fact impacts to healthcare costs according to the research and so our average score only went up a couple of points so we had a big chunk of the population shift in to that safer zone of over 75. But what is driving your wellbeing score up and what fast factors