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Instead of having your Diabetic Management Program happen through Insurance Company x, it is now happening through Venture Capital backed technology organizational wide. For hospitals and providers area and, i mean, an example of a disruptors telemedicine. Finding the opportunity, if you are a telemedicine organization to say we know individuals are not getting as much primary care, or at least lets say in that moment of need, it is 2 00 a. M. , child wakes up crying, you know, holding the ear. The telemedicine organization would say we are going to disrupt by not just assuming that persons should go person should go to the emergency room at 2 30 a. M. They can use their smart phone to patch into a physician who, with some information, can look through the phone, possibly prescribe an antibiotic to help the child because of a probable ear infection. Those are a couple of examples. I think it is disrupting in both ways. I understand the impact. I guess the word is weird to me. But anyway. The only other point i would make is the integration and collaboration to changing Healthcare Delivery. It is a more value based my challenges to understanding, and we hear all this information about where the United States falls in terms of Healthcare Delivery and how poorly we do in terms of many other countries. That doesnt really say how we are doing in the Health Service system and using those same parameters. Are we number one in the world compared to norway, sweden and those countries that do well . I think we seem to be mixing the National Healthcare agenda from what our agenda should be. That is the challenge. This is really looking at a bigger system. Thank you for those comments. On page ten, so leaving from this discussion we show here highlevel spectrum of design and contracting strategies. You see the words at the top, simple on the left and complex on the right. We classify on the more simplistic side helping to guide people you see a couple of examples there. Whether they are Transparency Solutions are hightech navigation platforms. The support to help individuals navigate an extremely complex healthcare system. In the middle, we say insight into emerging network solutions. One example is platforms that they have two rate providers. Have identified provider designations. We can talk all day about their methodologies. The highest level of trying to collect combination of cost and quality information on Services Providers that are delivering. And how the health plans collect that information and make affirmations. You also see in the alphabet soup of healthcare comments li like, Accountable Care organizations. We focus on that a lot with blue shield as an example. The blue shield hmo platform relies heavily on their partnerships with for instance the Health Physician group, and their partnerships with Dignity Health. This notion of primary care medical homes. Taking an advanced view of how primary care physicians can guide a patient through the healthcare system. For a types of services, centers of excellence strategies. On the more complex side, taking an advanced view of local contracting strategies that could include things like incentive designs. Instead of having in network and not outofnetwork or there might be different layers. Referenced base pricing. For Certain Services, lets say knee surgery, your setting a certain price by which you wont reimburse over that. And if the patient decides to go to a lower cost provider, you know, having access to quality data as well as their selection, that could be fully covered. If someone chooses to go to a very very high cost provider they may have to pay for more of that service themselves area direct contracting. Certainly that is always on the mind of sfhss. Looking at opportunities to consider direct contracts. This is something we will want to think through, you know, pause it as we develop the questions around the rfp. Specific to helping people navigate the system. Helping decide what may be the best approach to Network Based strategies. On this slide, where would you put us now . You do a little bit of each of these. I would say more in the middle, because that is where we focus especially with the Accountable Care organization platform. Thats been the primary focus from a blue shield standpoint. I would say from akp standpoint there is probably elements across all of this, certainly from what you provide within sfhss itself, the support you do provide two members certainly fits into that high touch advocacy. The fact that people can call, and visit the office on the third floor, and receive support with sfhss, with guidance on their needs, certainly as an example of how that is being t to delivered today on the left. I think we also challenge the health plans to think through as a result of this rfp, how can we elevate this aspect of their service . They are all providing it to some degree today. I think it is fair to ask for an elevated level as we roll out the expectations of the health plans. Actually eking i welcome abbys comments as well. Sfhss the degree that we might be taking the first step with the guiding people. Insight to emerging. To take as an outcome. Are we really trying to step back and say we want to use all of these tools . I think we are evaluating all of them, at this. What we are learning more how to do is to really measure quality so that we can pay for quality. Regardless of the outcome we pay the same price. How we design that, i think a few months ago we were here from catalyst for payment reform. They and the group on health, the National Business group on health and many others. Whether it be for certain kinds of cancer care, joint replacement. Those types of things. [please stand by] we cant look at our robust data base, i think, and make those determinations. There are some best practise examples around the nation of purchasers that are doing these practises and pacific Business Group on health has a model of centers of excellence that its a model that is worth looking at. There are some areas where these measures are in place and we certainly can consider how to do that. So could you kind of we want to get to the point where the since this is about our members input today we want to make sure we get to that so maybe condense some of these and point out the high points. Ok. I will just hit keys on each one. On page 11, just trying to show that theres been annie involving the Market Assessment has evolved so the process of looking for vendor partners and what we looked for in the 80s is different from what we look for in the 2000s and the 2010s currently and then looking into that future is really, as we roll out the r. F. P. Thinking about current as well as future and making sure were set up with the right partner to achieve those. Page 12 is kind of saying similar message to page 11 and so with the evolution, we need to manage costs and away want to maximize value for our membership across our five strategic goals. Page 13 we recapped our five strategic goals because those are going to be core components we want to consider as we move forward. On page 14, moving into ideal state, we framed this around the triple aim to minimize healthcare costs and improve population, health and then optimize the member experience. We have several key statements we want to focus on and weve captured a lot of these and some of the conversations that weve had so far today. Of course cost is going to be important, costs to the system. Cost to the member and making sure we understand that and were using money wisely. Improving Population Health and recognizing we have a diverse population with varies needs and making sure theyre getting the right care at the right place and time. Integrating with communitybased organizations and social services that third bullet and weve had a lot of conversations about social determinants on health and the impact of that on our membership help. Thinking about the person and how were integrated with Community Programmes available. You talk about our population and everyone we have is in the city or county or School Director it has attention or retirement so it isnt like the general public for social determinants the way i see it. It isnt people that dont have means or dont have a job. I mean, when you talk about social determinants, in our population, what do we have . We may not have the severity of our uninsured population but we have concerns of seniors living in isolation, persons whose pension sounded good at the time and they retired and perhaps is inadequate today. And theyre making choices about food and drugs and all those types of things that people are making choices for. Its important that we recognize that and attend to those needs where they exist. Do we have any idea . How many people we have like that . General population . Im going to carry because we did with the retiree survey and we asked questions about good security and of those that responded at least 2 indicated that they dont have adequate food and thats of those that responded so it was a red flag that we need to delve into deeper into that. Its one stat i know off hand. There are other good questions we should be asking to determine the need. Its vague to me. Its one that is really kind of well understand and theres San Francisco Food Security task force and theres a lot of experts on that and it really points to that question that you dont have adequate food and you are having to make decisions on whether to buy food or pay rent or whatever. You have to make decisions around food for most of us that are we have resources, its really not a question. Its more about food choice and its not about whether or not you can afford to buy the next meal. Also, social determinants goes beyond economic. It goes how far do our members have to drive to get healthcare . What is their Family Structure . What is there religious or ethnic background . What is their their sexuality. There are all kinds of social determinants that we have to address beyond simply the economy or economics of healthcare. Quite frankly. We can imagine that our employees who have to drive 90 minutes in each direction to get to their jobs have very different requirements in terms of what we can provide and should provide than someone who can walk across the street to their place of employment. I dont know how many people would do that. So we have to think of a very broad scio logical stance. Meeting with the wellbeing champion at police department, theyve described to us to our community what the officers are doing before and after work and the long shifts and the stressful work and when do they have time to take care of themselves . And those are really important matters that come into play and to have a direct impact on health. They are. But theyre things that cant being changed a lot of the times. They cant change it if someone has to drive two hours to work. You cant change their culture. These are things that you can talk about but, you know, how would you influence them . It isnt so much of trying to influence it its a matter of recognizing there are factors that a person is engage in that do in deed impact their need to be and their use of the healthcare system. Over a period of time, long commutes a commute is a commute but over time it may stress that person out. Not having sufficient time to exercise. So on and so on. Its really a construct of saying here are other factors that, in your everyday living, which in deed impacts your health or your ability to use the healthcare system. Thats true of a lot of things. Whether you can do anything about it thats a question. Its a matter of recognizing which of those factors there are and and could they be undressed by something that were doing in our Health System. Thats the question. Exactly. Right. Its where we have opportunities to meet people where they are and what their needs are. Just the third item on this page 14 is optimizing the member experience. So always wanting to keep that in mind to make sure that care is convenient, coordinated. Weve talked about advocacy and navigation previously. So those are all underlying components of what we want to look for in an ideal state. I want it to be noted inoperability is on every page. Can you spell it . Its not appeared once. We have that on a word search. [laughter] all right. Page 15. Again, just considerations as we think about the ideal states about the current relationships that we have. I am going to talk a little bit about this slide because it will feed into what well talk about later. Looking at what we refer to as health plans. So health plans being blue shield of california, United Healthcare, so the carrier or insurer that are interchangeable terms. Looking at Health Systems, so, kind of the delivery systems. There are programmes such a as s canopy, anthem, and merger of Dignity Health and integrated plans systems. Examples could be kaiser which is a fully integrated system. Cchp is a health plan and a Health System and then sutter of course has their Health Delivery system and their health plans. So, again, we have a lot of things that well look at. The Network Provider and facility contracts data and inter operability. A range of connection points so looking at inperson virtual and tele health opportunities. Support staff to meet people where theyre at. So with that slide we come to a section break so i want to pause for a minute and we have thrown a lot at to you see if there are any other comments before we move on. Id like to go back to slide number 12. After that. Where you have the table of slide 14. So id like to focus more on that and look into the consideration on the r. F. P. Coming forward and we have discussed the items. The ideal one is to minimize healthcare costs and optimize member experience. Id like to have the members take a look on that slide as we move forward and ask questions because you have a lot of mergers and everything but what really drives us is really to minimize healthcare costs, improve the Population Health of the members and the member experience. Id like to go to that slide. Thank you. All right. So mike will walk us through some concepts for consideration and well get into this model. So slide 17 illustrates a model construct from a spectrum around care coordination and management at the top. It is correlated with cost the at the bottom. You can see the highest cost tends to be associated with models where you have a minimum amount of care coordination and management happening. Contrast that cost contend to be optimized where you have more of them happening. So, from the left side of the page, the open system approach so the United Healthcare p. P. O. Is an example of that. So no surprise its the highest cost plan on your platform. As an example, theres an out of network availability, which helps to drive that. The pricing with the hospitals and positions tends to be discounted fee for service. There is care coordination and management but not as i would say inter operable as you have so even though that word isnt on the page i had to throw it in. That is true. Its true of the other models on the right and more individual driven. When you get into kind of the little blue box organized systems of care, what you have in the middle with the Accountable Care organization or Patient Centre medical approach its basic with your blue shields plan with discounted fee for services but Certain Services, like primary care, subject to fixed costs, where theres incentives for those providors to guide care in a certain way from a quality perspective but also from a cost perspective to kind of maximize the financial benefit to the partners through the ca model to deliver a certain set of services. On the right side, the staff or the group model. Kaiser is a great example of that. So much of what is driven we put capitation in quotes so you are playing a flat rate for everybody. That delivers the financing that kaiser needs to deliver on care coordination and management to the organizations. This is an example of what you have in place today. With some examples of which each of the systems delivers in their care approach. When we talk about the network models, so, network only is commencerit and you will see with the foot note on the network is for Emergency Care only. Services are delivered inside a network of physicians and hospital and other practitioners that are contracted directly with those plans. Ra additional, that would be commence rit with the United Healthcare today, p. P. O. Where its delivered in the network and theres the opportunity that the member has to Seek Services out of network. We talked about industry jargon but a tiered Network Place out nicely. Within the internet work framework you actually have a significantment within that of High Performance where the cost of the member for services would be less if delivered by a practitioner on the High Performance circle than the network. You can see examples at the bottom of the page that might be High Performance. You dont have this in place today but it could be an avenue persuade going forwarpursued gof this process. Im not sure of the term advance primary care practises. Primary care practises i am but advanced, what does it refer to in this future model . To me, i think its more of the concept of cap tated typically, even the primary care physicians, all physicians are reimbursed fee for service. The idea is you may have a certain subset of quoteunquote High Performance practises that may be willing to take on capitation to deliver their Services Within the framework of that network construct. Its similar to the presentation that we had on primary care medical home that some of the university documents did for us. This is an emerging term and the advance primary care where they actually, theres a emphasis encore din eighting wit on coordinating and ucsf just got annan award and managing the special care consultation that advance primary care that practises can do so Specialty Care Office Visits are often very difficult to get. Its a management of Specialty Care by primary care. Theres other avenues that advance practises are able to achieve better outcomes. As a retired kaiser physician, i can tell you how referrals work now. They all carry cellphones and when the primary when a patient is in the primary care office and they need a specialist, the primary care calls the office and the three people now interact. The member, the primary care and sub specialist and often times if their employment is if more tests are needed theyre organized at that moment and if a followup appointment is needed its at that moment. If its an emergency or one down the line. To me that fulfills and theres consult system. We put kaiser into the network only and so i think if were going to use these terms, we need to not pretend that they exist only in one set of contracts that they will be able to demand this from all of our insurers frankly. I think. Because some people may argue that were already getting some of this even though quoteunquote its in the future. I totally agree with what you are stating. On page 19, we listed out other components of models. You can see down the left side categories or elements of the models and what those mean and what examples are so i wont go through this page. You can see were going to focus on type of organizations and how the funding works, how the point of cost or how cost works appoint of service and network construct and these are some examples that weve displayed here. On page 20, well focus on carbon versus carve out and deliberations leading up to the r. F. P. This gives it the point of maybe caution to bring up the word disrupt or a gun and the carvein approach kind of assumes the carrier or the insurer is doing everything from a program standpoint and Everything Else and carve out shows willingness to possibly bring quoteunquote disrupters into the process if theres a sense that common examples. You can see some terms here that we use just to give greater definition and that is the general concept of whether to consider additional organizations to fill what might be gaps in the system through strict carbon with insurance administrators. There are core components and we like to call it blocking and tackling. The fees you pay. Making sure the access to providers is maximized for members. Theres minimal disruption of members and we want to consider those members outside the barrier area on this as well as those in the barrier area. The vast majority are here in the bay area and lets not lose sight of that retirees that live outside the bay area. And beyond that, challenging that and innovation and their ability to shape outcomes elevating what were going to seeking in terms of guarantees that organizations place behind their promises in the f. R. F. P. The price of admission is just commitments on delivering outstanding claim payments service, outstanding performance with their call centers, et cetera. And performance guarantees. Looking at the funding. At the end of the day, what you spend here is obviously critical element of what wore going to be evaluating across organizations and the r. F. P. Part of that is well look at exitinexisting models and alters methods that could come out of the r. F. P. Analysis. I would like to just suggest that we realign of couple of these lines. The Service Level agreements are a core component to whatever were seeking for these plans. Were way past the point where we should even be considering a plan that doesnt absolutely have a minimum level of Service Requirements so it should be in column one as kind of core to whatever were seeking in terms of its relationship. We shouldnt be spending our time trying to figure out a plan is. [ please stand by ] alternative funding methods could include, we talked early about Certain Service delivery. That could be an element going back to the chart that we looked at earlier where he may have surfing types of specialties or Services Within the work of your composition that you would like out in that way. Ideally constructing financing mechanisms with provider groups especially with Accountable Care organizations that have a two way element to it. Not just incentive payments, if a partner delivers betterthanexpected. Also mechanisms by where there may be payments due, if performance from cost and quality perspective falls below expectation. Fully insured and selfinsured is looking at opportunities to build payment mechanisms within the insurer and administrator environment but perhaps down to the environment level to mimic more of that value based care approach. Im not advocating this. When we talk about centers of excellence, one could imagine that we decide as a Health Service that we want replacements done at one center of excellence. We carve out for all of our insurers, you will be doing none of our knee, hip and joint replacements on all of our members will go to one place and they will get an x number of dollars per year to do all of the joint replacements. They will agree to 15 million. Three hips or 3,000 hips. Im but that is the kind of thing that i think people are considering in terms of the centers of excellence. Im not advocating this, just saying these are the things that are on the table. My offbase . No. What we is a huge variation in cost and outcome. When you are paying exorbitant prices for more outcomes, there is something wrong. That is what we need to aim to correct for. Again, im sorry, im taking too much time. I know you want to move this along. If we are considering such a wild proposal, then we go back to our insurers and say prove to us that you are providing, with all of your providers, not just the top two, but with all of your providers, for all joint replacements that you are providing this level of care, and show us that you have that information. That is the big challenge. Again im not advocating it. Im just saying this is within our responsibility if we are going to be considering this to go back to the insurers and ask for data. We are not getting that now i suspect. I will skip this again, again member focused looking out the interactions with the carriers on providers and how we think about that as we go through the interoperability and data integrations. Page 24, summarizes the models we have talked about today. There are an infinite number of models, we focused on five core models that we want to throw out there, as options, as consideration refinement. I think i will just go straight into them. On page 25, i will orient you first. All of the models look the same, putting the member at the top, their perspective, but the questions on the left. What are my choices with open enrollment. Under the current model you have your kaiser plan, blue shield access plus and the United Healthcare healthcare ppo plan choices at open enrollments. You can see where you seek care, where you are primarily staying within kaiser. There is a footnote that this is general information, Emergency Care is treated completely differently. You have your and network only providers and hospitals under the two blue shield plans and then any provider for hospitals under the ppo plan. Your cost share will vary for in or out of the three carriers on the left are yes, and no under United Healthcare ppo. Lower cost generally for those three lefthand side plans with your deductible and coinsurance on the right. And then for coordination of care, kaiser coordinates with you under blue shield with your primary care provider. No plan interruption. However, that second bullet, the ppo sustainability concerns will continue under status quo. That last bullet, having the three separate carriers managing the claims, it limits the ability to negotiate you hc and spread the risk along the non kaiser plans. When we have them split up into three buckets of claims, blue shield, United Healthcare, we are managing and negotiating those all individually. Versus trying to spread risk. What are you saying . The more plans you have the less you can negotiate . Generally. The more players you are negotiating with, when they have a smaller population, that is assumption that makes it more difficult to negotiate with the carrier on that plan. Say we had ten carriers, for your population and, you know, thats extreme, you know, but a couple of those carriers dominate the population and then the rest are just split up amongst the other eight carrie carriers. If im carrier h and i have 500 employees covered, im not going to be quite as willing to negotiate as someone who might have 5,000 members. Im not sure if im explaining very well. Competition usually, is not for the benefit of us. Its for the benefit of the insurance companies. Say for instance, for the medicare population you have two carriers for kaiser and United Healthcare which is something, they dont want kaiser, they only have one option. This year they came with a 17 increase. Appreciate your focus about the medicare, this particular comment is focused on the non medicare population. The concept is United Healthcare has only 3 of their members so there negotiating with you on behalf of 28,000 2800 members, i dont have that particular viewpoint. While United Healthcare has been a good partner in negotiations and we have achieved some negotiation savings along the way and certain elements. United healthcare perhaps is not able to bring a degree of focus on this particular group, only because it is 2800 members. That is the idea of this statement of this bullet. This particular organization is negotiating based on what their world is with us at sfhss. If you had another ppo for competition for this, you would be in a better negotiating position . Potentially. The only difficulty is, then you are losing leverage with each individual partner, the fewer lives they have. To me its the concept of who has the bigger stick. If you only have 2800 lives that is not a big stick for a provider across the country that may provide care to 3 million, or 5 million or whatever. Our 2800 doesnt factor much on the bottom line as opposed to more other plans where we have 50,000. We have a bigger stick in terms of our ability to negotiate, because if they lose 50,000, that shows up on a Balance Sheet much more than a teeny population of 50, or 2800. Thats the way i see it. They keep going back to how expensive the city plan is. Blue shield total cost last year for early retirees was more than it was for the city plan. If the city plan is so expensive why is blue shield more expensive. The cost is higher, the premium is higher. You know, something is wrong there. Could be utilization. But, the premium is the premium. It is based prior experience. The population that is being covered. That could be a factor as to why premiums are going up. We have to look at that. There are many components that go into that. The size varies. The question now is enhanced current models. Page 27 this is essentially the same as what we have today. Adding that bottom row which i put in red so it will really stand out there. That is trying to bring a layer of resource for membership as they navigate within the three plans that are not kaiser. Would not be considered a carve out thirdparty services . Yes. Again, it retains the current structure of the designs and creates an enhanced member advocacy navigation. Page 29, kind of the same concept we had before. Except that last bullet. Bringing in a third party we would want to consider the data interface about thirdparty with the health plan, or the acos. We are trying to change that relationship with the provider. We are trying to enhance it. To promote know this may be a heart stopping question. How would this Group Interface with our existing staff . The third party . Yes. It would become a new contract that would be managed by staff at another resource. As i understand the way these thirdparty advocacy Navigation Services work is they help you figure out where to go next and how to resolve communication issues. Instead of a virtual solution like many of these Digital Solutions are, these are a real person solution or somebody answers the phone and they really know your plan and how to navigate it so they can help you figure out where to go next for services and if there is a problem that is where the interface with our Member Services would occur. Because our Member Services resolved issues with these people and has Clinical Knowledge and can guide you and navigate you around the system. They become of the hub and spoke to differ out to different programs and that is what i have ended on with the messaging. If theres a program that is not available, or provided by blue shield it is something that the Health System is providing. That person could also say, did you know sfhss offers this, which you provider may not know that you have access to the service. Its creating more comprehensive communication as well. Are there such organizations that exist now . This is something i have delved into a little bit. There is a couple of them that are well known in the industry. One called quantum. I attended a workshop last march where i was learning about them. They have actually been around for about 20 years. Theyve got quite a track record and have gotten more Sophisticated Technology wise. Its a lot easier to log into the systems that tell you what plans are in place and what your benefits are and they can help you navigate. Its kind of like you and i probably doing this all the time for our friends and family, tell them how to navigate a healthcare system. All of that kind of advocacy navigation stuff has been package, if you will into a service, from what i understand from other purchasers that are receiving this is really an excellent customer service, and it also helps in Patient Outcomes and that you get to the right place at the right time. This is a small component of this. Were talking about services, may be physical therapy or something that they are not getting, there may be other components. Most physicians have a 24 hour, you know coverage, and a lot of these physician groups have 247 coverage as well. If you remember, i think they are providing more and more this level. , at some point because this may actually go away. My ideal world it would. It would be necessary. Also from the consumers perspective. These are people that they will not mind bothering, or they dont mind bothering. So, how does this work with. [inaudible] [inaudible] raise a good. That we were going to avoid the word. Treo has an advocacy Navigator Service that they call concierge . It is developing a service very much like this, it is well recognized the systems of care that are not fully integrated and even sometimes when they are fully integrated. Patients need help figuring out what to do next or where to go next or can i get this . You raise a good question, we would have to look at it in that light on whether it is useful or necessary. These are ways, what we are putting here before you are ways that weve thought about and a highlevel way of advancing the Current System that we have, because the complexity and fragmentation of the systems that we have is a big problem. What im looking for, because with United Healthcare, on the third line. For United Healthcare you dont need [inaudible] you still have to go through your medicare physician. That might help you navigate, but you still have to go back again to your primary physician. [inaudible] the way i understand it and these fully sanctioned advocacy services, you give them the hippo permission and all of that to act on your behalf so they can help you with some of this connections

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