Consideration, i think it would be most helpful to our membership. Absolutely. And do apologize for the miscommunication during open enrollment. It was our intent, we had started conversations with january to try to get ahead of this, and it was slow to respond once they notified us of building their own network. Commissioner follansbee one point and request for the future. One point, how does brown and toland update their open panel list of primary care . Is it updated every day . Every month . And how do members access that . So brown and toland update the health plans weekly with changes as in terms if a physician based on the policy qualifies to close their panel, then they notify us and we notify the health plan of that change within a week. So we send it out every week depending on when they send us notification. The lag would be about two weeks. And then the burden is on the health plans when they load it. We can also there is a phone number there for Member Services and that is updated realtime, so a member can call Member Services and we know realtime, if a physician is open or closed. Commissioner follansbee can we ask for maybe an update on this, maybe in february, how many if we identified 49 i believe, and how many of them either left and went to access plus and how many were successfully able to within a window find a new primary, so we have sense about the process for future . Because this will happen again. We know this. I think thats a great idea. I know its a constant juggle for everyone to know who is on what plan on what day of the week. I think the other thing, i would enjoy working with brown and toland and the other physician groups on, not just are they open to new patients, but are they truly available. Because thats especially when there is diminishing number of primary care, we are very interested in supporting primary care practices, because its the core. So wed love to continue to work with brown and toland and other groups on that matter. Happy to come back. President breslin thank you. Im going to defer anything else because we have a guest here from kaiser, so i want to respect the time. Ets up its up to the president , would it be okay to defer the Financial Report for the kaiser conference care . President breslin yes. Are you finished with the directors report . Yeah, im finished. I have one followup matter but we can take it later. President breslin okay. So were going to the item number 9 now. Right . Yes. Out of order, item 9, complex Care Management presentation presented by dawn ogawa. Hi, kate kesler, area Vice President for Kaiser Permanente. Wanted to thank you all for having us back to discuss complex Care Management. We have one of our physicians here. Ill let her introduce herself to you all. And dawn ogawa. Thank you so much for inviting me and to those in the audience as well. My name is dawn ogawa. Im an obgynhe assistant chief overseeing health promotion. We wanted to continue the conversation we started in the last Board Meeting and based on questions about complex Care Management. So i wanted to start with the focus on the broader approach to managing the care of our members with more complex cases. And i wanted to touch briefly on how complex Care Management is core to what we do as an organization and how we have invested in tools to support this work, like the Electronic Medical record. Id also like to focus on the experience of our Kaiser Permanente members with more complex conditions in the outpatient and inpatient setting and what were able to achieve through this care. What can our members and Family Members expect if they have a complex or catastrophic condition . You see here on the next slide, a general overview. We placed the patient purposely in the center here with the support system around them. Our members have the benefit of awardwinning disease management programs that give them comprehensive range of integrated tools, resources, and services. So what makes Kaiser Permanentes approach different and successful . First of all, its proactive. We use Clinical Data drawn from our Electronic Medical record. The second and very importantly, its teambased and physicianled. Our physicianled care teams are individualized and assembled according to to the members care needs. The care is comprehensive. So we have a wide range of Preventive Care and selfmanagement tools to motivate members to effectively manage their conditions and to make that as easy as possible to do. Its also systemwide, because our industryleading electron medical record links every member, caregiver, hospital, physician office, pharmacy and lab in realtime, helping ensure accuracy and consistency of care. Its also data driven. Disease care registries help track outcome and determine effectiveness, enabling continuous improvement. Finally, and probably most importantly, its really patient centred. Members and care teams Work Together to determine the most appropriate clinical, social and educational interventions to meet their health goals. For example, i bring up the example of my patient who tested positive for diabetes in pregnancy. All of my patients get testing for this. If the patient has elevated blood sugar, shell be called right way by a specialized nurse who answers her question, and refers her to one of our dieticians. She has a number to call directly to a specialized nurse and i work closely with the nurse and the Patient Care Team to ensure her blood sugars are well controlled. This reduces her risk of complication related csections, low blood sugar for baby and making sure she is kept safe. My patient and her Health Care Team knows to recommend screening for diabetes yearly given the increased risk of this. Thats because its front and center in the Electronic Medical record. So we all know that lack of coordination can be a major barrier to providing safe care, particularly between the hospital and outpatient setting. At k. P. We focus on collaboration. This leads to better outcomes. K. P. Health connect is our leading Electronic Health record that identifies and eliminates gap in care while ensuring patient safety, every member, every time. All of the staff share this one medical record and the members care team can pull the entire medical history, labs, test results and prescriptions up. For example, going back to the prenatal patient with diabetes in pregnancy, shell now get reminders to do her diabetes screening along with Breast Cancer and Cervical Cancer screening when due. This eliminates care ga gaps and increases quality of care. So for our members with multichronic conditions who need complex care, k. P. s model is set up to reduce fragmentation. Were able to provide the right care at the right time. For example, i might see a patient in the office. I was seeing many this morning for abdominal pain or pelvic pain. When i see her, i can search her Health Record for emergency room visits. This improves parity safety by avoiding unnecessary testing. For example, a ct scan that would expose her to radiation that she might have had done a couple of weeks ago, or the overuse of antibiotics. In an Outpatient Care setting as a primary care doctor, were the quarterback for the members with complex care needs. We help them navigate through their care journey. Our Case Management is a focused high level care program for our sickest members with significant medical problems. That is there to assist the patients along with primary care doctors. Case management involves a process consisting of identifying high risk members, offering comprehensive assessments of their needs, providing assistance and setting treatment goals and coordinating care by a team of physicians and other health care professionals. You can see on the slide, all of the different people that are involved, whether its a dietician, a health coach, a health educator, you know, my medical assistant or program assistant. Members with chronic or catastrophic conditions are automatically enrolled in these programs and there is no sign up required, no homework they need to do. We want to make the right thing easy to do for members and families particularly when they have a chronic or catastrophic condition. Another key feature of our program, it isnt outsourced, so our physicians deliver and manage the care. We are the patients quarterback and best advocate. Im proud were able to do this quickly and compassionately because of our integration. I had a patient i diagnosed with uterine cancer and when i provided the results, i was able to hand off to oncology. She had an appointment within a day and her lifesaving surgery were quickly scheduled. Being able to provide this type of care is the reason i do my job, the reason i enjoy doing my job. Five years later, i continue to see her regularly for her followup and shes doing well. We also provide robust discharge support for patients. During the hospital stay, my hospitalbased physician colleagues partner with nurse patient care coordinators to develop a post discharge plan that leverages our integrated system. In this case, for patients who are hospitalized, it is the p. C. C. Who acts as the quarterback. They help navigate them through the care in the inpatient care setting. Closer to discharge, transition care pharmacists review medications with the patients. Additionally for complex patients at high risk of readmission, they follow up after discharge to ensure that theyre supported during the transition to home. Because of our comprehensive electron medical record, the entire outPatient Care Team, including myself, their primary care physician, specialists and disease specific care managers can view the entire course of treatment in the hospital. Im notified realtime if patients are admitted and discharged and what followup might be needed for them, all thanks to this integrated system. My team has access to discuss care and transitions. This is true for our patients discharged from both the hospital and the emergency room. In addition, all patients are provided clear written discharge instruction, including the 247 phone number to call. In our internal and contracted Home Health Agencies a Multidisciplinary Team provides care. Depending on the needs, nurses, social workers, therapists work to develop a care plan. We have nurse coordinators to provide oversight to them. The other area that we have the same system is our Skilled Nursing facilities. Skilled nursing facilities based p. C. C. S help with similar transitions to the outpatient setting. So Kaiser Permanente strives to reduce the rate of admissions in various ways. Effective discharge summaries and patient instructions, including postdischarge follow skraup and coordination followup and coordination with primary care. I know that was a lot of information about how we manage our care for our members with complex needs. But i think the proof is in the outcome. How does this impact members and what is their experience . I wanted to share this last these last two slides. This one is the performance for diabetes and Heart Disease management where we receive the highest level at five stars. Next slide. The result of the prevention and control has led to Kaiser Permanente outpacing the nation in reducing death from heart attack and strokes. If your Family Member is cared for at Kaiser Permanente, we know they have reduced risks of these outcomes. This is why Kaiser Permanente are focused on management and making sure members with complex needs are at the center of our approach to managing care. Id be happy to take questions. Commissioner follansbee i was a kaiser physician, so ive seen a lot of transition during my 16 years. I want to compliment you. The department of obstetrics and gynecology, their ability to track residents is one of the outstanding ones on the west coast. I would encourage you to include the education part as one of your one of our circles, because i think it really does. Absolutely. Commissioner follansbee a lot of what you referred to really does reinforce the impression about obgyn. A lot of your data in terms of Blood Pressure control and glucose is great, but the majority dont have complex conditions. Theyre being followed for one of two conditions and theyre ambulatory and certainly able to be monitored and engaged. So were looking at a narrower window. You mentioned home health care. From my standpoint, and i think i would suspect from our standpoint, is not a problem because it is totally integrated system. Usually the primary care provider transitions out. Yeah and they have a new primary care provider. Nd the system works because theyre homebound. Right. Commissioner follansbee it was a relief to me to see some of the patients transition to that because i knew they were getting superb care at that stage. Nursing homes i have to say was a bigger problem. Because most the Nursing Homes are not kaiser facilities, so what goes on, the primary care provider you refer to see the center of this, is completely out of the loop until somebody gets a discharge summary from so i guess of the questions, i have is could you focus on complex Care Management . We had a member stand up and say she and her husband were in the Emergency Rooms several times and never gotten a followup call from the emergency room. I know there is attempts to improve the liaisons, but i got the impression from earlier presentations there is an institutionalspecific and maybe dont translate across all kaiser facilities. And maybe departmentspecific. And i think that is kind of, from my standpoint, what were interested in. How that Smaller Group of people really get managed and handled. Ill just say one thing. That is when i joined kaiser in 98, the adult primary care model was rolling out. I think it was before your time. A little bit. Commissioner follansbee in medicine, we had a nurse on our module, we had behavioralist, all kinds of personnel in various stages of support and it was a team. And over the time of 16 years, i saw that nurse, we often used in a complex case for the department of medicine, transition out. And a lot of these nurses are now program not the same nurses, but if i developed Heart Failure, i have no doubt there is a Heart Failure nurse, but he or she is not necessarily dealing with kidney failure, hip fracture or my stroke and all that. So again, do you have information maybe on how those patients who are really complex and chronic get handled maybe outside the department of obgyn . Only what i shared with you in terms of primary care from the hospital. I think from the emergency room, the calls, those 24hour calls and pcps, thats are from discharges from the hospital setting in terms of the emergency room. You know, that i think its more the integration through the Electronic Medical record and the notification to the primary care doctor, to follow up with the pry imary care doctor. One of the opportunities for us is in the Geriatric Population and thats where we see a lot of, you know, the Management Opportunities for these more complex patients. Not just that one narrow specific disease for the whole person. Commissioner follansbee i guess i still hear a gap. And i think that we would be interested in hearing how that gap is being looked at. In terms of, i know as a specialist in the hospital, i would often say to the hospital and the house staff team, have you called the primary doctor . Do they know the patient is here and what is happening to them . A small fraction of them, i would bet, 5 of them make rounds in the hospital, on their own time to see their patients during hospitalization, by may be brief of longer. I understand the model, butt system but the system doesnt really encourage that and all of a sudden, the primary sort of gets handed a patient on discharge and sometimes the hospitals, they institute a program where the hospital called the patient a week later to see how theyre doing, but after that, the hospital was out of the picture. Assumption was the primary care, but they have, as in every health care system, not just kaiser, they have their hands fall just dealing with walkins that dont have insurance that day [laughter]. I want to make sure and i think this is your understanding, that the presentation wasnt about complex Care Management just in the obgyn setting. I know that, yeah. Its across all areas. I know in the discussions weve had in working on all of this, there has been a great deal of attention making sure that when members are discharged from the hospital, that there is that connection. So while i know that is not your area of specialty, we can certainly get somebody in here who can talk about that. I know in all of the prep work weve done that is a major focus. So maybe its a discussion about what has changed possibly. Because it is my understanding that is happening. Yeah, and the other thing i would say, we dont have to the apm model youre describing exactly, but we have brought back some elements of that. Over the past years weve worked to strengthen our medical assistant and physician partnerships. I was at lunch with three assistants who were talking about every day, every friday, they talk about their patients that theyre outreaching to. They share patient stories. The shared the story of a gentleman through their care team they were able to bring down his home globen from 1 down to 5. Not a nurse, but the m. A. Is also helping with the Care Management for the physician and weve brought Behavioral Health back into the primary care sort of team. This has been a focus over the past several years, making sure that is happening. But i didnt mean to say this was only for obgyn. Commissioner follansbee i understood that. I only hyded because i know that highlighted that because i know that department in San Francisco is the platinum standard for management of problems of any level of severity and complexity. I guess that, again, some of this is my prejudice from my own training, is that the nurse is the one in the complex chronic who can answer the phone, deal with any kind of problem, yes, you need to call an ambulance, yes, i can help you get in to see your kidney specialist, yes, i can help with the durable medical group. I will tell you, unless things have changed, the medical assistants, the behavioralist, all those people great at what they do, cant respond to the complex chronic patients urgent and semiurgent requests and i guess i would like to hear nursing that been reinvigorated into this role. Maybe im too vague. I appreciate that. I know we use nurses quite a bit in helping with that. I think that the fact is that the other piece of it is the email. For better or worse, that is an easy access point and a way for it to come through the primary care doctor and for the doctor to decide how to disseminate that and connect the patients with what they need. Whereas more traditionally, it was a call to a nurse. But what about members who dont have access to email . Commissioner follansbee im sorry. One more thing. Its a bugaboo. One is that i get a call, if im not picking up my most expensive medication from a pharmacist in their time frame. Because its so expensive. They want to make sure im adhering to it, i appreciate that. But all the other blood work asked for on a routine basis, because im not following a chronic condition, ive been ordered by my heart specialist, i get no reminders. I have no way to go into my medical record and find out what was due. And so i know that i had lab that was due at three months and i made the decision, because i remembered that, to wait six months, because i didnt think i needed it that often. So i went in when i thought i was ready. Thats great for me as a retired physician, but particularly for the chronic complex patient, the medical record doesnt support their selfmanagement. Gee, maybe its time you check out the peak flows. We havent seen documentation of that. See what im saying. I guess also i would say also we need to do a better job of advertising. My patients just joined k. P. Because they moved to california so im able to have proxy access, see when they refilled medication, see when theyre due for screenings. The app is one we did for just that. The my k. P. Meds app tells you when you refilled medications, when its coming due. Thats the other tool that we created to address that gap. I dont know if that commissioner follansbee it does. Just to point out that your list of manage the health care, misses i can see when the last hemoglobin was, but i cant see if i have one on order. And when that was due. And so thats what im trying to sort of bring in. That in order to get the results that you want, and want the member to be kind of in charge or his or her caretaker or spouse or whatever. It would be nice if there was a little more enhancement in that regard. Thats the only thing. That is good feedback and it is constantly being enhanced and changing. Absolutely, hopefully this will help to continue the discussion. I know there is still followup. And were happy to talk about complex Care Management as long as we need to. So director, we can follow up and see what other discussions we have, but im glad the doctor could come and share some of the information. Any other questions . Thank you. Thank you very much. President breslin is there any Public Comment on this item . Richard again, retiree. Ive been a kaiser member for more years than i care to remember. The kaiser doctors are great. I know two instances when a doctor came in on sunday night and operated and another instance, the doctor operated at 3 00 in the morning and saved the persons life. The integrated system is fine, but there is one flaw. Its the home health care. Kaiser contracts out with staffing nursing. And these staffing nurses are great, but they cant communicate with electronically with kaiser. They dont have access to kaisers date database. They cant send email to the doctor like a photo or send an email or communicate with the doctor. You know, either the kaiser patient has to do it or they have to send you know, do it over the telephone. And i think this is a serious flaw. You know, what upsets me is that kaiser wants to give a lot of money to the warriors and to the sharks, but they need to fix their infill system. Their doctors are great, but like this nursing issue. This really bothers me. Because its happening with my wife. And you know, the nurses are great, but they should be able to communicate with kaiser doctors. I dont see why cant they do that. And other things, about the shingles shot. Ive been waiting over a year and kaiser hasnt communicated. They said come in. Apparently now they have a weighting system, but why didnt they send out an email about it. I have to hear the only reason i heard about it, because my friends not in kaiser got them. So i started asking, you know, just by chance, my doctor told me to come when he got it to see him. And they didnt have any. Then i found out there is a waiting list. I dont know how long the waiting list is. And you know, there are other things. Try calling durable equipment sometime and waiting on the phone for 45 minutes or a half hour. The other thing, my doctor ive seen for 30 years is cutting back. And the only reason i knew, because i was in to see him, but when you go online to make an appointment, you dont get him, you get apparently hes training the new doctor why doesnt kaiser send out an email saying he is retiring and you can see this other doctor, instead of looking online. If i went online, would have started calling up and saying why cant i see my doctor ive seen for 30 years . You know, kaiser needs to get down in the weeds and fix some of the issues before they start spending money on the warriors and the sharks. Thank you. President breslin thank you. Any other Public Comment . Seeing none. Now well go back to number 8. Back to the regular scheduled agenda. Item is the finance reporting as of june 30, 2019, and as of september 30, 2019. This is presented by pamela levin, the chief financial officer. Pamela levin, chief financial officer. Im going over the report for fy201819. The report in front of you i know is dense and long. This typically would be given at the same time as the audit results. Those are still delayed we think, as i understood from yesterday, that i thought they were going to be out in the middle of december, or next week, and i think theyre still going to be delayed. But all the data that im presenting is exactly the data that will come out in the Financial Report. They just havent finished all the work. So the trust ended fy1819 with balance of 91. 2 million, this is increase of 4. 7 million from the 17. 74 balance as of june 30, 2018. Ill discuss the increases against this 92. 1 million fund balance. The 4. 7 million increases because of 3. 6 million decrease in the trust fund associated with United Health care ppo plan, resulting from subsidizing the 1819 the 2018 and the 2019 rates from the stabilization reserve. And unfavorable claims experience. Particlely upsets partially upsets. Unfavorable claims experience is offset by the pharmacy rebates and the 3. 6 million decrease in the trust fund. For blue shield access plus, there is a 7. 1 million increase. This is several different factors are contributing to this. The first one is that we had a buyup in the rates to cover the 2016 and 2017 deficits that blue shield had. There are pharmacy rebates and favorable claim experiences. These are offset, these positive balances are offset by incent to payment to brown and toland for the 2018 year, plan year performance. For blue shield trio, there is a 5. 5 million increase in the trust fund balance. Its resulting from the buyup in the rates to cover 2016 and 2017 deficits. There is also pharmacy rebates and favorable claims experience. For delta dental selffunded plan, there is a 1. 2 million increase in the trust fund balance. Resulting from favorable claims experience. Which is offset by the use of the stabilization reserve to subsidize the 2018 and 2019 rates. We have a 800,000 increase in the trust fund associated with kaiser due to three factors. The first is the impact of the pay calendars through the School District and college district. When you have fiscal year ending and there is still a contribution coming from the entities. And thats the its just a timing factor. There is contractual provision governing the timing of the Premium Payments and also members are moving from active to retiree and from nonmedicare to medicare status. There is 100,000 decrease in the trust fund balance associated with claims payments for flexible spending accounts exceeding the payroll deductions as a result of the timing and the reductions. Its the same sort of thing. When the fiscal year ends, there is it doesnt necessarily mean that that all the payroll deductions are actually done. There is some timing issues. Weve always had that. There is 400,000 increase in the trust fund balance due to forfeitures for flexible spending accounts. As we discussed before, the irs allows forfeitures to be used to fund the administration of the flex spending accounts. The forfeitures reside in the trust fund and the expenses for the administration reside in the general fund. So a transfer is required at the end of the fiscal year. So on the chart that you have, at the beginning of the report, youll see a forfeiture is up 400,000 and then negative transfer for forfeiture, fsa administration. I want to note that we keep this transfer to the minimum required to fulfill our obligations in terms of our budget. And we dont transfer any more than what is actually brought in from the forfeitures. There is 500,000 increase in the trust fund associated with the Health Care Sustainability fund. The table that is in there shows budget versus actual, but at the end we have increase of 500,000. There is a 2. 9 million increase in the trust fund associated with investment earnings. This is considerably better than what we had several years ago. I think we can all remember those years. And there is 400,000 increase in the trust fund balance for performance guarantees which is net of the 100,000 dollars paid in 1819 under the adoption and surrogacy plan. There was 8. 1 million in pharmacy rebates received in fy1819. The end of the year, 92. 1 and for the fund balance, but there are obligations and reserves against that. So im going to go through those. There is 44. 7 million in future obligations against the 92. 1 million. Trust fund balance, they consist of 23. 5 million in contingency reserves, 16. 1 million in stabilization reserves. 3. 9 million for the Health Care Sustainability fund. 1. 2 million in performance guarantees for the adoption surrogacy benefit. And after that, the total is 44. 7 million in future obligations. Once that is netted out of the 92. 1, the fund balance is 47. 4. I provided a chart to look at where we are in terms of, you know, the fund balance and then the future obligations. And over the last five years and youll be able to see that the value of the future obligations and reserves has remained relatively stable since 201617. Turing now to the general Fund Administrative budget. There was a balance of 698,000 at the end of the fiscal year due to delays in hiring. After we carried forward 195,000 into this year, a balance of 504,000 remained. We went to the Controllers Office and Mayors Office and requested manual carry forwards. These are up to the discretion of the it requires approval by the Controllers Office and the Mayors Office. They have to be justified and we had 130,000 carried over into 1920 for professional services, materials, and supplies and work orders. You cant carry over surpluses or balances in salaries and fringes. So is there any questions on this report . Id like to take that before i go onto the next. The report for this fiscal year. Okay. All right. I turn to this fiscal year. So were giving a report that summarizes through september 30, 2019, and then a projection for the year end being june 30, 2020. In terms of the trust fund, as i just reported, were starting with a balance of 92. 1 million based on the activities through september. The fund balance is projected to be 89. 1 million, which is a decrease of 3 million. Were projecting no change in the fund balance for the ppo plan. For access plus, the fund balance is projected to increase 11. 2 million primarily due to pharmacy rebates and favorable claims experience. And i just like to put a caveat on all of this, this is only three months, july, august and september. So you know, the crystal ball is not fully developed until about may when we can tell you what well end up in june. For the trio plan, were projecting 8. 9 million decrease in the fund balance primarily due to large claims incurred in july, august and september. We have were working with aon and blue shield to dig deeper into this the large claims. Were projecting 3. 4 million decrease in the fund balance fort delta dental selffunded plan. And that is a result of subsidizing the rates and and when you look at this, its greater than the favorable claims experience. For the Health Care Sustainability fund, were projecting a yearend balance of 1. 8 million. This when you look at the projection in the chart, that is provided in here, budget versus actual, and the projection, were projecting 14. 5 14,000 left at the end of the year when you just look at the annual expenses and the annual revenues. Which obviously indicates that the expenditures, annual expenditures, ongoing expenditures are cripesing at fast increasing at faster rates than the revenues and well have to do something about that. In terms of investment earnings, were projecting 1 million. There are no performance guarantee payments received as of september 30. We paid out a total of 45,000 under the adoption surrogacy assistant plan through september. And we are projecting that we will use 200,000 for reimbursements this fiscal year based on Prior Experience in what were seeing right now. Just to right size this, when you went to approve the servicing adoption plan, we set aside a maximum of 300,000 would be distributed in a year. So were still staying well below, as far as im concerned, well below 300,000. The ammana forfeitures or unused spending account balances, which i described coming to the trust, that wont be known until july 2020 after the runout. And as previously described in terms of use of the forfeitures for the administration of the flexible spending accounts, currently there is a budget of 600,000, but as i mentioned before, well only transfer forfeitures up to the amount that the forfeitures come in and no more. So at the maximum, it would be 600,000, but as you can see from this year, it was 400,000. And in prior years we havent transferred anything at all. I have tried very hard to be fiscally responsible for the forfeitur forfeitures. No pharmacy rebates have been received this fiscal year, but we are projecting an 8 million balance based on prior years experience. The plan showing the expenses compared to the budget of premiums. The cumulative expenses are tracking higher than revenues for the uhc ma ppo plan and the expenses are tracking lower for access plus and delta dental. Again, three months into the fiscal year, well continue to work on that and see how that flows out and continue to monitor it. And then in terms of the general fund right now, were projecting that well end the year on budget. Is there any questions . Commissioner follansbee can you go back to page 4, the blue shield trio flex funded. You said there was during this period, 12 million decrease in fund balance due to unfavorable claim experience, what kind of claims are those, do you have any idea . So in trio, let me make sure i have the right report. Were talking about through september . Yes. Yes. So in the last three months, weve seen a peak in high cost claims. Those are claims over a Million Dollars. What happens with trio is that the correct me if im wrong, mike but in trio, the risk on the claims is born by blue shield. So while this is alarming, there it still doesnt present a really super i believe that at the end of the year, this will wash out. But we are we have a meeting with blue shield tomorrow. Were planning to ask questions. Were seeing their utilization where mike has been in contact along with me with aon. With the account Management Team for blue shield. And were really monitoring this carefully. All right. Mike clark, aon. When we started to see the uptick in the claim experience overall for the trio plan, july, august, september, we did reach out to blue shield, because my inclination is always to focus on large claims first. There is a reason why claims may be spiking one month to the next. But also we put a general ask, what are you soo eking in the data what are you seeing in the data . Theyre saying its isolated. Were seeing one high cost Chronic Kidney Disease claim that just rolled onto medicare, because thats one of the qualifying events, but it takes 29 months for that to happen. Highly unusual cerebral vascular events. But when we look at it over the course of the year, and look at where the claims have come in on trio, its really unusual to see the spike for july, august, september, that we frankly hadnt seen earlier in the year. Pamela commented on the favorability of trio through june 30 where we didnt see spiked large claim experience, but we did see it for july, august, september. Weve had ongoing conversations, just in general discussions around large Case Management with blue shield and how the partners are working with patients who are incurring large claims, so those discussions continue from a Care Management for those patients standpoint. But ill also say that sometimes you just see peaks and valleys and incidents of large claims. We have gotten Early Advance preview of, okay, what portrayed for october and november as well. Obviously not verified yet, but very early reporting, where we did continue to see a little bit of large claim activity in october. And to pamelas point, too, anything over a million does roll into blue shield responsibility because there is Million Dollars per individual for a calendar year on large claim in both the trio and the access plus plans. So part of what also happens, is when a claimant goes over a million, it will still play into the data that pamela has through a given period. And it may take a month or two then for the stop loss reimbursement, to vend that out in the experience. I think thats also happened when you look at data through september, versus some of the early information weve now seen through november. Thank you. Were on it. Any other questions . Thank you. President breslin any Public Comment on this item . Seeing none. Would anybody be interested in a break . Well be on a president breslin in session. Madame secretary, item number 10. Item 10, open enrollment report. Summary of the open enrollment Key Statistics and the member plan migration. This is presented by mitchell griggs. Mitchell, you survived. We did. Mitchell griggs, its that time of year again where were coming to report out about october. As i like to call it, our really big show. It takes a lot of work. Up to it and during that 30 days 31 days, whatever its going to be of open enrollment, and then after, its a lot of work, too. I always get fussed at by the Members Services staff when i say open enrollment is over october 31, because as you see it continues to go throughout the year. This is my 8th open enrollment and i do consider this one as one of the most successful and well get into why i feel that way. Just as a reminder, back in september i mentioned the size of open enrollment. We mailed out 76,000 packets this year. We brought in the county and Court Commissioners into selfservice this year. So that was a total of 36,000 people. We did do a pilot for selfservice for the School District which i believe was about 337 people. And we added more retirees for a total of about 6,000 there. 7,000. So last year we only had 8,000 actives and 4800 retirees. All in all, we had 42,000 people in selfservice. So we were anxious and excited to see how the adherence was. Im going to talk about that, but putting off, because im going to talk about that later. And talk a little more about member assistance. This year, the phone calls, we received 11,000 calls. Thats down 8. 5 . Last year, it was 12,000. We met all the Custom Service metrics. That was good, people waited average of 8 seconds for analyst to answer the phone. And inperson assistance, this is when people come in during the month of october, and the number there says 2158. That is last years number. It didnt get updated. It was 2900 this year. That was increase of 26 . Thats what we want. We want to be able to provide this assistance to people facetoface when they come in. We also go offsite. This year, we got 1800 members we spoke to. We have a lot of people who ask a quick question, grab a benefits guide. We dont necessarily count them, but i went to several of them and is looked like attendance had decreased a bit. This is not necessarily a bad thing. In the years where we dont have huge plan changes, some of that will decrease like the phone calls. But all in all, you know, its good to have that many offsite events. I did notice in looking at all the statistics, it was the lowest call volume in three years. Three years ago we implemented trio, which caused a lot of calls. And then in the last year, were still trying to figure out why we got so many calls. Its the way the planets were aligned. I think there was still after effect of trio. But this year, pretty steady. On slide 3, still about member assistance, we had upgraded and improved our website this year, earlier this year, i believe it was march. So for open enrollment, we looked through october and we had 27,000 individual users go in and check it out. As typical, though i wanted to look at this, everyone looks at it on october 1 and then everyone looks october 30 and 31st. There are few things in between. Some peaks in between that corresponds with our emails, our mass emails we send out to people. And some of them are actually, after the offsite events, people must go home and look at things. On the slide 4, speaking about our website, it appears that 25 , a quarter of the people actually access it through their smart phone, mobile phone. Which is good news for us, because we know there are employees out there who dont necessarily sit at a desk, not at a computer all day at work, but we do believe that most of them have a smart phone. So were glad that people are looking at it through their mobile device. And on the righthand side of this particular page, this is the top 10 pages that were accessed. We had 16 116,000 sessions. So if i were to go to the website three separate times day, thats three different sessions. Thats a lot of people accessing the website. And 40,000 of the top 10 pages were accessed and youll see number 2, the second highest, of course, the home page is always going to be the highest. Thats the first page everyone goes to, but the most visited outside the home pages were pages for ebenefits. Again, thats what we wanted. We wanted people to learn and use ebenefits. On page 5, how many paper applications did we receive versus people putting their changes through selfservice. Last year we got about 12,000 pieces of paper. When you do that, we have to manually review it. Someone has to manually enter it, check it. So its a lot of repetitive work, computer work for the benefit analyst. So people use selfservice, that helps us a lot. So this year we received 5,000 applications. That was a decrease by 55 . Which is the less paper that received since ive been there and certainly a lot less than last year. Then we received electronic changes and we received 8710. So the vast majority, 66 of all the changes, went in through selfservice and that was one of the success points that i was talking about earlier. We were hoping and thinking the unreachable goal would be 50 of changes. So getting that 66 is massive. And there was some reasons why, which well get into. But i just wanted to demonstrate here in this chart below those numbers is how many people submitted by ebenefits, broken down by employer, how many forms did we receive from the employers. So it kind of helps us see where we need to do work. The bar graph on the bottom is percentage of people who have access to selfservice. If you see on the first line, for example, the court, 68 of people that had access to selfservice didnt submit any change. 24 of the people that had access to selfservice actually