Commissioner lim. Required Financial Reporting during the audit when we do the financial report, required with the audit, and also reviewed by aon and reviewed by independent auditor. Ok. So, further certification we are using the funds properly and for the purposes intended. Correct. So, we provide the calculations but you are correct in that is audited and i know that was reported on last month. Ok, thank you. Commissioner lim. Ibnr for the city plan was substantially reduced 2008, because pretty much all of the city plan is fully funded now. For the medicare retirees. So it would go down, expect it to go down in 2018. All right. Thank you. Any questions, other questions from the board . Any Public Comments . Hearing and seeing none, thank you. We will now return to our regular board meeting. We are no longer the committee of the whole on rates and benefits. Have we changed . No. Madam secretary. Thank you. Item 10, discussion item, update on blue shield trio hmo implementation and provider partners. Jeanette moen, blue shield of california. Hi there, thank you. Jeanette moen with blue shield. I just wanted to give the board an update on the trio implementations and some other provider relationships that have changed in the product. I always have to remind myself why we are doing this because it is herculian project and undertaking, and again its to leverage those relationships that we have already forged with provider partners en the community who are doing an outstanding job for the city and county of San Francisco delivering high quality care and reducing costs. Its to reduce costs and make the plans sustainable for h. H. S. Members longterm. Its an attempt to transform Health Care Delivery by disrupting competition nuances in our marketplace. And its to ensure that longterm all members of actually california, part of our mission, have access to high quality affordable Sustainable Health care. I just wanted to give an update to the board to amend some numbers i had provided last month, we have final numbers in. Based on the january 1st trio enrollment, 14,500 members, approximately enrolled, equivalent to 13. 5 million in 2018 savings. Continued enrollment of that number, 2019 and 20, and beyond, will only be compounded. Meaning that 13. 5 million for the same cohort or of members will only increase in savings. If you add more membership, it will compound even further. So, updating this pie chart, 62 of all h. S. S. Members are using trio providers, and of that 62 , 40 of those 22,500 members enrolled in trio ultimately. Excuse me, why arent the rest of them automatically enrolled . You know, so we used a logic to automatically enroll members only if every Family Member in a family unit was using a trio provider. And some have 5, 6, 10 different doctors sometimes in a family. Right. If nine of the doctors were trooi trio and the tenth wasnt, they were not a candidate for auto enrolling. We did not want to prompt any relationship changes with physicians. Ok, thank you. So, we have some really exciting updates. We have we will continue having bumps along the road and changes. Fortunately today i have mostly very positive things to report. I will get the hard message out first. With meritage, if you look at the pie chart, it does not constitute a large portion of the h. S. S. Membership but what we did learn, we did auto enrollment based on people having meritage providers. That is actually divided into three divisions. Marin, and two sonoma divisions. The two sonoma divisions would not be part of trio. We enrolled 32 that we should have not done, we moved them back to access plus, we want full disclosure of our learnings along the way. Any questions about that . Ok. This is the interesting news. As you know, big change for h. S. S. , for access plus versus trio, is that the cpmc hospitals or any Center Facilities are included in trio at all. And met with resistance from suter, even though they were unwilling to partner with us for trio. Once the numbers were in, we had a new dialogue, and it is our hope, always keep in mind, suter is our partner as well, whether you are blue shield or h. S. S. , suter is the partner as well. But it does not mean you are going to partner on everything. So, they have, they came back to the table and we have added a variety of sutter facilities to the trio network as a result. And that is effective january 1, 2018. Those included the ambulatory Surgical Centers sutter in San Francisco, i have a list here. And a list of the Surgical Centers in alameda, a little bit of a Health Care Delivery desert, where 580 and 880 intersect, and one ambulatory Surgical Center in costa costa. We did not really have a need there, im not sure why we added that, but its added. It will not hurt anyone, only an enhancement. What is very notable is alta bates, and the Eden Medical Center are add, and thats 3, 4 hospital campuses added, also where we had from what we perceived, even though the department of managed Health Care Found it to meet all standards of a robust network, we did not like the way the network looked in that 58080 corridor, we filled that entirely. I thought sutter facilities were out, but now they are in. Because a deal was made with them or a better because a deal was made with them. Yes. Yes. And they were open to talking to us about it. Jeanette, if i might add, open to it after the numbers were in. Ok. So, i mean i think that is important to realize its also important to, when you look at the 13. 5 million that we are saving next year, as well as this change, you know, this is a market change that we worked really hard on, even though i know last month we sounded a little whiny and a big open enrollment and heavy lift, but these numbers and happenings make it well worth it. And that was the intention of this, to really talk about market competition, and if we were able to leverage that. Dr. Follansbee. Part of the problem was sutter insisted you could not deal with each campus separately, you accept one, they all had to be part of the network and you have managed now to either carve out or whatever term you want to do, some Sutter Centers without forced to use all of them. That is correct, that is correct. 100 of sutter is access plus. 100 in the p. P. O. As well, two name Brand Networks we have, that is correct. This is an exception. And if we think back to my first slide, it is disrupting the marketplace, it is creating competition, and it is creating change, and at the same time, its improving outcomes and making plans sustainable and affordable. So, there will be bumps. This is really positive news. Its a difficult balancing act. I understand. Thank you. Along that line, to continue along with the provider partner update, moving on to slide five. Oh, we did have our utilization management, we had a series of very indepth meetings around claims, basically, and how the risk and the claims are performing. And i wanted to go over a couple highlights. The meetings are actually two hours long, and i pulled out one slide to share. So, its really important for everyone to understand that the risk has increased and that means its a higher risk to finance. Its costing more to finance, and thats because a term called dxcg, commonly used term in Health Care Risk assessment, and basically what it does, describes a value of risk to a patient, and we all are born with a one, or we are all introduced into a plan with a one, and then based on claims and combined with demographics, our risk score alters. And so the medicare was really notable is h. S. S. Has a very, very, very high risk score, and they continue to get higher. And this is why it is very difficult to negotiate with our partners to take down that risk. I would like to ask, is this profile similar to other employers in your book of business . Unique to us . I find it hard to believe to be unique to us. Well that, is exactly what the slide will tell you. So, if you see the dark blue line, and you see it creep up, that represents blue shields book of business. So the highest risk employer is at the top of that blue line at the 100 and the lowest risk employer at the 0 . The nonmedicare retiree risk is the Golden Diamonds. The gold diamond. Almost at the 100 level. So, i think there are 3 or 4 other accounts that are higher risk. Than we are. Than h. S. S. For early, for nonmedicare retirees. Thats early retirees. Correct. Compared to other early retirees. The average age of early retirees for h. S. S. Is 60 versus 48 for other Employer Groups. The other notable score is your active score, which continues to deteriorate and part of the result of slight, and its been very well managed and this is not uncommon, especially municipal accounts, but the shift of membership out of a network h. M. O. Into kaiser, it continues to deteriorate the risk score and we saw that, we saw reduction in membership, a slight, and also saw a slight reduction or worsening of the risk score. This is another reason of, for doing trio. We need to partner with the providers to get the cohort healthier and cared for. So, you can see where h. S. S. Active employees compare. And you can see that it slightly, went from 1. 47 to 1. 59. Say to director griggs, publicly and to incoming director, each time ive ever seen a slide like this it is a prelude to increased premium rates in the ensuing year. And so i understand you are just giving us the facts today. Actually i think you will be happy about this. Trio has a cap on this. I understand. But each time, the precursor of whats to come. Hold on to your wallet, saving money in medicare. So as we look at this, and there will be ample time for discussion, so i actually did it because i wanted to talk to you about your results as far as costs. And i would yes, so, lets talk about while your risk is where it is, lets talk about where your claims dollars are, relative to the prior year period. So, moving on to the next slide, h. S. S. Medical trend, 1. 3 , im going to use rough numbers here, but National Trend is 7. 5. So, somehow with the worsening risk score, we are at 1. 3. Im sorry, im confused. What does the medical trend refer to, what is that . Medical trend is the inflation for medical delivery. So, its not just your rents going up here in San Francisco, for cpmc, its improvements in medicine technology, cost of health care, higher litigation rates, the list just goes on. There is so much pressure on this particular sector of the industry. So, medical trend always outdoes inflation. Why is ours so low . Because we are doing good things. Because we are doing really good things is right. Thats exactly what it is. It is unbelievable that we are getting these trends. And ill finish it out, for prescription, it was 3. 5 . For active, negative 1. 7 for early retirees, and the national r. X. Trend roughly at 12 . So testament to the partnerships. I really did show you that prior slide for this. I did not it was not a prelude to opening your wallet. Ok. Im sorry, just to make sure im clear. So, what interval is this trend, is it a monitoring, is it a month, two months, a year, trio year over year. Calendar year over calendar year. 1. 3 is what, calendar year 2016 over 15 i dont think its no, goodness. I did not bring the snapshot of the time frame. It must be 7 1 to 6 1, 17 over 16. We cant produce these until we have three months of runouts and then present on them. So probably mid year to mid year, 17 over 16. Really nothing to do with trio, but all the rest of the things happening in terms of looking at services and accountability. A. C. O. Well, you are correct, it does not have to do with the labelling trio but what is trio. 62 of your members are using trio today, and have been now we are refining that and focussing on the partnerships and calling it a product, trio. So, it is trio. And thats produced, just those trends alone, 22 million in savings. All right. Commissioner lim. So, assuming the rest call for early retirees, way higher, but as far as medical trend and drug prescription which means our early retirees are more healthier probably because we didnt have that much medical claims and prescription claims. Well, i will say that the risk trend for the early retirees went down slightly. It went from 2. 84 to 2. 74. Its still that Golden Diamond at the top of that 100 curve. And i always like to point out when i see fabulous numbers, i dont care if they are fabulous. You you already overcharged me x amount and given me 1. 3 discount, its meaningless to me. I want you to charge me the right amount. We know we are being charged the right amount because we exercise so much Due Diligence partnering with the providers that we look at everything and we have carrots and sticks that they do charge the right amount. What it is saying, director lim, is that its being held at bay. Those trends are completely counter intuitive to the risk and counterintuitive to national and bay area trends. Maybe i could say this, part of that probably is attributable to our wellness program. I cannot say it would be attributable to the wellness program. And im happy, we have an opportunity next month to talk about prescription, and you can see all the various stealth prescription programs in play to manage the high cost drugs. At risk, have some created for the wellness program. On the page five presentation, early retirees 60, versus 48. How did you arrive at 48 . Thats too for the whole you could not have early retirees most employers nationwide or book of business. Workers retire at age 48, that early, i could not i could see for 60 for the City Employees, because of the incentives when you become 60 you have more the present age of your retirement is going higher. But 48 for early retirees . I asked the same question at the meeting, i think its driven by dependents. So, when you are an early retiree, we take into account the dependents as well. So, other groups are having more dependents who are bringing down that age in that early retiree category. Accounting for dependents for the city, it cannot just be 60, it could be lower. Most of the City Employees retire at age 60 but the dependents are way, way younger and i cant believe its 60 then, if you accounting for dependents. I would ask, rather than trying to unravel this, we come back to this point. If you are talking about the age of early retirees, i dont know what their dependents would have to do with it. I would like to have a little broader explanation about your methodology for arriving at that number. You only become an early retiree when you are, its nothing to do with the fact my grandmother im taking care of or my two stepchildren. H. S. S. Transmits early retirees along with their dependents and we have to bucket them all in the same bucket together. So we do take into account the ages of the dependents and the more children that are in there, thousands, it will mix up the ages. I understand youre explaining what you do. Im asking a broader question. Why do you do it that way and that would mean that you would have to get into explaining your methodology a little bit more as to why you do it that way. Its not intuitive to me, if im counting early retirees, those are belly buttons. Thats an early retiree, it has nothing to do with the fact, you know, where they come from and how many kids they have. But i would like to have a clearer explanation of your methodology at a later point. Later point, yes, of course. I have one comment and then a question. Because the city offers a defined benefit pension plan that doubles in Service Value when you reach age 60, theres a tendency for Public Employees to stay until they are 60 years old. I think many other employers dont offer a defined benefit plan at all, they have a 401k or some other deferred compensation plans. There is no benefit to waiting until a particular time. If you have a, the ability to retire, lets say you know, you can sell your house for Million Dollars for less than that you bought it for, and look at the overall financial package and the money in your 401ks, then you make a decision based upon your assets and your forecast. For City Employees, age 60 is a critical date for just about everyone. My question is, are we the only Employer Group in trio right now . How many Employer Groups are there, and is it pers is not in it right now, they are in a similar version of their own and have been for some time. I can get back to you with the exact numbers. We have had a significant uptick january 1st. It was hard for me to imagine any sutter facility coming back to the table if the only Employer Group were us. Its you. Even in the east bay, we have that big impact on some of the providers in the east bay . I will say that ulta bates facilities are not heavily used by h. S. S. And access plus. Those were added in. I was not involved in the negotiations, but they were added in. Right. So you are correct. There is not a huge use there. But they were added in. Okay. Thank you. Thank you. Any other questions . Any Public Comment on this item . Thank you very much, we look forward to your next update. Thank you. Next item. Item 11, discussion item, update on best doctors, Second Opinion vendor, best doctors representative. Hi, good afternoon. My name is nancy oh, im with best doctors. Nice to be here. What is your responsibility with best doctors, please . Account executive to Health Service systems. And you have been with us for how long . I have been with h. S. S. Since may of last year. All right. Thank you. So, what im here to do today is, im sorry, struggling to get this down near my face. What im here to do today is to provide an update in terms of utilization. So, the first time in may when best doctors representative john fisher, Vice President of development was here, he went through two months of uti