Provide that because what best doctors intends to do is try to provide the right treatment Going Forward and not after the fact. So, sometimes people may want to get a Second Opinion, but its after they have already had a procedure done. Other questions. I have a lot of comments about this. First of all, its not free, its 1. 40 per member per month, adds over 1 million to the rates. Talking about a looming excise tax and i dont understand how you know your diagnosis is better than the other doctor diagnosis. 509 cases open, 413 closed. Unless you follow the case for a long time down the road you wont know whether your diagnosis was better than the other persons diagnosis. And we already have this Service Available to us. If a member has a certain problem, they can get a Second Opinion and a facetoface opinion with another doctor. As far as i know. I know people that do it. And if they dont, i know that h. S. S. Would probably help them facilitate that, and those particular cases. So, and these are not facetoface visits, and you are looking at the same stuff that the other doctor looked at. And i just, i just think that this is a duplication of services and i have a few other things, but its getting late. I just dont also dont see why you think these are the best doctors. The bay area has the best doctors, really, some of the best doctors. Yes. So, they can already go to them. They dont have to go through you. And anyway one of the thing best doctors focusses on, two things. The virtual part of it, people dont have to go anywhere and repeat another visit with another physician if they already have their medical records and the clinical notes. Theres nothing like a facetoface from everyone you talk to, to look at the patient. Sure. And that makes a huge difference rather than just looking at a bunch of papers and stuff. Thats missing here. Sure. Of course its going to be missing from a virtual visit, yes. The other part of a virtual visit is you are taking away any kind of geographic limitations, so if somebody, you are right. We have a lot of physicians from the bay area that are in the best doctors experts database. I have seen them because ive seen a lot of the requests come through. But also there are other specialists who are considered, you know, the premier, most knowledgeable or working on some research or, you know, on the clinical edge of whatever they are doing, im not a clinical person, i cant really express this. But they might have access to more knowledge in certain circles and they might be located in the southeast, and it takes away that limitation is basically what it is. All right. Are there other questions from the board, director griggs. I would like to make a statement for the purpose of the minutes, h. S. S. Will go back and look at savings and costs reporting. It is one of the performance guarantees that we have with best doctors for february, i believe. So that is coming and we will work heavily getting it appropriate to present to the board. Second thing, go through the reporting, too, and look at refining some of the labels on whats on the report to further clarify for some of the things brought up. But it is and what i have heard and the member interaction ive had, it is at this particular point in the existence with h. S. S. , one of the peace of mind things that people feel confident, more information or different, you know, from a different source, or some networks or some integrated h. M. O. S limit where the Second Opinion can come from, too. So, you know, this is an area where i see its benefitting. We will go back, the department will go back and provide this additional information. Thank you. Public comment on this topic . Public comment . All right. Yes, hi, i realize this is atypical, speaking as an h. S. S. Member, not as an employee of the Health Service system. Im speaking because i am somebody who recently utilized the best doctor Second Opinion service. I heard a few comments here and as somebody firsthand experience the service what it meant for me. I did get a somewhat serious diagnosis for me, cardiology related, and there was, im with kaiser, so my Second Opinion options were all in the network of kaiser or my mother did want me to go to see her cardiologist. And that was going to be completely out of pocket, and very expensive. So i thought i would avail myself of the services that we provide to our members. And i did open up a case. I ended up with an hour telephone call with a cardiology specialist at the cleaveland clinic. I dont know when in my life im going to get an hour with a cleaveland clinic cardiologist, and that conversation was very helpful to me. When we talk about risk factors, when we talked about how do you define success, that was not a conversation i had had with my kaiser doctor, they are like giving me percentage of success rate and even my service system, we talk about how, you know, people have to advocate for themself, ask the right questions and its so difficult. And so to commissioner sass, or commissioner follansbee, its not cost and peace of mind. I have to tell you, i got peace of mind out of my experience and i did go through the procedure and it was costly, so if you are going gonna look for cost savings you are not going to find it on my particular claim. But what im hoping is i will continue to be a productive and effective member, employee of the city and county of San Francisco, and Health Services system and that service to me meant the world. All right, thank you for your comment. Any other Public Comment . My name is diane erlick, i used the best drs. , im a kaiser member and also cardiology. In kaiser you are limited. You can go do any kaiser doctor but its the kaiser line that you hear when you go to a kaiser doctor. And i used best doctors and i found it extremely helpful and it did result in a change of medication that i am much more pleased with. So i think it is very valuable. Thank you for your comment. Any other Public Comment . Hearing and seeing none, we are now ready to go to our next item. Item 12, discussion item, presentation of q3 express dashboard, marina coleridge. Oh, sure, now i have to collect myself and play this other person. I understand. I started to say we could defer this to the next meeting, but i dared not without permission from director griggs chlth. The first time we have presented marina coleridge, back in august of this year, was the first presentation of our new express dashboard where we are really trying to, on a repeatable, recurring timely basis bring integrated dashboard that looks performance across all three of our health plans. In last month board materials we did provide the dashboard through q2 of 2017. That was a very packed agenda. So, we did not actually list it as an agenda topic, as well as i knew we would have the q3 one available by the january meeting to be more timely. We have a present station, gov tv. A presentation. Knowing that this is a late hour. Yes. And that the material is dense in terms of how its presented, i would ask that you provide thematically the information on the succeeding slides or key points. You have done a great job of putting down kind of some key footnotes and so forth, but i think that in order for us to get the best understanding of what youve taken time to collect here, we need some highlig highlight guidance. Certainly, i will not read the dashboard notes, they are the same notations we provide each time. There are two dashboards in the deck, one looks at the nonmedicare population, so active and early retirees, and then we repeat some of the dashboard components for the medicare population, and that does not have the financials in it. Looking at page 2 of 9 for the nonmedicare population, these members are all trending pretty consistently, when we look at previous period for your med and rx spend, while that is down over the dashboard that you saw in december, we are slightly trending upwards, and i dont think thats really any surprise. I think weve gone from a spend of 599 million, up to 606 million, high claim costs also very consistent, if you go back over the last couple dashboards and look at those numbers. Slight uptick from q1, but otherwise all these members are holding steady. Our cost per employee per year, which is found on page three, this, over the course of 2017, has also been increasing. A total allowed amount of 12 thousand 9 hundred 0. 82 per employee per year. Thats trending up about 1. 7 as we look at slide four ask one im sorry, make sure im clear. The total, is that sort of, you know, in each of these graphs, is that the, like under high cost claimants overview, so the h. C. C. Allow amount per patient, the total is higher than any one of the three components. So that means that we allow into the contracting more than any of the claimants . Im confused what the totals are supposed to be. Please be clear as to which slide. Slide two, under high cost claimants overview. For example, a number of high cost claimants. The total, its close but not exactly the number, the three components. But allowed amount per patient med and rx, and blue shield, 128,759, city plan, 106,000, kaiser 126,000, but the total 129,137 which is higher than any of these three Component Health plans. So, im just i dont know what the total actually means. Yeah. Im going to have to go back and look specifically at the code behind that. I believe its going back out and recalculating without putting a plan on there. And so we have additional dollars that end up showing up for some cobra and other utilization, and i believe it ends up in the total, but its not ending up in the blue shield city plan on kaiser, because now this gets technical silly, but we the Health Service system owns the eligibility feeds into this. The claim feeds from the health plans and they can marry up to our eligibility, we dont have the cobra people. And because of that, some of the dollars drop off. But when you go to total, you are not restricting the data and doing other things, so it will pull it back in. I suspect its that piece making numbers like this look a little odd, ill confirm that to you by the next board meeting. Thank you. I guess my question, somewhat similar, when i see a number like 129, is that an average . Versus a total number . Its an average, its a per patient. Im just wondering if total is the right. Total column, i see what you mean. Yeah. Cant be i think, it cant be an average when you add 128, 106, 126 and weight it for the number of enrollees per plan. Cant be any greater than any one of the three columns. I understand. I thought you were talking about the specific measure, the per patient, averaging out over population. I see where you are going. Thats just a question. With the terminology there. We will clean that up. You were on page three. I believe i was shifting to page four. Fine, thank you. I was done, wasnt i . Cost and utilization trends. Yep. Cost and utilization trends. What youll notice on here, kaiser is the only plan thats below the western norm and significantly so, but what i want to call out for you is that western norm which is whats available to us in the apcd, is compiled by really looking at p. P. O. Data, and so its not an ideal norm to use, because its somewhat misrepresenting, but we have struggled and in ernest are constant sly trying to find a proper benchmark so that we can really see how our plans are performing based on what our reality is. We are looking at some other modifications that might actually make us sort of create our own norm, all things cost money, though, its a decision where you are spending your budget dollars. I did want to call that out. So, more than anything, i look at the west norm to get some general idea, but looking longitudinally whats going on with the numbers. And of course, the plan performance in the middle of this page, my personal favorite. Done as an annual update. This tries to do a ratio by the average by looking at the risk score, which again, still the dxcg methodology other people have mentioned instead of list being it in the they scale it to 100, thats why they see 106 for blue shield, normally read it as 1. 06 risk score. And then a note as you read through and absorb the data, premium contributions, because they are based on the medical premium and as you know from other budget conversations that happen today, embedded in the medical premium, you have, for example, the 3 p. M. P. Under sustainability and doctors and other items embedded in there. Chronic condition prevalence on slide 5 of 9. Really important to us in continuing to look at what sort of information can we use to look at both the quality and also help provide some information into our Wellness Programs. These, im pleased to report, trending downward. In the shortterm, up ticks, hypertension, diabetes, low back. But where we were at the end of 2016, dropping down in terms of our per 1,000. And preventive screenings, the next one. And what i would like to call out on the next slide, six again, we dont necessarily have perfect data, but always said if we waited for perfect data, we would never have anything to look at and evaluate and inform where we needed to go. And so on these, for example, you know, if we look at kaiser screening weights, around 90 on the cervical and the mammogram and the colon cancer. Those in here are not set to the measure which exists in the engine we have to pay for to make happen, it should be every two years versus one year, just a look at the year and where we are looking at, get a sense of are our members taking advantage of the preventive screenings, do we see variability by plan, just a caution how we are consuming this information. And lastly, i know stephanie presented last month in terms of where shes at with her Wellness Programs and i loved that piece about the score of 75 on the overall wellbeing, the number of population, drives to a lot of other good things. The bottom left, 72. 4 of our population are sitting in healthy and stable, and thats where we want to keep them. No news to any of you, 1. 9 of our members are driving 40. 1 of our costs. So, we want to stop our members from getting over to further right along the risk band profiles, and point of note on the top ten summary groups, hepatitis has dropped off of that, and looking at some episodes and some costs, and so and other than that, no other specific notes on your commercial population moving quickly, since it is late in the day, to the medicare dashboard, page 2 of 6, once you get into the medicare section of this document, i would like to say this is one of the first ones ive had a chance to look at since we have incurred data now moving into the 2017 year. It is it is rolling 12 months, so when jeanette from blue shield was talking to you about the early retirees with blue shield and the average age, if you are trying to crosswalk to this and you see 72 years on this, and wondering why, 12month rolling, so i still have six months of those medicare blue shield members in here. So, just so you are not thrown off by that. And also maybe some of the six months, the risk scores are looking really kind of whacky here, both blue shield and city plans spiked significantly. So, well bring back, some further analysis, positing possibly some of the healthier blue shield medical retirees have moved out to the p. P. O. Product and what was left in blue shield was some of our sicker individuals which is driving up the risk score, but also the city plan score spiked from 315 at the end of incurred december 2016, up to 497. We did not have time to get into that level of analysis before the board meeting. Well bring back and see what we are noticing there with our medicare population in those particular categories. And just some notes on chronic conditions. Same thing we are seeing in our nonmedicare population, a lot of these are dropping down. I do need to do some similar analysis to your question, commissioner, about why the total was higher. We see that here with the hypertension patients per 1,000, each of our plans, the numbers have dropped on our patients per thousand on the prevalence but the total is higher than what it was previously, well look at that and bring that back to you as well. And those are primarily the big callouts and are there any other questions that i can attempt to answer for you . All right. Any questions from the board . Any Public Comments . I i appreciate very much your, appreciate all this very much. Particularly the preventive screening rates, to put that into perspective. I was taken aback by how low they are. But when you clarify they are not linked to the guidelines, not Everyone Needs a colon Cancer Screening every year, maybe every five years, so i dont know if there needs to be an anecdote, you know, to say these are not these are just overall. Looks like we should be, we shouldnt be comparing one health plan to another because the populations are different. Particularly above, you know, in the premedicare. If i understand that correctly. Yeah. Because, and so not so discouraged. Pay a lot of money to have such a low mammography rate, so but if its not is and also looking at trying to actually incorporate the measure in there. Thank you commissioner. Mike, do you have something to add here . Mike clark. This data does cross plan years, so one member could represent in multiple columns. So for instance on page 2 of 9 of the nonmedicare data, if you add up the sum of high cost claimants, 58 people may be in multiple columns, because of this spreading across two plan years. Ok. All right. Thank you for that point. Any Public Comment . Hearing and seeing none, now going to come to our end game very quickly. Yes. Item 13, discussion item, report on health and network plans, if any. All right. Please, any plan representatives that have something that they wish to share. Kay kiepler, kaiser permanente. We are in height of the flu season and still encouraging all of our members to get flu shots. We have updated our website with flu information and continue to offer our flu shots at no cost and no appointment necessary, so, wanted to make sure that you knew that we are in the height of all of it, but there is still time for members to be able to go in and get the flu shots. Thank you, i think thats very good given whats ahead of us. We know the flu shot did not accurately predict whats circulating in the influenza a. In the past, kaiser had protocol, diagnosis of influenza over the phone and in a certain period of time, i think 48 hours, prescription is sent directly to the pharmacy so they can get started on treatment. Are these kinds of protocols still in existence . And whats your supply of medication