19 cases. That means u. H. C. Referred over members to best doctors and out of all the members they referred, we had actually seen through cases through closed status from 19 members. 19 unique users. It says referred to benefit partner seven, what does that mean . That means from best doctors we sent out Seven Members back to u. H. C. And its not the same members that were referred in. It was members that obviously didnt know that u. H. C. Had a particular program or could help support them or clarify their questions about their claim or their physician or innetwork status. Looks like it should be 12. Seven from 19, 12. Unique users. 19 people that completed cases with best doctors, and then best doctors sent seven different members to u. H. C. Because they needed Additional Support from u. H. C. So this is best doctors referring to the health plan. Yes. All right. Thats what the second column is. So the first one is in to best doctors from the benefit partners. Dont really know what happens to the 19, necessarily . Im sorry . Dont really know what happened to the 19 . The 19 members that were referred from u. H. C. To best doctors had completed an interConsultation Service. Thats the Second Opinion service. All right. Are there other members, other questions from members of the board . Regarding this . Yeah, i have some questions. So, appreciate this presentation. Its different than the presentation we had at month two. And in some ways. This focusses, i think, in terms of outcomes, focusses on Member Satisfaction with your three cases, which is encouraging, anecdotes of members being satisfied with this. It doesnt refer at all to any cost savings or additional costs, which i had some concerns about when i saw some of the initial cases. Are you abandoning cost savings, dont really have access to that . We are spending a fair amount of money and the way it was sold, not only for Member Satisfaction but also to try to improve our overcharges and our over utilization. And get to that, ill get to son of the cases. Sure. To answer the first part of your question, commissioner, we are not moving away from still looking at potential and projected cost savings for cases. We do actually include that in a supplemental report. Its called a clinical impact summary that we dont typically put out for members to look at. Its aggregate data and deidentified, but has a lot of clinical information, thats why it was not submitted for the public viewing. But, so we are not moving away from that. We still do do that and its part of our contract with Health Service systems in order to project and calculate the savings for each case. Well, i understand that you may not want to do that on an individual level but some aggregate summary of cost savings impact due to these services being provided is going to be to me essential as we look at Going Forward with contract renewal of the service in the coming year. Yes, we understood that it was a new service, it was being applied in different way. We are obviously very large population, but we did bake it into the cost, if you will, to our members, and we need to know what is the benefit side for those who have utilized the service. Its good to know the total aggregate numbers of cases that you have addressed and so forth, but attached to all of that at the end of the day is a cost impact. And we need to see that. Yes. So, that will be included at the annual report. And you know, the other supplemental report that i had mentioned, clinical impact summary has the projected savings per each case, deidentified, annual when we calculate on aggregate basis. Well, i would like to request that we have an interim report regarding cost savings, just as you are able to go through three quarters, give us this level of detail about what happened. There should be some, again summary that relates to cost savings. Estimated, known, or something. Uhhuh. Yes. Very helpful. I can get that to you. And again, just to reiterate my previous concern, we dont have any cost information here, was that i was a little concerned the data we were presented was not very robust. That that projection for the one case, as i recall, was based on surgery was averted because some tests were ordered, but there was no six month or one year or two year followup and we cant really expect you to have one year or two year followup in some of the reports, even at one year, because you have just started. But the methodology would be very important, not just project the cost if everything goes perfectly well based on one interconsultation, but what the ultimate cost was. Do we just delay procedures or cost. So the methodology is very important in that. So i have another point. So, on slide two in the upper righthand corner you talk about clinical impact. You said 44 change in refinement and diagnosis. This is change and diagnosis. At least from a medical side, refinement and change are actually quite different terms. Refinement means there was a nuance that was added as part of a review that wasnt really a change. They didnt go from leukemia to Prostate Cancer or diabetes to something else. And so im a little concerned about what, how you used the term change or refinement. What does that refer to exactly, in terms of the significance. Grade those refinements in terms of serious or minor or something, you have a scale . We dont grade adjustments in diagnosis or treatment plan changes. What it is is basically as you touched on, it might be a lab test or imaging that was missed or overlooked. And that typically when you see a lot of the cases that we do, it can contribute to why a person cant get a unifying diagnosis or why its been diagnosed a certain way or graded in terms of staging a different way. So, when we are talking about an adjustment in diagnosis or treatment plan, it could be just as you said, misstep they are calling out. But if its something dramatic, like you mentioned, your example of leukemia to Prostate Cancer, that would be a very distinct change in diagnosis and that would be called out on the report. Right. About you this is 44 change in diagnosis. Which implies to me the diagnosis was in fact changed. And thats a different term than refinement. Refinement has a different impact, at least in my mind and maybe im just being overly sensitive to this, but as someone who for my practice often refined diagnoses and some cases changed, i know the difference. Likewise, 87 change in treatment, that change in treatment or refinement in treatment . You know, we had a case in, at the twomonth interval, recommendation was for followup scans at a certain interval that was within the same guidelines as the original doctors recommendations, just three months versus six, but the guidelines said 3 to 6 months. So, i dont know if it was coded as a change because even in the range of all the, you know, subspecialist consensus statements. So, change in treatment and refinement are important terms, and i think for us to judge on the impact, 87 changes to me is in treatment is actually, would put every Health Plan Partner that we have on notice here that we are really missing the boat, and ill when i go to the cases, ill reiterate that. This is reconcerning to me, that we see when you go from the first case on page, whatever it is, six, the, no change. Page seven, you mean. I think six is the case the one with the heart attack, coronary artery disease. Thats page seven. Ok. Im sorry, the slides ok, page seven. It says that the treatment clarification, confirmed the diagnosis, how different was the plan compared to what the member understood from the previous, you know, from his own, or her own provider. If it was a significant change, that means that that first provider needs some counseling, if they were not providing adequate recommendations, if this is some tweaking, maybe have the cholesterol done every three months instead of every six or something, that is, would not put any health plan in this room on notice that they have messed up. I have the same concern about the third, the second case. Which was the neck pain. Case basically they recommended additional images. Well, you know, who, was this member not really referred to a specialist . And thats why they went to best doctors, and that would put that health plan on notice that that physician is not utilizing their available services. If it takes this kind of a consultation to recommend some more imaging because of chronic neck pain. Thats a concern of quality that we are, our Health Partners are missing. Same with the last case. Apparently this member provided all kinds of data, and in the absence of any diagnosis or treatment according to this scenario, just the doctor ordered a bunch of stuff, i dont know what it means and what to tell you to do with it, go to best doctors to figure out what all the stuff i ordered really means and what you should do about it, and so the member was very satisfied because they got a diagnosis and treatment plan that doesnt involve really anything other than selfcare which is important, which is clearly important. And so if the doctor was saying no, i dont know what this is, i dont know how to treat it, im going to give you a pill, then there was a cost savings to us and to the health plan. But this is this case really strikes me as sort of like, what doctor would order tests and then not provide any guidelines to what the tests mean so the poor member has to go to you know, Consultation Service to interpret. That is terrible communication from the Health Plan Partner. Whatever communication for this specific members case was broken down, i cant speak to. What i can tell you is that the member was the one that initiated the service of best doctors because the member could not get a unifying diagnosis. And the reality, im sure that everybody has seen this because its been really big news for a number of years is the staggering statistic about misdiagnosis. And misdiagnosis is, you know, we were using this case as an example of the physician who orders a bunch of tests and then you know, doesnt really help the member identify exactly what the issue is. I think the reality is, is that physicians are typically very overburdened with the number of patients they are required to see, and we are trying to get everyone in the medical industry and the health care industry, to get in front of quality and so all of these measures are there, and you know, theres a lot of different programs to improve quality of care but times human error can happen and i think thats why we see what happens with misdiagnosis, and its not because we believe that any physician doesnt really care about the patients care or the delivery of care, it could just be an error in ernest. I appreciate all that, im a retired physician, i appreciate all the stresses and demands and the issues you say. What im trying to say is we spend a lot of time working with our health care, you know, provider partners to actually show that they can do quality, you know, prove to us that they can do quality work, screening, mammogram, all the whole shebang. And so you know, so this service to some extent, the more you advertise it, by the way you just advertise it to me, is that there are just mistakes being made all the time and we are the ones who can save you, ok . Doesnt help to have you advertise that to me or our members saying dont trust the health plans that the Health Service system of simi county or San Francisco will contract with, they are going to screw up and we can save you are what your Health System is doing or monitoring. I think that is a completely valid point. If you look at any of our mailers, we do not use hyperbole like that. With me, you just used hyperbole with me, you did. I did not say that misdiagnosis happens every time. I said that it is a staggering statistic that we are seeing. But the reality is that all of the material is not there to scare people into thinking that every single physician is going to make that mistake. We do have material that is memberfacing, thats shows that its going to be a third of the cases across the entire United States that has misdiagnosis, and thats not a statistic, thats actually made up by best doctors, its something thats shared. But we also urge people to get a Second Opinion because it is a free and Confidential Service and it can provide peace of mind. We also share the statistic of members who have had services with best doctors out of the cases that we have seen, we have seen an adjustment in diagnosis and treatment plans of this percentage, and best doctors most recent book of business. So, obviously its not going to be 100 changes all the time, and its not trying to trick the member thinking if they bring in the case they can always expect to see a change in their diagnosis or treatment plan. One more comment then ill be quiet. I apologize for my fervor over this. But, and i appreciate what you are saying. To me this part of the presentation looks like an advertisement in a magazine i pick up off the rack at my supermarket. And when you say not 100 of the time, you are right. You dont say that, you say 44 of the time. Our case, when we review cases we got a change in diagnosis, 44. Almost half. And 87 of the time we change, we recommend changes in the treatment. Thats not 100 , but thats pretty high. And so if i were naive and thought oh, my god, i need some peace of mind because theres an 87 chance my clinician has not provided the appropriate treatment plan, i would be pretty alarmed and, i like the peace of mind. That part i think is great and may be worth that if thats what you are doing but these slides dont tell me thats what you are trying to do. You are trying to advertise your service, 44 change in diagnosis and 87 change in treatment plan. Well, the clinical impact summaries line by line actually calls out if it was changed or if there was an adjustment. We are not seeing so thats the problem, all right. Thats ok. Points taken, commissioner breslin. I do have just i wanted to just say what i what this, the way this was sold to me, not that it was going to be cost savings in fairness. The reason for this, i think the overriding reason was that sometimes someone gets a diagnosis that requires surgery or requires maybe radiation therapy, serious diagnosis, they are concerned about, is that the right thing for me to do and they want a Second Opinion. So, that to me is a value to the members. Whether it costs more, whether they wind up doing something that costs more or costs less as an out come is secondary totally, but that peace of mind is the critical reason for the program. What worries me is on the very last slide when i see, when you talk about having 700 contacts and i see so many being referred right back into our system for, to get the answer to the question they are asking, im kind of worried that many of our members are just calling the wrong person with their concern, that they are picking up because of that mailer or magnet, they are calling you about something that needs to be taken by u. H. C. Or kaiser, their own provider. I want to know what percentage of your calls are significant in, around the Second Opinion sort of service, and how many of them are just misdirected calls that shouldnt even be counted in your end. Ok, because, or i want to see that n, for that number of misdirected calls. That is not efficient, that is really not a useful service if all it does is cause confusion among our members. So, Second Opinion, yes. I think we really need to emphasize the value of that, and every communication to every person. Second opinion. You know, not call me because you know, somebody did not pay my bill right or somebody you know, im not quite sure what to do about this problem, what should i do. I just dont see that as being your role. Sure. I can tell you that im using bigger numbers, statistically speaking. We are not getting a majority of callers that should be talking to their medical provider because of some billing inquiry or mixup. A lot of the questions come from not quite understanding what the service is, so they think of it as like if i call in and i have a sore throat, can somebody tell me what i need to be doing, so its its that one. But so we try to emphasize that its the Second Opinion, its, as if you would get a Second Opinion from an actual physician in person. So need to get those statistics as to which is which. When i see 744 contacts, i want a breakdown of what those are about. How many are Second Opinion calls and how many are something that is not, you know, your primary function. Sure. You can see on slide number five three, i think this is. Four. Four, sorry. That is three, yes. Slide number four, you can see from the total contacts, the correct number of folks that had contacted us for a Second Opinion or that we could help them with a Second Opinion was 509 cases, so 509 unique cases. And then also, sometimes when members call us, they do want a Second Opinion but its not appropriate to get a Second Opinion because many of the folks that are turned away and we cant really help them with the Second Opinion services because its no longer relevant, sometimes people want this Second Opinion to be done postmortem, so that they can go back and make a case for mistreatment, and so we dont 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 won