I think we would have to think about, you know, how the interoperability, the Data Integration and how that would work under the various models. I think that would be different under the hmo plans today versus the ppo plans. Page 30, the consolidated scenarios, this is where we would consolidate down to three plans. At open enrollment you would have choice of kaiser, and hmo potentially in this model and a ppo plan. However, the difference here is the hmo and the ppo plan would be provided by a single carrier. A carrier or insurer, or health plan, so at night, cigna, blue shield, United Healthcare would have both of these plans. They would manage both of these plans. Does that make sense . You are saying one of the Healthcare Providers would be providing us with an hmo . Correct. Today we have that split by health plans, this would say we are bringing those together under one health plan. Retaining and hmo plan design choice for the member at enrollments on a ppo plan at open enrollment. It is my understanding, i was in Service Practice for half of my career, these already exist. There are lots of ppo and hmo plans. All of the carriers do not have just one template. We would set out the criteria that we want and then find a plan that probably already exists. They would not be writing new plans out of the blue. Correct. In this example we have kept that Third Party Support service for advocacy and navigation. On page 31 some considerations. There will be some level member disruptions for plans if we consolidate them to one hmo. Additionally if there is a carrier change, there will be a carrier change for one of the other, the hmo or the ppo potentially. There would be a change there. That second bullet, i think is what becomes key here is it creates a single risk whole along the non kaiser plans. Today we have our blue shield bucket and our healthcare bucket. In this model we would say these are one bucket of claims we can manage. It is self underrated or funded and spread that risk. It helps with the longterm sustainability of the ppo. That is one of the primary reasons we have this scenario forward. It can enable contract provisions if we are negotiating with one larger stick. To use our phrase earlier. And then carrier programs and care coordination can be consistently delivered which can be different from today having the two health plans. It will one be be one single set of care coordination programs. The scenario we propose. We propose one hmo and ppo design. It is just the employee contribution varies. The design is the same. From that aspect he would have the same Design Choices for copays and coinsurance. It is meant for members to have choices. It is written in the charter. I think if we consolidate too much, were back to the competition thing and choices. Again, just. Out, lots of physicians belong to multiple groups. We looked at this before when we looked at trio, and where would the disruption be . Member still had a choice. If they switched it to trio, it wasnt a huge choice and providers within that it wasnt as if they were assigned to one or two primary care providers. They could stay with their old providers may be under this scenario they couldnt do that. Obviously if we were to look at this what would this disruption be. Would it affected 50 of our members or. 05 of our members because of the way our providers are already members of multiple groups. They would still have the ppo plan design option it shows that they may have a different carrier than they have today. In your second bullet. For the non kaiser vendor, it would just create single risk. [inaudible] all of the populations on the hmo and the ppo would be considered one risk . [inaudible] correct. [inaudible] it is creating a shared risk pool. Actuary should really answer this question. The way we would view it is looking at the concept of the entire experience that is coming through under both the hmo and ppo, and then do more to look at the differences between the plans as a foundation for setting rates, rather than the specific experience, and again i point back to the uhc ppo today, it is 2800 people is a Large Population within the broader framework of sfhss. It is a high risk population. Today, the rating methodology looks strictly at the experience of that group and designs rates based on that that ultimately result in higher premiums granted there are differences in rating methodologies that i think construct the difference that president breslin talked about earlier. From our framework, what we are trying to do is create a more level Playing Field in how we would rate the hmo plan versus the ppo plan. The other aspect of this is, today, trying to communicate to members. If you have a particular condition, here is what each health plan can offer in terms of support, as you work with your physicians. Here is some incremental support that can be offered. It is different today across all of the carriers. The other aspect of bringing things together under an umbrella over the framework of these plans is to be able to do communicate consistent messaging on how to access benefits. You know social Health Related benefits or how to access resources within specific programs. That is a lot of what this consolidated scenario was trying to accomplish from a pure rate setting again risk pool standpoint as well as just consistency and messaging the members about Resources Available from the plan. Just to clarify, im assuming you have United Healthcare as hmo and United Healthcare as ppo. On the ppo you have 2800, on the hmo you have 45,000. For risk polling you just combine the 45,000 in it doesnt take into account each one, so. Using more actuarial values to determine rate differences between the hmo and the ppo rather than relying on the absolute experience of each particular plan. Premium wise. In aggregate it will equate to the same as it does under todays methodology. Page 32 we have the next option. Our scenarios for consideration that we named the stem competition scenario. This is where we would focus more at open enrollment for a member to pick the Health System that they want to receive their care within that framework. We are saying potentially retaining that ppo on the right hand side. And then you would pick like you do today, and a trio youre picking with him, i guess thats not a good example. The acos could include but not limited to blue shield canopy, see chp and or sutter. You would have broader choices. Youre picking your Health System at open enrollments. Again, these would be hmo plan designs similar to the access plus plans today. And then with the coordination of care with your primary care provider without ppo remaining on the righthand side. This would be one provider. What this recognizes is that the Health Systems in the bay area are consolidating and integrating. You can make your choice about which system to enter. That is what this is considering. It is similar to Health Access to you, its more similar that they are adding one more aco. Potentially. As far as the health plan that we didnt go into that, that is where you could come by some of these scenarios is just say we want one carrier, multiple carriers, some of these, they have a Health Delivery system. To be want to solidify that. There is a lot of variables within that scenario. On 33 it creates Competition Among the Health Delivery system to engage in management members. The Provider Network choices in the hands of the member at open enrollment when they select the Health System that they want to take care of. Member instructions is a possibility. This may be a viable option for 2022. Something that is in our lands for the future. As a potential future states. It really warrants further research and studies. We talked about this earlier. Studies that show increased costs under system competition scenarios. Really wanting to think about that. It was on our radar is something we wanted to throw out there. Any other questions on that . Just to make sure i am clear, because this is more of a system driven, although blue shield its different then see chp, canopy is what used to be Catholic Healthcare west. Canopy is and they have added there in general, sequoia, they do have some dignity hospitals between them. I think united is there carrier and they are currently filing, right. Those are ones that i think it is useful, they wouldnt be even eligible canopy has a product. And now they have aetna as their carrier. Dignity has joined up with anthem. The changes are very real and very dynamic. I want our board and membership to be fully informed about what is going on. To make sure im clear. Say a member is used to getting her care through ucsf and they might choose canopy with the idea that they would not be able to go to see someone at any of the other hospitals, and other hospital systems. They would continue with what they identified and then they would be restricted to that. Right now, we discussed this further health plans. Yes restricted and more open. Canopy designed to compete with kaiser. If you lived in the east bay and you were working a 12 hour shift for the Police Department and had that book ended for our commute or whatever grade you could go to a physician at ucsf in your Canopy Network during the day. And then, you know, use john deere for your Emergency Services or your elective surgery or whatever. That is what is going on. In the marketplace. I was going to ask one question. Im absorbing the content. It seems our preferences of the partnership. Im not aware, correct me if im wrong if theres been any sort of comprehensive surveys of our memberships as it would help and guide our decisionmaking. Not yet. You are stealing my thunder on the next step. Yeah, we have spoken to this at a high level and we describe that we are doing a roadshow and a listening show, surveys as a whole. Listening to members input into much of what we presented here today. I know it is a ton of information and we wont necessarily be repeating that. Thats why it is great that it is recorded. We will have this conversation and dialogue for membership over the next several months. Please do hold that thought, because we will get to it after i complete the last model description which is called private exchange. Part of the concept is, you know, if were all familiar with public exchanges, you know, for instance californias exchange has gone out, contracted with Certain Health plans and they have put their plan designs on an open marketplace and then i, as a californian can go out and choose whatever plan is best for me, whatever carrier is best for me. The idea of a private exchange is to bring a marketplace to the employer and the plan sponsor. They can be done and fully insured frameworks where the experience of that employer is given to the marketplace of plans and they have designed their rates to compete for members, or it could also be done on a soul funded basis. The idea is put an array of choice. These are just examples. Certainly, examples. I can choose from among any of those particular plans, the Provider Networks, their framework for care management, et cetera. As well as variations of plan designs. We say how much do i pay varies by metallic plan. Aetna may put four plans on the spectrum in blue. This really maximizes choice, to me, as a member. What it does is pulls a lot of the control that you have as an employer to, lets say, from sfhss standpoint, its done and a very different way. On page 35, again, just defining what a private exchange is using a thirdparty administrator, create that exchange like shopping experience, broad array of plants. Its not a public exchange. It may look like a public exchange, it is not. There is not a relationship between those two. Its also not eliminating employer sponsored an offense. It is eliminating what they provide to their members in a different way. It is still done with all of the underlying financing delivered by the plans based on the pool of experience of sfhss members. Not any other employer, not any other person outside of sfhss. Considerations on 36, a lot of choice. Member disruption could happen depending on the choices a given member makes. It does add complexity. People now need to understand both carrier choice as well as plan design choice. It certainly dilutes your ability to look at data for the population, as a whole. It really puts pressure on all party claim database to bring information to look at information as a whole. Its somewhat limit your control. In a sense this is, youre almost outsourcing the financial control to the health plans and telling the health plans, dont compete for my members. We do see, as you can see here at the end of the day, probably not viable for 2022. We will see how this evolves. Its been around for several years. There are concepts out there that some employers have latched onto. It will certainly be a viable opportunity for the future. We will certainly get inputs on this along with the other models we have looked at. I just wanted to state here. We may not see this as completely viable among the five models that we have. You say some employers have latched onto this. Corporate employers for the most part. Which i think is another reason why we dont see this as viable. Thank you. A couple of questions. Are we limited because we are public from engaging in this right now im taking a change in our charter or anything . Yeah. Is all part the problem. We shouldnt be discussing anything if there is not a. I think we wanted to mention this today, because this is a session where we want to say these are all models that are out there. Yes there would have to be a lot of work through i think. I dont want to speak for the legal team i dont want to speak for the contracting team. There are complexities in this. I think he would face if you decided to move forward with this model as opposed to the other four for 2022. Where a concept like this warrants some discernment is, as the market does consolidate, and public providers throughout the bay area are grappling with the highest insurance rates, in the country, is there an opportunity for us to at least begin a dialogue, with the public providers around the bay area about how a concept like this could benefit all of us, as far as, you know, again, i havent sat down with eric and talked through all of this. There is obviously as many challenges as there are opportunities to really think about whether or not if we pooled our membership as far as a buyer goes, could we have more weight in purchasing. And then it would make sense if that were a Bay Area Council kind of way of approaching this. Would it then make sense to think about having an exchange like a vehicle for delivering those choices around the bay . It is an out there idea and that can redo do it tomorrow, but should we be thinking about this . Do we have a responsibility to be thinking into the future. That is why we have introduced it, because i havent yet had the opportunity to meet with my counterparts in the other counties. It is on my to do list to see if others are thinking this way. We certainly have gotten the squeeze here. Calpers just redid their entire way that they approach their benefits carving out Northern California because it is so expensive. I think we just have to be forward thinking and are there good ideas out there for the future that we should be exploring now. These kinds of things would take several years to consider even if everybody agreed. There would be a lot to consider and talk about. Not all counties have a charter. Most counties do not have a charter and we have a charter. That is important. Am certain they all have rules and regulations whether its a charter government are not. Their membership has their involvement, i mean. Im not sure who else has a charter in the ten counties. I doubt it. Can i make a couple of other small points. To me that might be some variation based on metallic plant whether youre in a silver, gold or premium. That may be a selling point for people. It seems like that may be an overstatement. The other thing, im kind of curious about which is a purchasing pool with other employers, only based on our cost and premiums. Part of the potency would be as if we actually did have a bigger stick. We werent talking about 125,0 125,000, when you cut out the medicare it is less. If you are able to combine with some of the other big counties. That would be a bigger stick. Therefore we would be able to negotiate better. Im a little concerned about why this is excluded why it is not a purchasing tool. I would say present state it is not because as abby said, how those conversations started, counties collaborating to perhaps thinking about building a bigger risk pool to increase their leverage back to health plans. Those conversations havent necessarily occurred to date. But as you said, they are intended to move forward based on what the executive director said. The other aspect, if you are looking to bring a larger purchasing pool collective together. You really do need some sort of risk stabilization mechanism to prevent certain entities in the pool to feel like okay, i have brought my more favorable risk into this pool so im going to start paying higher costs for other entities in the pool. There would have to be careful consideration among any eventful partners in a venture like this. I think we should move on here and get Public Comment. Just a recap of today was really to inform and gather input, so thank you. We discussed and identified some must haves and additional ideas for our considerations list. On 39, we will continue to define and refine our carrier partners. I understand the latest version of our presentation, we were changing a daily didnt actually show up on our website until noon today. I apologize for that. The next steps are not in your versions that you saw. Anyway, our intention is the next steps is certainly to respond to the many questions i came up today. A list of hot topics that will consider how best to provide that information back to the board and the memberships. As we have these conversations b