We can see our Breast Cancer exceeds california and national rates, as well as our skin cancer and our Prostate Cancer are higher than those benchmarks as well. When we look in our nonmedicare population, on the top right, we see that we are lower than benchmark for breast and cervical and skin, but the prostate is higher than the california average in the Health Service system population. The next slide is doing the same sort of comparison here, but we are looking at it by cost. Instead of looking at it by prevalence, which is what the previous slide was doing. We have, again, Breast Cancer, leukemia, and lymphoma, all of those are our costliest cancers, and we are exceeding the california benchmark and exceeding the national rate. Moving to slide 11, here we are taking a look at it from a longer to do no approach trending three years. We have 2016 through 2018, and there is a Little Orange dash line in there that shows you a trendline of how is our prevalence going over the years. So even though 2018 has increased over where we were in 2017, we do see, for example, in the Prostate Cancer and our male population, that has trended downwards over the threeyear period. Our Breast Cancer has trended up significantly over 2017, but slightly over 2016. That is also true of the Cervical Cancer that has been increasing over the three year trend. Can i ask a question . Yes, please. It is curious to me that 2017 was your middle column and lower for everything. So i am just curious, do you think your data captures all the diagnoses . Is there something theres something that is strange about why one year all the cancers would be lower. Yeah. I think so, too. As far as we know, all of our data is there. We do know we have some anomalies with some plans that we are looking into, with that is one we are still researching. It may take a while for our investigations to identify the reasons for it. That is something we are still continuing to look at. And your chronology goes from 2018 on the left, 2016 on the right. Usually we are used to seeing things the opposite way. Is that making you pay more attention . [laughter]. It makes me pay more attention. That is like when you go to trader joes on the fourth and they have the escalator on the right side and it is now on the left. I know there was a reason why they what you did that. It does keep us awake. [laughter] i was wondering if we could blame it on where you are from england, right . So, moving on, what are you looking forward to . What we anticipate in 2020 and beyond is, first of all, that you will see about a 12 to 15 increase yearoveryear Going Forward, and what you can see is , globally, they are increasing the same as the rest of the world. It is expecting to increase about nine to 12 . Japan is as low as 6 . From that perspective, unfortunately cancer is being treated and is being globally treated and everybody expects about the same growth rate. So then what does that mean to you all as far as this . If we are looking at the top 10 cancer episode treatment groups, what you are spending for breast is about 13. 8 million. You are spending about 7. 4 Million Dollars on leukemia. You are spending 2. 8 million on skin. I do have to draw attention to the fact that skin is orange and Everything Else is green. When you are thinking of acute, you usually think of appendicitis, you think of flu, but skin, because it is usually treated and then it is gone, has one episode. So if you had a swarm his cell on your finger, they would exercise it and so it up. That would be done. They would be no additional treatment and thats why it is considered acute versus chronic versus Something LikeBreast Cancer where you have chemotherapy or Radiation Therapy and things of that nature. If that makes sense. And so as you can see, you have kidney and urinary cancers at 2. 3, but that is basically looking at your cost 182018 based on the treatments that you have, which is, at 10 of your 550 milliondollar budget. So, i will move aside. As we take a look at slide 14 , we are looking at a per member per year cost and were doing that for our active and early retiring members. We do not have the financials for the medicare population. Is our top cancers yearoveryear, same thing where we are going left to right. And so cancer cost is trending upwards on the leukemia side. We have the cost trending downwards pretty significantly there. And our lung cancer trend upwards and same with lymphoma. That is what the trend has been looking like over these years. Same thing as applicable here in terms of what the commissioner has noted with the 2017 members that dip in some areas, not so on the cost of Breast Cancer, but that still is pieces that we are investigating. I want to talk a little bit about how treatment has changed over the past three years. If you look at the right column you will find them and you will notice that hospital inpatient stays was significant. It was almost it was slightly more, maybe two more than what the Outpatient Services were, and radiology, which is your Radiation Therapy, came in at 10 million. If you fastforward to 2018, which is the second column, you will see that your inpatient care actually dropped by almost 5 million, which is a significant change and your outpatient stayed somewhat flat, although it did go down a little bit at 14 million, but what you will see is that your pharmaceutical treatment of cancer increased by about, a little over 2 million. About 30 . So from that perspective, you see your growth and your outpatient because if you were to have maintains the 5050 ratio , you would expect the outpatient would have been around 11 million and instead, it is at 14 million and your pharmacy increase, where is radiation, what you would have expected may have caught up, but hasnt really changed yearoveryear during the same time period. So from that perspective, the good thing is that you are being able to treat people, outpatients, which means they are able to be in their own home and in their own setting. The difficult part is that was the changes in the treatment patterns with the drugs and the costs now are on the outpatient side. Questions . What would other be. That would be dme. Wheelchairs, it could be some of the genetic testing that would fall in there. It would be home health, hospice , things of that nature. Thank you. Any other questions . So one of the things that people often forget about when you think of cancer is longterm survivorship. There is a Significant Impact of cancer, and it remains high yearoveryear. It may be you are no longer being treated, but lets say you need to be fitted with a special appliance for a breast, lets say you did not have reconstruction, or you had a deformity caused by the removal of the cancer. All of those costs will continue as your body changes and ages, you will need to update. Those costs will continue. One of the stories that im sure some people have heard, but i always it just comes to mind, i had a family. I am a clinician. The wife had lung cancer. They were at a University Facility not in california and they were being treated aggressively and she passed. Her passing meant her husband not only lost his wife, which they were incredibly close, but he lost his house because he didnt have enough insurance to pay for it. He not only was grieving the loss of his house and his wife, he now had to figure out where he was going to live. And so those costs that go along with cancer lingered for many, many years after the active treatment. That is one of the things that often we forget about Going Forward. So earlier on in the presentation, i mentioned that the positive things that we are seeing with your increased screening is the earlier detection. So if we look at pages 17, 18, and 19, i will not go over i will not go over all three pages , but focus on the active, is what you see is that, for Breast Cancer, the disease stage zero, which means there is no test to says, there is no lymph nodes involvement, it is a localized lesion, is significant that out of your 680 people that were identified, almost 90 of them were at stage zero, and only, again i will use 90, my measurements might be slightly off here, were at stage three. The rest were stage stage one. That means it is very receptive to treatment and it is a positive finding. If you go down and look at the list, you will find very few stage four. You will find a few unspecified, a few, if my colours are correct here in the oral cancers, but very few stage four. You do have a fair amount of stage three, which is the yellow , particularly in lung cancer, and in colon cancer his. But overall, you are finding your cancers earlier, and that pattern is seen both in the pre 65 retirees as well as medicare retirees. So in conclusion, what we are going to watch for Going Forward is we will be reporting back on cancer because unfortunately i anticipate it will remain in a top consumer of your resources. So we will Pay Attention to the stage of the disease, when it was diagnosed. We are going to hopefully look for increasing screening rates, again for cervical, breast, in colon cancer as compared to the national averages, and we are going to really keep on top of the prevalences by each type of cancer to see if there is any targeted interventions or wellness activities or outreaches that we can collaborate with your various health plans on to improve screening and Early Detection. Any questions . I have a question. Thank you for the very thorough presentation. Im wondering if you have a breakdown by gender or by race or anything further broken down that breaks down the types of cancer. At this point we do have the Data Available to us by gender. Some of the cancers in this report we have made some comments about specific genders, for example, on the Breast Cancer, both genders can get Breast Cancer, but we have looked at it with a male population and without. That is not a problem. As far as looking at things by race and ethnicity, that is not something we are able to do today. It is a focus under our Strategic Plan and the direction we are going. Thank you for this. Is a really thorough presentation. Im not sure what your reasoning is, but i applaud the exclusion of Prostate Cancer from early screening. It is my understanding that Prostate Cancer in the United States, the issue around Early Detection and early identification of men with Prostate Cancer is still quite controversial in the developed countries. The europeans feel that the americans diagnosed early, label men with Prostate Cancer, treat, and yet their survival rates at 10 years, 15 years, are actually identical to their history, which is a much later diagnosis time, and so the fact that we are not necessarily encouraging early screening while this question is still being identified, and i know a lot of men with Prostate Cancer who have entered Clinical Trials looking to see what the history might be, and not necessarily accepting medical or surgical interventions. So i dont know if that is the rationale for your failure to follow that, or it is coincidence, but i applaud it. No, actually, it is a usps task force. The United States has taken it off a recommendation at this point in time. That is why we took it off of our screening policy. Any other questions . Thank you. Any Public Comment on this item . Seeing none. Would anyone prefer a break right now rather than charge through . Yes. [laughter]. We will take we are back in session. We are on item number 11. Item 11. Item 11 is a presentation on delta dental Teaching Network and utilization report this will be presented by the account manager from delta dental. Is it on . Okay. You have a presentation that we will go through. It is really some information and updated stats regarding some of the programs we have implemented as of january first of 2019. So with the first item, we are actually going to talk about our dentist accreditation. There were some questions regarding how we go through that process and so we do credential all of our dentists in the network. Before a dentist can be permitted to those networks to actually be listed as a provider we go through the credentialing and utilize the standards of the National Committee of quality and assurance. And our common practice is that in order, we do have a unit within delta dental that is fully responsible for this credential process. So making sure we are continuing to do this on an annual basis. The credential process, we actually obtain a state license making sure that also the dentist has evidence of malpractice coverage. They also have to provide us with a Drug EnforcementAdministration Certificate and specialty training verification. That would be for a pediatric dentist or an orthodontist where they are having to have additional training because they are providing a specialty within the dentist world. We do verify this annually and we do utilize the National Practitioner data bank to make sure that license is uptodate. We also read credential at least once every three years all the dentists. So making sure, again, not that their license is uptodate , we have a current malpractice insurance policy, we are also making sure that we are sharing with the dentist Employee Satisfaction surveys, or any kind of grievance and appeal that we received for people who are enrolled in their specific practice. So this is only in . This is for the p. P. O. And our premier network. Those are our two networks. Okay. Yes. I dont know, but is there continuing medical education requirements for dentists like there are for physicians . In california they have to show so many hours. Some are specific for certain kinds of training, but most was not. If you are a neurosurgeon, you can your credits can be for the specialty boards now are requiring recertification every 10 years for all the specialties , both surgical and nonsurgical. Are there requirements for dentists . I believe there are, but i dont know the specific our requirements because i do know that we do specific webinars for our dentists, and then i know that they also participate in a lot of the dental Association CongressNational Seminars and conferences that they attend. I can definitely i just want some information. If you are relying on re licensure, which the state does, obviously, and that requires cme, we would note that because you are not asking for independent verification of hours, youre just relying on the state. They will be fine, but we would know that. There are continuing education requirements for dentists in the state of california to the extent that we can provide more detailed information. Just to know that there are. Yes. The next set of slides will talk about the network and under the p. B. O. Plan. And remember that we have two sets of contracts. P. P. O. Contracts and premier contracts with our dentists. And then all members are eligible to Seek Services by a noncontracted dentist with us. So the first slide is on active, your active population. It is for the p. B. O. Contracted dentist, and we ran this report specific to your geographic locations and the particular of the data, or criteria of the data, was within a 10mile radius. You can see on the first slide, it is almost 100 . 99. 7 of your members that are enrolled in delta dental who have access to a p. P. O. Dentist with less than a mile away from their location. On the next slide, it is our premier dentist network. Again, very close, 99. 8 within a 0. 8mile radius. Our next slide is focused on retirees, and again, p. B. O. We are presenting first. 99. 3 in a 1. 2 mile radius. They have access to a p. P. O. Dentist. And then on the next page, premier, 99. 8, a little less than a mile. We are going to transition into your smile way Wellness Program benefits. This first slide is a reminder as to what that benefit is. You did approve that benefit to be installed into your plan both active and retiree plans. This is a specific wellness that for individuals that have diabetes, heart disease, h. I. V. Or aids, Rheumatoid Arthritis or stroke, they can and roll in this plan either by phone, by calling our Customer Service, or online through their online portal, and in role in this plan , and they get additional benefits. Typically this is the scaling where it is the deep cleaning of the teeth that individuals that have inflammation of the gums, and in all five of these chronic conditions, have a result of inflammation, and so typically theres that need to have additional dental work. So now you are providing that free of charge, meaning no charge to the member to have these Additional Services. Im sorry, i am asking questions. So the Rheumatoid Arthritis jumped out. Maybe i have asked this before or maybe i didnt know this, i didnt know if Rheumatoid Arthritis, per se, has a specific dental co