And what is happening to them . A small fraction of them, i would bet, 5 of them make rounds in the hospital, on their own time to see their patients during hospitalization, by may be brief of longer. I understand the model, butt system but the system doesnt really encourage that and all of a sudden, the primary sort of gets handed a patient on discharge and sometimes the hospitals, they institute a program where the hospital called the patient a week later to see how theyre doing, but after that, the hospital was out of the picture. Assumption was the primary care, but they have, as in every health care system, not just kaiser, they have their hands fall just dealing with walkins that dont have insurance that day [laughter]. I want to make sure and i think this is your understanding, that the presentation wasnt about complex Care Management just in the obgyn setting. I know that, yeah. Its across all areas. I know in the discussions weve had in working on all of this, there has been a great deal of attention making sure that when members are discharged from the hospital, that there is that connection. So while i know that is not your area of specialty, we can certainly get somebody in here who can talk about that. I know in all of the prep work weve done that is a major focus. So maybe its a discussion about what has changed possibly. Because it is my understanding that is happening. Yeah, and the other thing i would say, we dont have to the apm model youre describing exactly, but we have brought back some elements of that. Over the past years weve worked to strengthen our medical assistant and physician partnerships. I was at lunch with three assistants who were talking about every day, every friday, they talk about their patients that theyre outreaching to. They share patient stories. The shared the story of a gentleman through their care team they were able to bring down his home globen from 1 down to 5. Not a nurse, but the m. A. Is also helping with the Care Management for the physician and weve brought Behavioral Health back into the primary care sort of team. This has been a focus over the past several years, making sure that is happening. But i didnt mean to say this was only for obgyn. Commissioner follansbee i understood that. I only hyded because i know that highlighted that because i know that department in San Francisco is the platinum standard for management of problems of any level of severity and complexity. I guess that, again, some of this is my prejudice from my own training, is that the nurse is the one in the complex chronic who can answer the phone, deal with any kind of problem, yes, you need to call an ambulance, yes, i can help you get in to see your kidney specialist, yes, i can help with the durable medical group. I will tell you, unless things have changed, the medical assistants, the behavioralist, all those people great at what they do, cant respond to the complex chronic patients urgent and semiurgent requests and i guess i would like to hear nursing that been reinvigorated into this role. Maybe im too vague. I appreciate that. I know we use nurses quite a bit in helping with that. I think that the fact is that the other piece of it is the email. For better or worse, that is an easy access point and a way for it to come through the primary care doctor and for the doctor to decide how to disseminate that and connect the patients with what they need. Whereas more traditionally, it was a call to a nurse. But what about members who dont have access to email . Commissioner follansbee im sorry. One more thing. Its a bugaboo. One is that i get a call, if im not picking up my most expensive medication from a pharmacist in their time frame. Because its so expensive. They want to make sure im adhering to it, i appreciate that. But all the other blood work asked for on a routine basis, because im not following a chronic condition, ive been ordered by my heart specialist, i get no reminders. I have no way to go into my medical record and find out what was due. And so i know that i had lab that was due at three months and i made the decision, because i remembered that, to wait six months, because i didnt think i needed it that often. So i went in when i thought i was ready. Thats great for me as a retired physician, but particularly for the chronic complex patient, the medical record doesnt support their selfmanagement. Gee, maybe its time you check out the peak flows. We havent seen documentation of that. See what im saying. I guess also i would say also we need to do a better job of advertising. My patients just joined k. P. Because they moved to california so im able to have proxy access, see when they refilled medication, see when theyre due for screenings. The app is one we did for just that. The my k. P. Meds app tells you when you refilled medications, when its coming due. Thats the other tool that we created to address that gap. I dont know if that commissioner follansbee it does. Just to point out that your list of manage the health care, misses i can see when the last hemoglobin was, but i cant see if i have one on order. And when that was due. And so thats what im trying to sort of bring in. That in order to get the results that you want, and want the member to be kind of in charge or his or her caretaker or spouse or whatever. It would be nice if there was a little more enhancement in that regard. Thats the only thing. That is good feedback and it is constantly being enhanced and changing. Absolutely, hopefully this will help to continue the discussion. I know there is still followup. And were happy to talk about complex Care Management as long as we need to. So director, we can follow up and see what other discussions we have, but im glad the doctor could come and share some of the information. Any other questions . Thank you. Thank you very much. President breslin is there any Public Comment on this item . Richard again, retiree. Ive been a kaiser member for more years than i care to remember. The kaiser doctors are great. I know two instances when a doctor came in on sunday night and operated and another instance, the doctor operated at 3 00 in the morning and saved the persons life. The integrated system is fine, but there is one flaw. Its the home health care. Kaiser contracts out with staffing nursing. And these staffing nurses are great, but they cant communicate with electronically with kaiser. They dont have access to kaisers date database. They cant send email to the doctor like a photo or send an email or communicate with the doctor. You know, either the kaiser patient has to do it or they have to send you know, do it over the telephone. And i think this is a serious flaw. You know, what upsets me is that kaiser wants to give a lot of money to the warriors and to the sharks, but they need to fix their infill system. Their doctors are great, but like this nursing issue. This really bothers me. Because its happening with my wife. And you know, the nurses are great, but they should be able to communicate with kaiser doctors. I dont see why cant they do that. And other things, about the shingles shot. Ive been waiting over a year and kaiser hasnt communicated. They said come in. Apparently now they have a weighting system, but why didnt they send out an email about it. I have to hear the only reason i heard about it, because my friends not in kaiser got them. So i started asking, you know, just by chance, my doctor told me to come when he got it to see him. And they didnt have any. Then i found out there is a waiting list. I dont know how long the waiting list is. And you know, there are other things. Try calling durable equipment sometime and waiting on the phone for 45 minutes or a half hour. The other thing, my doctor ive seen for 30 years is cutting back. And the only reason i knew, because i was in to see him, but when you go online to make an appointment, you dont get him, you get apparently hes training the new doctor why doesnt kaiser send out an email saying he is retiring and you can see this other doctor, instead of looking online. If i went online, would have started calling up and saying why cant i see my doctor ive seen for 30 years . You know, kaiser needs to get down in the weeds and fix some of the issues before they start spending money on the warriors and the sharks. Thank you. President breslin thank you. Any other Public Comment . Seeing none. Now well go back to number 8. Back to the regular scheduled agenda. Item is the finance reporting as of june 30, 2019, and as of september 30, 2019. This is presented by pamela levin, the chief financial officer. Pamela levin, chief financial officer. Im going over the report for fy201819. The report in front of you i know is dense and long. This typically would be given at the same time as the audit results. Those are still delayed we think, as i understood from yesterday, that i thought they were going to be out in the middle of december, or next week, and i think theyre still going to be delayed. But all the data that im presenting is exactly the data that will come out in the financial report. They just havent finished all the work. So the trust ended fy1819 with balance of 91. 2 million, this is increase of 4. 7 million from the 17. 74 balance as of june 30, 2018. Ill discuss the increases against this 92. 1 million fund balance. The 4. 7 million increases because of 3. 6 million decrease in the trust fund associated with United Health care ppo plan, resulting from subsidizing the 1819 the 2018 and the 2019 rates from the stabilization reserve. And unfavorable claims experience. Particlely upsets partially upsets. Unfavorable claims experience is offset by the pharmacy rebates and the 3. 6 million decrease in the trust fund. For blue shield access plus, there is a 7. 1 million increase. This is several different factors are contributing to this. The first one is that we had a buyup in the rates to cover the 2016 and 2017 deficits that blue shield had. There are pharmacy rebates and favorable claim experiences. These are offset, these positive balances are offset by incent to payment to brown and toland for the 2018 year, plan year performance. For blue shield trio, there is a 5. 5 million increase in the trust fund balance. Its resulting from the buyup in the rates to cover 2016 and 2017 deficits. There is also pharmacy rebates and favorable claims experience. For delta dental selffunded plan, there is a 1. 2 million increase in the trust fund balance. Resulting from favorable claims experience. Which is offset by the use of the stabilization reserve to subsidize the 2018 and 2019 rates. We have a 800,000 increase in the trust fund associated with kaiser due to three factors. The first is the impact of the pay calendars through the School District and college district. When you have fiscal year ending and there is still a contribution coming from the entities. And thats the its just a timing factor. There is contractual provision governing the timing of the Premium Payments and also members are moving from active to retiree and from nonmedicare to medicare status. There is 100,000 decrease in the trust fund balance associated with claims payments for flexible spending accounts exceeding the payroll deductions as a result of the timing and the reductions. Its the same sort of thing. When the fiscal year ends, there is it doesnt necessarily mean that that all the payroll deductions are actually done. There is some timing issues. Weve always had that. There is 400,000 increase in the trust fund balance due to forfeitures for flexible spending accounts. As we discussed before, the irs allows forfeitures to be used to fund the administration of the flex spending accounts. The forfeitures reside in the trust fund and the expenses for the administration reside in the general fund. So a transfer is required at the end of the fiscal year. So on the chart that you have, at the beginning of the report, youll see a forfeiture is up 400,000 and then negative transfer for forfeiture, fsa administration. I want to note that we keep this transfer to the minimum required to fulfill our obligations in terms of our budget. And we dont transfer any more than what is actually brought in from the forfeitures. There is 500,000 increase in the trust fund associated with the Health Care Sustainability fund. The table that is in there shows budget versus actual, but at the end we have increase of 500,000. There is a 2. 9 million increase in the trust fund associated with investment earnings. This is considerably better than what we had several years ago. I think we can all remember those years. And there is 400,000 increase in the trust fund balance for performance guarantees which is net of the 100,000 dollars paid in 1819 under the adoption and surrogacy plan. There was 8. 1 million in pharmacy rebates received in fy1819. The end of the year, 92. 1 and for the fund balance, but there are obligations and reserves against that. So im going to go through those. There is 44. 7 million in future obligations against the 92. 1 million. Trust fund balance, they consist of 23. 5 million in contingency reserves, 16. 1 million in stabilization reserves. 3. 9 million for the Health Care Sustainability fund. 1. 2 million in performance guarantees for the adoption surrogacy benefit. And after that, the total is 44. 7 million in future obligations. Once that is netted out of the 92. 1, the fund balance is 47. 4. I provided a chart to look at where we are in terms of, you know, the fund balance and then the future obligations. And over the last five years and youll be able to see that the value of the future obligations and reserves has remained relatively stable since 201617. Turing now to the general Fund Administrative budget. There was a balance of 698,000 at the end of the fiscal year due to delays in hiring. After we carried forward 195,000 into this year, a balance of 504,000 remained. We went to the Controllers Office and Mayors Office and requested manual carry forwards. These are up to the discretion of the it requires approval by the Controllers Office and the Mayors Office. They have to be justified and we had 130,000 carried over into 1920 for professional services, materials, and supplies and work orders. You cant carry over surpluses or balances in salaries and fringes. So is there any questions on this report . Id like to take that before i go onto the next. The report for this fiscal year. Okay. All right. I turn to this fiscal year. So were giving a report that summarizes through september 30, 2019, and then a projection for the year end being june 30, 2020. In terms of the trust fund, as i just reported, were starting with a balance of 92. 1 million based on the activities through september. The fund balance is projected to be 89. 1 million, which is a decrease of 3 million. Were projecting no change in the fund balance for the ppo plan. For access plus, the fund balance is projected to increase 11. 2 million primarily due to pharmacy rebates and favorable claims experience. And i just like to put a caveat on all of this, this is only three months, july, august and september. So you know, the crystal ball is not fully developed until about may when we can tell you what well end up in june. For the trio plan, were projecting 8. 9 million decrease in the fund balance primarily due to large claims incurred in july, august and september. We have were working with aon and blue shield to dig deeper into this the large claims. Were projecting 3. 4 million decrease in the fund balance fort delta dental selffunded plan. And that is a result of subsidizing the rates and and when you look at this, its greater than the favorable claims experience. For the Health Care Sustainability fund, were projecting a yearend balance of 1. 8 million. This when you look at the projection in the chart, that is provided in here, budget versus actual, and the projection, were projecting 14. 5 14,000 left at the end of the year when you just look at the annual expenses and the annual revenues. Which obviously indicates that the expenditures, annual expenditures, ongoing expenditures are cripesing at fast increasing at faster rates than the revenues and well have to do something about that. In terms of investment earnings, were projecting 1 million. There are no performance guarantee payments received as of september 30. We paid out a total of 45,000 under the adoption surrogacy assistant plan through september. And we are projecting that we will use 200,000 for reimbursements this fiscal year based on Prior Experience in what were seeing right now. Just to right size this, when you went to approve the servicing adoption plan, we set aside a maximum of 300,000 would be distributed in a year. So were still staying well below, as far as im concerned, well below 300,000. The ammana forfeitures or unused spending account balances, which i described coming to the trust, that wont be known until july 2020 after the runout. And as previously described in terms of use of the forfeitures for the administration of the flexible spending accounts, currently there is a budget of 600,000, but as i mentioned before, well only transfer forfeitures up to the amount that the forfeitures come in and no more. So at the maximum, it would be 600,000, but as you can see from this year, it was 400,000. And in prior years we havent transferred anything at all. I have tried very hard to be fiscally responsible for the forfeitur forfeitures. No pharmacy rebates have been received this fiscal year, but we are projecting an 8 million balance based on prior years experience. The plan showing the expenses compared to the budget of premiums. The cumulative expenses are tracking higher than revenues for the uhc ma ppo plan and the expenses are tracking lower for access plus and delta dental. Again, three months into the fiscal year, well continue to work on that and see how that flows out and continue to monitor it. And then in terms of the general fund right now, were projecting that well end the year on budget. Is there any questions . Commissioner follansbee can you go back to page 4, the blue shield trio flex funded. You said there was during this period, 12 million decrease in fund balance due to unfavorable claim experience, what kind of claims are those, do you have any idea . So in trio, let me make sure i have the right report. Were talking about through september . Yes. Yes. So in the last three months, weve seen a peak in high cost claims. Those are claims over a Million Dollars. What happens with trio is that the correct me if im wrong, mike but in trio, the risk on the claims is born by blue shield. So while this is alarming, t