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tv   Government Access Programming  SFGTV  April 18, 2019 5:00am-6:01am PDT

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governance a warehouse will be implemented for long-term data use. there's been a day in the system build so if you are looking at the system configuration in january the date test for training had been completed however, we have remaining what are called build buckets with epic so build bucket five and build bucket six and pre-live build bucket as well. we are extending that out. right now we're anticipating and it looked good. we had a report out today april 19th, build bucket will be done and we hoped to vit done april 14 and we're days out from the date but will be completed this
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week. build bucket six we're targeting for april 26. i am showing you 6/19 on the slide because there's other content build and pre-live builds that will continue on but they won't affect other things at that point in time. testing because we were focussed on completing the build buckets also with -- was extended but we're looking to be back in may for integrated testing. you might say why was the delay. why did it happen. it's about two primary reasons. we had some staffing challenges. staff have left the project for a number of reasons, for personal reasons. some were let go for performance. we did have staff take time off for medical reasons and one is going to med school. there's not a pattern to them leaving. what we're doing with that is hiring staff on as soon as we
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can and using consulting personnel to close the gap but every time we have someone leave we lose the resource we needed. and we have the agreed upon use of ethic foundation has been a challenge because it's looking at a new system of across d.p.h. acting as one organization and forcing the issue of making decisions d.p.h. wide. all these have contributed to the delay but i'll talk about it in a couple slides what we're doing to make sure we're not going to have further delays. this outlines the activities going on. then a little bit of an accomplishments. we continue to have build. we know we're well over 21,000 now. direction setting decisions we're at 1,945. 120 interface connections and still testing so 900 plus
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testing issues we've identified and resolved. as of today we have 109 days before we go live. and we will. the design and build i have change the status here. it's from green to yellow because it's been a watch date. we added additional resources onto the team. right now we're ensuring all the s remainings which are not just in the build buckets are in one place and they work on the tasks on a daily basis and signed out and check in so we're tracking closely to that. i'm pretty confident it will be back on track on testing in the same situation and we are behind because of enrollment and we're currently at 34% enrollment. enrollment has proven to be
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complex. d.p.h. is centralized in issues going on with d.p.h. as well. we've been work closely with the controller's office to use the investment in people's soft and their management system. with the centralized enroll many plans to catch up with the enrollment goals and there's no immediate impact to live because we're behind in enrollment and have complexities with the enrollment and we have moved this to a watch state. we're an early dao adopter to the early management system. interfaces, good news for you here. it's green. so the presentations are slightly behind and this one is gren and on track. infrastructure and infrastructure and technology on a watch date. since the inventory was slightly behind and that means we look up every single work station and every single printer and label printer and bar code reader. we know where it is and have to say where it is in a particular
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location and that inventory is not completed. we have half dozen left to do. we have a technical database where we look at every printer and everything connected to it. and on here as part of this data conversion from the exists systems to epic is on target with thousands and today i heard that 150,000 patients had been converted over to epic and we're validating that. we're next moving clinic data over and go live is on track. contracts an budget has been in a yellow state. contracts are moving up with the final contracts being finalized. so moving on to training. our goal is to train them and feed jam was given and that has
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been incorporates into the curriculum. trainers arrived this week to help with te training. we'll be training them between now and 5:24 and begin user training may 28. principle trainers create the content and other trainers do the training and. 10,000 providers and staff averaging 15 1/2 hours per learn in e-learning and in classroom training and our capacity is 26 classrooms with 620 seats. we'll be conducted two sessions per day to accommodate the training staff or over 130,000 offering and over 120 different classes. so the training staff is currently 117 trainers.
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tea -- 52 provide tore provider resources and the credentialed trainers. both provider resources have been offered by their respective services to perform training and super users will not be conducting training we're using them for at-elbow support when we go live. go live planning is on track. we're doing cut over which is complex. that's underway with the plans and details for that now. we plan to have a command center a centralized i.t. with spokes at laguna, zuckerberg and san francisco general and ambulatory. we plan to provide four weeks of 24/7 support. i hope that answered your questions you had, commissioner
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green. >> i'm the chief information officer for the health department. i'll give you a very high level update on how we're organizing the project from the perspective of a business project not an i.t. project. these are the domain groups we have stood up over the past year. they're essentially haired by some of the most senior leaders in our organization including senior directors. spa they're supported by a project manager either an internal d.p.h. manager or external consultant. these bodies of the groups that includes frontline staff managers, champions that have participated and informed the adoption decisions and build decisions that we proceeded on
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and they're looking at how to get the organization ready and staff and training and super users are identified and ready to support the work in the next three months. this was the simplest way to organize a complex slide. i was trying to illustrate how the organization change management structure with the domain groups line up with the lean daily management structure that zuckerberg, laguna honda and p.h.d. and other section have undertaken. i'll orient you to the vertical columns first. the vertical columns are broken into three is meant to show how the tier 1 to tier 4 status huddles or the stand-up daily huddles are being sku skukt executed.
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this top row is the structure of the organization with zuckerberg or primary care and the operational level frontline staff does the daily huddle in the work in the next 24 hour cycle. the tier 2 and 3 are the managers and d.m.s. leaders doing the service line or clinic level improvement board huddles and the tier 4s are the suites at each one of this divisions. the first diamond on the top row shows how the super user coordinator and operational readiness coordinator as part of the structure and work we i'd tide for each one of the divisions and a cooperator for the super users and can speak to the c suite whether it's a command center or training or the technical dress rehearsal in
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terms of end point devices. that's where the coordinators as well as the office of health and informatics lead. that's as well the o.c.m. program director is the key resources that connect the t3 and 26 -- t4. they're right in the center of the problem solving. the bottom line are the o.c.m. project manager. that hern huddles with the domain group with their weekly huddles. we have an integrated domain group meetings where every one of the managers including the super user coordinator and operational coordinator and informatics leaders look at the issues across domains. there's many training issues that are not domain specific. so that's where the second integrated meeting happens.
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then obviously every tuesday we have an epic project leadership team where the application in addition to the o.c.m. team and training comes together to talk about issues ta that cut across work streams we talk about. this is a simple way to try to visual for you how we're providing project management visibility, tracking of although issues that are surface from the standpoint of the business as part of the readiness work the top left is an example of the epic super user program visible at loo -- laguna honda and the bottom left is an example of a high level project plan by domain areas so we can actually track all the gap closure areas
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and the bottom right is a more drill-down level. the green/blue vertical bar gives you status of the high value targets which are areas we have to make sure we either clarify, establish, formalize before go ready and the numbers on top are examples of super users that have been nominated and volunteer. to give an example, we're using a model consultant who respected a 10% super user count based on total employee as a model to best support our go live
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internalization and the more the better because they know the environment and they'll be trained properly rather than having external consultants. we didn't expect to hit the 10,000 and with 7,000 employees, some may be redundant but from the initial numbers is promising and reassuring there's interest internally and they believe they can have super users and still keep the lights on while we prepare for go live. that's all the slides in terms of the o.c.m. program. >> dr. green. >> elaborating more on the
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training how are you allocating the expectation of classroom and individual training and have you looked at what they'll be responsible for in a classroom setting? >> i'm responsible for he training program. >> the training has the e-learning or structural aid training component. there's over 1200 classes and e-learning are paired together relative to the job roles the end user perform. curriculum has been baked out by the principle trainers and tested. ultimately when they're in the
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classroom we're looking for super user support and they'll look for peers who are struggling and we'll be able to identify individuals who need nor -- more coax org one-on-one support -- more coaxing or one-on-one support before good live because we'll have time from end of july until we go live. we can reinforce the training prior to go live or make sure the super user resources have been identified to coordinate and support them. >> one more comment, epic has incredible data that tracks how long a user, regardless of the role or duties, using the epic system outside of what they call
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typic typic typical schedule and they will show you literally down to individual user by program by area so that we can target them post live to see why you're spending hypothetically four hours at the clinic and i spend 30 minutes and we're in the same clinic. that information comes from epic navigational tracking will be informative for us in the post-live state to begin to identify either certain programs or certain areas where we didn't build stuff right therefore it took the area much longer versus certain individuals within an area that may need more specialized focussed retraining or observation to see why you may be taking longer than i i am in the same clinic and that will be used to gauge post-live
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additional training. >> commissioner guillermo. >> commissioner: my assumption is the overall epic implementation is going to be pushing up demand on the time line and achest achievement and some of the priority will have to change and some of the considerations on how are you going to deploy staff and be able to move up the requirements particularly around cyber security and i want to compliment the enterprise wide
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strategic plan because i think it covers a lot of what's required and given the way the department is structured it's structured for success but however, it still has to be execute and the resources and the requirements that are going to be placed on the epic implementation. the fact we don't have a permanent position. it's going to be difficult to manage and so i'm just wondering, how are we going to be able to assist in making sure that this strategic plan isn't something that just looks good on paper and then is not necessarily going to be able to be
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this isn't just about i.t. resources but about operational resources too. i think those are two areas we can look at and i'm also going to say this is going as a bit of a road map. here's where we are for our next c.i.o. and the next working with business and operations around the constraints you're describing, when we know we have to make an inroad in some of these things in a smart and fast order. >> i would just it would be helpful to get a baseline on a number of these things so whenever things are going get moving, and i'm assuming some is being stood up already, it's easier to pressure and for us to be as informed as we possibly can, when and if the constraints begin to push up against other
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priorities. and in fact the potential for not being able to achieve some of the goals stated in the plan. >> thank you. we'll bring benchmarks in as they develop. >> dr. chow. >> commissioner: thank you for the report and for the optimism of the go live date. and also for correcting one of those is really green. it seems to me that our next meeting in a quarter is going to be at the time that you will or will not meet the deadline. >> we will. >> commissioner: good. i want to be initially alerted if there are problems they need to be brought to our attention
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prior not anticipating problems. i'm looking towards and after we reach the end of this phase 1 or wave, wa -- what we would be looking at for the next parts of the roll out of epic and the , looking at for the next parts of the roll out of epic and the1, looking at for the next parts of the roll out of epic and the strategic plan going back to commissioner guillermo's point. i think it's only fair to be able to ask the new c.i.o. have an opportunity to review this because it's with the considerations he or she to carry it out. we also need to have some sort of time frame in which then a confirmation of the strategic plan and probably maybe around that same time the next waves that we're going to to be
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looking at so that i think the process has been very valuable and the staff has been incredible up bringing us the data and to simplify what are thousands, if not hundreds of thousands of moving parts. and at the same time, really be able to improve the operation itself to reduce the number of major incidents compared to 2015 and to actually put in place an up-to-date. and follow construction projects because he's. and if they don't become surprises to us or to the public
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and that we also then could be supportive of where we're going. so i wanted to commend you for that. and for giving us a brand new chart showing why the yellows are there because you put the actuals out and i think that's another indication of being aware of where you are and the confidence you have i commend you for and we look forward in august to learning it's right there and someone's pushed the button. and the outlying clinic is able to log on. that would be really nice. >> maybe we can do something in the director's report month to month so you know. >> and to reiterate the commission's thinking on making sure the new c.i.o. they're in alignment or have their perspective on the strategic plan is something we talked about internally as well.
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we had to move forward because it didn't make sense to wait because we'd been waiting so long. in the big picture of things the strategic plan is right in probably most areas but there's room for adjusting and there's going to be surprises in the process because it's a changed management system. we'll be transparent and manage the surprises as effectively as possible and to bring that to you but to emphasize that piece as well. thanks. >> commissioners, any other comments or questions? thank you very much. >> i'll note there were no public comment requests. item eight is the d.p.h. annual report.
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>> good evening, commissioners. thank you for your time. i'll try to be as exciting as the last one. i'm here from planning to present the final draft hopefully the final draft of the annual report for fiscal year '17 and '18. thank you for your time. last time i was able to incorporate most your recommendations and there's a few outstanding items we were unable to given the time frame but it's in our work plan and we'll make sure to take active steps to make sure they're
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incorporated for the next report which will be worked on in the next few months. i'll talk about what the outstanding items are in the upcoming slide. as you're aware the annual report is requirements by the city administrative code and provides a summary to the department's accomplishments over the past year. we've maintained the overall format and design elements over the last few years and switched the colors to incorporate a different part of the spectrum for this year. the report opens up with a message from director colfax and his introduction touches on the highlights featured in the report. the first is the black and african american health initiative and the major milestones they touched on and
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accomplished this year. the healthy streets center and the department's role and also the epic e.h.r. up plentation -- implementation we just got a got a great update. followed by a transmission from director chow on the work that was done with lean for the department and altogether the messages both provide an introduction of our leaderships and introduction to our department's work and accomplishments an expresses and reaffirms d.p.a.'s commitment to all san franciscans in the midst of federal uncertainty. the next section in the introduction is an introduction to d.p.h.'s two major divisions
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for the health network and population health division. that's followed by an overview of true north. and that was a recommendation from director colfax. there's the update organizational chart and altogether the secs provide the function -- sections provide the function and services the department offers. the final part of the introduction resection is focussed on the health commission provide overview of the structure, functions, biographies of commissioners and a recommendation from commissioner chow to include community assignment for each commissioner. the largest section focuses on feature stories and highlights that span the accomplishments over the past fiscal year. the first one is the black
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american health initiative and milestones they've accomplished and in the fourth year of existence, and these are around leadership developments and policy developments and goal planning, community engagement and data sharing. the next feature is on b.p.h.'s role in the news and in the media and even intermly. it's an expansion of efforts that started and the mission where d.p.h. was central in planning and implementing. and we have a unification of homeless needs and street
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cleanliness and other public safety issues. as a co-lead agency, d.p.h. has taken a leading role in staff education and training and outreach and engagement throughout the city. what does d.p.h. do? we offer comprehensive health care services. we identify individuals and top users of multiple systems. we hold healthy health fairs to help people who would not otherwise be accessing the services and have harm reduction and treatment services. there's syringe disposal efforts and more things. the third highlight feature is the implementation and showcases some tremendous progress that's been made in the past year where winona and her team just shared
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with us. after that, there are 24 shorter highlights that span services and programs and into the four major categories of protecting health, promoting health and building infrastructure and lean. i do want to thank they'll d.p.a. staff who drafted these highlights and sent them over and help us edit them. they were invaluable to this. while we were unable to incorporate a couple stories that were requested, we have taken active steps to make sure we worked with the programs on the p.a.c. side especially to make sure those are incorporated into the draft for next year's report. >> some of the things we want to showcase as was recommended was how does the department provide
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more tangible benefits outside of health care services for reside residents and businesses and other san francisco kiss cans. the other -- san franciscans. here we have budget data, expenditures and revenues and major investments such as $8 million to expand health bed capacities and patient demographics, payer sources and population health focus areas on the strategic plans and some of the program impact metrics. these include things like tobacco secession, training, healthy retail, link to primary care. based on recommendations from the planning and finance committee. we've added data on responses to
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hazardous materials. violations uncovered regarding legal tobacco to individuals under 21 years old and hiv diagnoses over the past decade and added the client health numbers and i want to thank the b.i.u. and b. hvm s. staff who were -- b.h.s. staff who were diligent to make sure our methodologies were lining up. a couple things we were not able to incorporate we'll prioritize for next year to include things around vision zero updates and highlights around the transgender health program. regarding the vision zero, there is the one situation where they
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report the data on a calendar year in alignment more on the city and they had an agreement with the controls office to report on a calendar year and so we want to support that and avoid any confusion with how we showcase our successes in the program. and so we'll work with them to see how we can best incorporate into this and any feedback you have is always welcome. the last part of the number section and the data section is are the health care resolutions that were passed the last fiscal year. wrapping up the report. we have locations in our health note work and they were updated
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and we included a list of our contractors who are invaluable partner in the work we do. the last part is a list of website link to d.p.h. resources. information on the health network and healthy sf and for those who are looking and some foundation partners as well. we'd like to continue to streamline this report moving forward and we are prn -- open to any ideas you have, commissioners and i'd be happy to take questions or comments. >> commissioner: thank you for bringing this back in final draft. commissioners, any comments or questions, commissioners? dr. chow. >> commissioner: thank you for being able to incorporate the suggestions some of us made on the early draft copy and so you
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were in the slides in protecting and promoting infrastructure but the titles don't match coming across and that's just a small issue on page 18. homeless advocacy is actually under promotion and you've still got it as protected.
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>> it reads fine but if we're going categorize it this way you just change the power point. it's not substantive but just trying to match the presentation. and i think for the future, while you have added some population health data, i think as you also consider it, i think it'd be good to add more out of environmental health and so forth and things like the various things that we are doing with restaurant surveys and so forth and as win of the public -- one of the public sites you might want to put in terms of access to coverage and
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care, i know a lot of people do use the environmental health restaurant thing. so it just shows kind of the general public also has the ability to have an interest in looking at the scores for the restaurant reviews. other wise i want to commend you for the work you have presented us with, thank you. >> thank you, commissioner. >> commissioner guillermo. >> >> commissioner: i wanted to congratulate you on a nice comprehensive report and fairly well laid out and logical and comprehensive given everything the department does. i was wondering, you have a section by the numbers a couple things, one, because of how the
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orientation to the work that shows up when we sit here and we hear the staff and members of the community talk about how well things go most the time, it would be helpful, i think, to have that reflected in the next report so numbers are good but stories or i have a quote by james baldwin somewhere or maybe quotes from providers or patients or the staff or something would help bring to life what otherwise be too objective in terms of numbers. the other is or maybe and i don't know whether this goes on online or not, but some vignettes or something that tells a story in that way. and then just in terms of presentation, i think particularly where there are bar charts where there's lots of bars, there's new ways of
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presenting data that is not column or pie chart that might make the numbers easier to read. again, those are nitpicking but if want to use it as a way to promote the kinds of accomplishments the department has made and to showcase that i think it might be helpful to consider some others. it's just well done, otherwise. >> commissioner green. >> i'm so impressed by this and so well done. we hear about the segments of the work in the meetings. when you see it in a report in its entirety besides being an excellent primer document and you look at the moving parts and the people that have come together and the staff and public, everyone has fed into the report. it's nothing short of remarkable
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to me. this is emblematic of the effort and it seems like it's written by one person and your editing has been wonderful. very much appreciate what you've done. thank you. >> so thank you so much. >> other question or comments? >> commissioner: i guess the last comment, and we've had the battle of how many numbers and people's stories. also, i think it would be good in the future and have you done some of it for some areas in which we highlighted good programs but also be able to not only characterize people that have been improved or how many outcomes we had done. we listed a good number of
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programs and we should be able to also then discuss the health. >> we're working towards that in our system wise initiates so hopefully we'll able to add those for next year. >> thank you very much. >> thank you, commissioners. >> clerk: item 9 is a resolution approving changes to the sliding scale program and change and change to patient billing and financing assistance programs. mr. wagner. >> good afternoon, commissioners, greg wagner chief financial officer. so we are here today to have a second conversation on the topic
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of billing practices particularly at zuckerberg general hospital. we had a hearing about two months ago at the commission and had director's reports items and we're here to follow-up and bring you our proposed recommended actions to address this issue. there's been a lot of conversations about the billing practic practices at our public hospital and a lot of centers around the issue of balance building which is the situation where the insured does not pay the full bill for the patient they are ensuring and the patient is left with the breaking news -- balance of the bill to pay on their own. it's a national and local issue at our public hospital and we
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have spent the last several months looking at what we can do in our you're of control to improve the way that we conduct ourselves and improve our practices around this issue. it's really clear to us having looked at this and spent some time thinking about this, there are gaps in our systems. we provide excellent patient care at our institutions and including zuckerberg san francisco general. for those affected by the billing practices we're not taking optimal care of their financial well being and that's important to us as a public hospital serving the people in this city. we spent a lot of time working on this. there were concerns and so we've been working on this and excited
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to come with recommendations we think can help do a better job for patients. i'll just say i'm up here but we had the whole department that's been focussed on trying to find areas we can improve. the ceo at zuckerberg has been working on this and the financial services team many of whom are here today and they have been as we've been developing recommendations, they've been sitting the ground running and trying to implement these as we go. many changes are underway. again, balance billing is when a private insurer pays a portion of the patient bill and leaves that balance to the patient.
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on february 1 after the conversation started coming to light, february 1, mayor breed issued a statement we're halting the practice of this billing so we placed a freeze on the practice of balance billing and gave ourselves a 90-daytime line to come back with recommendations. so the 90 days is approaching and we're here today with those recommendations. we had a hearing february 19th and at the board february 21st. also a little bit of a refresher on background of the scope of this issue. and we have about 104,000 patients per year. of those, the vast majority 94% or so are not affected because
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they're medicare, medical or in a plan that does not have a balanced billing provision under state law. there say group of about 4 -- is a group of about 4,000 patients in pp plans and 1700 are in plans that potentially affected by balance billing. so it's a relatively small group of our patients. but the fact is that for those individuals that are affected by this, it's a real issues and they're often while they're recovering from going through whatever medical issue that brought them to the hospital they're also dealing with the stress and anxiety of grappling with a complex financial system and potentially large bill they have to deal with. so there are a few areas we
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focussed on. our current financial policies, we have policies in place that provide several protections for people particularly on the lower end of the income spectrum. so up to about 500% of the federal poverty level in terms of income. we have programs in place but there are gaps in those programs and we've identified some of those and we have recommendations for you to look at here today. above 500% are programs to provide financial assistance to those patients are much more limited and that's been a key area particularly for people in san francisco we're being over 500% of the federal poverty level it's very difficult to live in a high-cost city at those levels and people cannot always afford a significant medical bill and that can be very disruptive and difficult.
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we've got some recommendations in that area. in addition to improving our patient communication and experience. that's how we communicate and work with patients on the financial situation in addition to their medical care. in terms of recommendations. we have a few core recommendations that are part of this plan. there's more detail in some of the materials that went to the commission but will focus on some of the larger recommendations. recommendation number one is that we are proposing to implement a new policy where patients who are insured, if they come to zuckerberg san francisco general, and z.s.f.g. is out of the plan we will charge no more than their in network plan so if they would
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pay a certain co-pay or insurance or deductible that what we'll get from insurance and charge them and continue to appeal to insurance and work with the insurance on getting adequate compensation for the hospital. that's consistent with proposed legislation a.b.1161. -- 1611. interdufd by asem -- introduced by assemblyman chu and it would make it state law. we're looking at that and the bort of supervisors passed in support of that provision so we're proposing to implement that based on the fact that it may become state law but also on the fact that it seems like a
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reasonable public policy solution. in addition to that there's the charity care and discount program. this is in addition to and complementary of the first recommendation. this recommendation would establish out-of-pocket caps what we would bill patients for and not limit our ability to work wing insurance to try to secure maximum reimbursement or the services we provide at zuckerberg san francisco general and provide a cap for patients based on their income and i'll go into more detail how the caps would work. but this is complementary to the first proposal for several reasons. this would affect people uninsured and affect people insured but having an out of pocket expense unaffordable
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based on income and also affect people in case where's they would have received a service not covered by their insurance or denied by their insurance so this is a second layer of protection for the patient. thirdly, on our financial policies we're proposing amendments to the existing sliding scale policy that would reduce the cost sharing for the very lowest patients we're seeing in our hospital. that's the 0% to 138% of poverty level will bring the fees down to zero. we're proposing to eliminate the asset test a provision in the sliding scale policy which take into consideration other financial assets for income for determining whether somebody's eligible. that could be someone low income but living off savings. we will take that into consideration and acknowledgement of the fact even
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if you have some savings you why living off of a big medical bill could be extremely disruptive to a patient with a very low income. and there's some provisions in our sliding scale policy where individuals who have lapsed their coverage in healthy san francisco need to reapply under this provision and will automatically apply this sliding scale policy to them while they're in the process of re-enrolling healthy san francisco. [please stand by]
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to provide financial protection for patients at higher income levels. >> just a little bit in terms of what this out of pocket cap
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means, there is a lot of information on these slides. we have included additional tables. the appendix to the memo on presentation that went to the health commission, but what you are seeing here are the current and proposed out of pocket payment caps so the existing discount policy and proposed discount policy. i will give you an example. if you look at the second horizontal bar. a patient at income level between 139 to 200% of federal poverty level high end is $24,280 per year. under current policy for an in patient stay, we have a cap of about $1,000 per day up to 10 days. maximum of $10,000. we are proposing to significantly reduce that to
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$250 per day for 3 days or $750. for outpatient, the current out special share of cost is $1,000. we propose $350. we have done similar out of pocket caps going up the income scale, and you can look how those change as you go up income scale, but again for 500% and over there was no out of pocket cap in place prior to this proposed policy. under this policy we would have out of pocket caps for each of the income levels. highest would be for those over 1,000% of the federal poverty level, $121,400 or a family income of $251,400 for a four person household. for those the out of pocket cap
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would be $1,600 per day for maximum of three days. highest out of pocket payment we would charge a individual is $4,800. these numbers the way we came to these numbers was by looking at our existing charity care and sliding scale policies and applying those on a graduated scale with the idea we would set the caps so in no case does a person pay over 5% of their income for an individual towards a medical bill. that was kind of the threshold we used for the categories. that is at the top end of income ranges so many cases in between would be lower than that. i will make one brief note. there is an issue we have been
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discussing with the tax collector and city attorney, there are cases today we may have a patient who comes in and has been injured. later on down the road they receive a payment from some third-party insurance. that could be health insurer, insurance payment through a lawsuit, and when those payments are calculated based on partially at least on patient's medical expense and the insurance payment is made in part to compensate for medical costs, in those cases, we do intend to continue to work to pursue that patient. we do get in a situation where the insurance company will pay the patient and the patient does not turn over the reimbursement to the hospital. the tax collector's office works with us in those cases to work to get fair compensation for the hospital for those unpaid services, and in those cases we would