tv Government Access Programming SFGTV May 9, 2019 10:00pm-11:01pm PDT
higher, right? 30% were not. yoyou know, anyway i am against any increases at this point in the plan because of the cost already and i don't know the percentage of people that take the health plan. that is one of the reasons they don't. go ahead. anybody else? >> okay. are you asking for a motion? >> go on page 18. do you want to do the motion individually or in total? >> finish the representation in page 18 here. >> recommendation number one on the active employee dental ppo plan to accept the recommended 2020 rates as presented in the
document with 5.3% reduction from 2019 to 2020 as well as holding the 2019aso fee for the 2020 plan year. >> i was enter training the possibility of moving recommendations 1, 2, 3, 4 and leaving 5 separate. if you feel we should take them individually, we can. maybe we can deal 1 through 4 together. i would recommend that we approve recommendations 1, 2, 3 and 4. >> i second the motion. >> any public comment on this item?
>> i would really like to. >> please state your name. >> gail ow is my last name. i would like to give stories to what karen has brought up. as a retired person, i went to the doctor and found out i needed a crown right then and there. there is no time to switch. often times if you are going to switch, you have to have an agreement with the dentist ahead of time. it looks like this is coming down the line and it is going to cost this much. you know, plan for it. having these differences in costs is something that a person can't really use that in making the decision because you find you have to have a root canal. usually you are in pain.
that is an issue. also, when you do need that person, then you have to find another doctor in a different program, a ppo, that is accepting you and wanting to do the work and it would entail x-rays. i think it is much more complex than the difference in the rates. thank you. >> any other public comment on this item? please come forward. >> . >> diane with the u.s. f retired division. i have a question. i got a phone call from my
dentist that they are no longer in the delta dental network. am i still eligible if i am out of network provider. i would like to keep the same paiperiperi dentist. >> sharon with delta dental. smile away is for in and out of network dentists. you can still be in the smile away program. >> any other public comment on this item? the motion would you please state the motion. >> to approve recommendations one, two, three, four as
presented in the minutes. >> that was seconded. >> i seconded it. >>ault those i -- all those in . opposed. it is unanimous. >> i asked for recommendation number five on page 19 except the plan design changes as in the document for the retiree ppo. move the retiree p po co-insurance from 50 to 60% as outlined on page 16 and move the premier and out of network individual deductible from $50 annually to $75 annually. >> i would like to make a motion to accept the plan design changes as presented in this document. >> second for number five, right?
>> number five. >> any public comment? >> one comment. we approved the rates the delta dental ppo. these are the design changes within retirees on premier or out of network will have a increase in deductibles. for those retirees that will be going to the ppo, there is an increase in the coverage it would be from 50%. the share would be from 50% to 40% for the crown and for the procedures. i am going for that one. this is purely the design
changes. >> may i absolutely clarify what i am asking you to vote on. item four you approved page 12. these are the rates for 2020. no change in rates for 2020 regardless of whether you approve number 5 or not. if you choose to approve number five, the plan design for the retiree p po for the 2020 plan year will be what is listed on page 16. if you choose not to approve number five, the current design listed on page 14 will remain for 2020 plan year. >> how about for item number four three year to the end of 2021. would that apply also if you approve the design change number five? >> the rates pulled through
december 21, 2021. >> are you making an item number four? >> number five. we passed four. >> i'm sorry, yes. >> could i comment as well. i want to make sure we tease out the concern about quality of delta dental ppo providers. if that is an issue i think we need to address that separately with delta dental or any of the providers. i don't think the board is in a position to be recommending a panel of providers that we find inadequate. some of the comments that say assume that ppo dentists are not as good as other dentists, i think it is not something that we have had evidence presented to us. if we have concerns about that based on member complaints or whatever, then that needs to be
addressed in a separate discussion. >> i understand the comment. we are not recommending retire wrist to move -- retirees to move that is their choice. i will remain on premier dentist will assume my deductible will be increased, but we are not recommending the retirees to move. they still have the choice if they want to remain out of network premier or ppo. all we are doing is making the planned design changes to benefit those that would go to a ppo dentist. >> any public comment on this item? >> you know, it is kind of a
tough call because most people love their dentists probably more than they like their primary care physician. i used to say when i was on the board our dentists are more important than gynecologists. we were having a little discussion in the back there. this is a tough one. i think we like the improvement of any benefit. it is always a plus. one of the things i looked at, if i am getting a crown from $600 to $1,500 depends what kind of crown you need. it is a lot of money. this additional $25 for the year is from 50 to 75 annual deduction. that 25 bucks is nothing compared to my 60% coverage and 40% i am picking up for the
crown. i don't see this as really impacting retirees all of that much. it is a high expense. if i go to a ppo dentist for 60% for the crown it saves more than 25 bucks for the year. i think this is a better deal and you should consider it. we watch every penny. in this case when it is a matter of annual deductible and the biggest expense is for the service, let's keep urging preventative care and hope weault keep our teeth in good shape. i have a beautiful set of crowns that kept me going for year. consider this option and vote positively. thank you. >> any other public comment.
all those in favor of item number 5. aye. opposed. motion passes. 4-1. now we are on to item number 11. >> review and approof staff recommends to not renew best doctor second opinion services presented by mike clark aon. >> on page one of the document we started a recommendation summary. we offered expert medical case review, expert medical pip services through the best doctors organization since january 1, 2017. this is available for all
members enrolled in sfhsf medical plans and retirees. this serviced commenced under a three year service agreement that ran january 2017 through 2019. after careful consideration of the services rendered under this agreement and review and also looking at the services that they provide to members that seek expert medical opinions which we will hear from the health plans to further describe approaches. we recommend today to the health service board that they not proceed with the third-party medical opinion service to the 2020 plan year. that means allowing this agreement with best doctors to
expire on december 31, 2019 as it is scheduled to. on page 2, we recommend the focus be placed on increasing knowledge and promotion how members can seek expert medical opinions within their health plan environments. we provide information in this material on that. this recommendation including a provision to include evaluation of expert opinion services and further marketing activities on behalf of sfhsf. page 3 lists one of the contributing factors behind today's recommendation. that is low utilization of the service during the past two years it has been offered to members. less than one-half percent has
engauged the best doctor service during the period of availability. we present a table where down at the left side are particular services that are available through best doctors that have been discussed by best doctors representatives at prior meetings. you will see data so you have an active member column and retiree and the sum total members. to the left is 2017 data. to the right is 2018 data. these are the number of members utilizing the various services available through best doctors each of the past two years. keeping in mind your overall base is over 120,000. though best doctors proposed a
reduction of the per month fees for 2019, you will see that in the. i should say 2020. you will see that in the appendix for details. that was on top of the reduction for 2019. there is an underlying question whether paying for the third party to deliver the services not integrated with the healthcare provider is prudent. we will talk about what they are to deliver for members. we know the plans have mechanisms. from is regular recognition that can be increased. posting the procedures of the plans on the website, on pages 5 and 6, we have listed out information that each of the plans have provided us so the
uhc city plan for non-medicare active employee and members for the ppo medicare advantage ppo for the blue shield access and trail plans and the kaiser plans that cover the non-medicare population and the medicare plan. you will see that on pages 5 and 6. rather than me readings through the tables, what i would like to do on page 7 is ask for comments from each health plan to comment to allow members to seek expert opinions. we also have fliers illustrate these for members. i did this alphabetically.
i will ask a representative from california to discuss their approach to expert medical opinions within the plan. >> . >> good afternoon. paul brown, director of account management for blue shield of california. i want to say first that all of our members are always entitled to a second opinion for any course of treatment or surgical proceed ush. any member with any question about a diagnosis they receive or they believe that they just need additional information regarding any condition this they have learned about, entitled to a second opinion. you generally go through your
primary care physician as you would for any course of treatment. your primary care physician can refer you for a second opinion. >> if it is a specialist with a second opinion that surgeon or specialist can give you a second referral or you can go through blue shield for that. for a surgical procedure, the common question is can i be referred outside of my medical group. implying if it is within the medical group you may get a rubber tamp opinion from your first opinion ag and we allow people to go out said of their medical group to seek a second
opinion from any blue shield specialist. >> any question on the blue shield policy? >> do you need a referral? >> yes, you need a referral from your primary, specialist or blue shield. >> can a person use a doctor in access plus? >> that is a good question. i don't believe they can. that would be in the providers in their plan. a trio provider would be access to any provider that is not exclusive to their group. it could be any group in the trio plan. >> they couldn't switched. >> so that was my concern. they may want to go out of, you
know, in both it is a delegated product, it has to be within the network configuration of your plan but you are not, you know, limited to in the case of a second opinion the medical you are involved in? check. >> in the bay area we have a number of medical groups. they could go to any one of those for the second opinion. >> they could pick a doctor and ask the doctor to refer to them aas lockas long as they were ine group. >> say that again. >> they know a doctor they would like to be referred to.
>> that is why we allow the members to go outside of the medical group to give them the feeling of a second opinion that doesn't have a relationship with the first opinion. >> any questions? >> board members? no. >> i want to ask you a question. you talked about th the customer service team for the trio here. >> this would not be for access plus. part of the configuration is a combination of customer service and clinical. there are pharmacy techs and medical directors on that team so they, too, with medical
background could assist in helps navigate that individual to a second opinion. they are used to this and can help guide people to another specialist. >> it is just access plus, just trio. >> yes in the trio design. >> concierge has been broadened to include all kinds of services. in san francisco and in many urban areas, concierge service was add on. individual members might pay to their preferred divider for additional access. if it is e-mail or phone access.
there are a couple doctors who charge $25,000 per person per year. those providers accompany them to every sub specialist examination and interview. it runs the gamut. it is a world that blew shield used in a different context than we may be hearing from neighbors and friends and shouldn't be equated with $1,000 or $12,000 a year for additional access. >> i would agree. it used to be the guy in the front of the hotel, now it is everything, includes primary care, food charge. thank you. >> i will ask for representation from kaiser. >> area vice president for
kaiser. as blue shield said kaiser supports second opinions. the process of this would be that any member can talk to a specialist, primary care physician or if they are not comfortable about the second opinion they can go through member services and choose from 9,000 physicians to get a second opinion. the beauty of the delivery system is that information will go right to their medical record which sets them up with the physician along with the person who gave them the second opinion. can somebody go outside of the network? there will be times that we may not have a specialist that treats a certain condition, and there may be authorization to go outside of the network. in general we find our members
find with 9,000 physicians an opportunity to see someone else within the network. if we have somebody who wants to go outside of the network and pays for that, our physicians are open to discussing any opinions they get from other physicians. i will too questions at this point. >> i want to be clear. you have to find a person in the network. >> they can find them themselves. >> the tests are the same tests that came from the original doctor and the same everything? >> not necessarily. each doctor practices independently and may choose different tests to order. it would be a new visit like going to any other physician.
>> that is my concern they are using the same information from the original doctor since it is all in the same system. >> i had a visit with a physician. that is what people feel. he said physicians arepletety determined what they want to do in their practice. if you would have asked many. they would go. there is no one directing kaiser physicians to do anything. >> i thought the doctor could should light on this. he has a lot of practice in this. that is my concern about kaiser. >> i am a retired physician. i have had contracts with everyone of our providers. 16 years forser his and 16 years for kaiser. as a physician i found myself
recommending to members they get another opinion. for example, a pathology report. i would talk to the pathologist. i have sent this to stanford. second and third opinions can come from the provider community. that is sometimes transparent to review the lab result to the member. i was in a position for 33 years to refer to out of plan specialists who had more area expertise than i did. i don't think i had denial from the health plan aing, no, you are our boy. you have got to do this. i do think we need to recognize
providers should be accountability for thee decisions and recommendations and be open to new suggestions and all of that. i could order tests as a kaiser doctor or blue shield doctor that were not on the normal menu sent to specialty labs that got covered and were done as i had ordered. >> the member paid normal laboratory fee. they weren't charged for a test within the contracted lab with blue shield. with the specialty labs they didn't pay more than normal lab co-pay. >> any other questions here? thank you. we have one more. >> we will ask for
representation of united healthcare on this topic. >> good afternoon, heather with united healthcare. there are differences on how the plans work. i will talk about city plan for early retirees. city plan is ppo and the members have in and out of network benefits, they can see any provider for second, third, fourth opinion. the only thing that will differ is the cost share. based on plan design they are responsible for their could insurance. they can seem another opinion both through customer service, talk to them and they will find another provider to see that is available. >> shannon with united healthcare.
it works same with the medicare advantage ppo. the provider does need to participate in the plan. >> i think your plan is ideal. thank you. any questions? no. the thing i was concerned about is when people are not feeling well, they can't do things themselves. they can't goat denied for an appealna asking that didn't work. it should be easy to get a second opinion. >> i will take you to the recommendation page. to note in the appendix we have contained rate and financial information on the fees for best
doctors. for you to know that it is here to round out the information we are presenting on this topic today. with that i will take you on page 8. today we are making the recommendation that the healthser chris board approval allowing the agreement with best doctors to expire on december 21, 2019 with the 2020 plan year. again in recognition this recommendation comes with the understandinunderstanding the pl increase awareness how to seek expert medical opinions within the framework of the health plans including posting information on the hs.org website and the evaluation of
the expert opinion services will continue as part of any future vending activities. >> any further questions? i think i need a motion here. >> i move that we accept the recommendation to allow the best doctors contract to expire as indicated in our recommendation. >> i second the motion. >> any public comment first as a member of the board. i want to say that i reviewed all 336 consultations provided in 2017 and 2018. there was a summary. i didn't review the data but
reviewed the summaries. i want to thank best doctors. they were very complete. they did not include identifier other than gender. it didn't include age, race, religious preference. i was blinded to look at the health the than. the expert opinions were comprehensive and very expert. despite some initial concerns the first time i reviewed the first set. the recommendations were interesconsidered a change. they seem to have cleaned that up. i really think they did provide a valuable review and accurate
review. the members who repond ponded to evaluate their reaction it was very high by the members lieu utilized this service. it was a tribute to their expert opinion and time spent. there was one treating physician who showed up and 336. he seemed to appreciate the consultations. there were snow mather respect. i -- i would congratulate any discussion about cost savings. that was bogus. over and over the cost
associated with the recommendations, there were cost savings but they were all sort of fabricated because it made a lot of assumptions. saying you saved $17,000 by recommendations the bilateral cataracts that he could avoid the surgery if he stopped driving at night was not the $17,000 cost saving to avoid the procedure if they didn't drive at night, they could drive in the day. iowa president to point out the -- i want to point out the issue early on there was no quality assurance plan. when there seemed to be a question about accuracy of diagnosis. there was no way best doctors got back to providers to where
this interpretation mate have happened and the resolution. that is a serious concern i have. best doctors clearly is correct in saying they have no doctor patient relationship. this is a review of records. there is no personal contact. then have more response built any other provider would have in care of our members. they have not come up with a resolution of the issue regarding when there were concerns about diagnosis how that information was handed. were they correct or incorrect or whatever? i feel very strongly that we as a board need to hold our health
plans accountable for the quality of care. that includes not only accuracy of diagnosis and cost benefit analysis. we make sure they are getting timely and comprehensive discussions about the care presented. there were cases where it was a first opinion. the member was asking about surgery when he or she hadn't seen a surgeon. the provider would say esophageal surgery but they had never seen the second opinion. those are not the kinds of situations on which we should allow. members need to know that they need to trust to some extent the
providers we are offering and get their opinions upfront. if the they have questions whate mechanisms are and they should include treatment and surgical options. they need to start with using our health plan providers. it was a lot of cases that showed ability to communicate with providekers. you want me to have a surgeon, maybe i should see my surgeon. they are saying experience with best doctors, i think the challenge is to us as the board to provide optimal care and i
support the recommendations aree accounareaccountable for that c. >> public comment. >> catherine guy, retiree. i reviewed the best doctor's report from last month. the discussion recorded in the minutes expressed concern about utilization. it does not address what you just mentioned in the minutes. how do you increase? >> yesterday i discovered a staff recommendation to not renew the best doctor's contract. in the reports on rates and benefits they note that best doctor's services is eliminated.
i oppose this. second, because it is a valuable benefit. members have expressed gratitude for it. when i was diagnosed with him wh lymphoma. i wanted to know what the physician who was going to do the bone-marrow transplant was best route to go. i made a big deal at kaiser and at the time i was director of health services that might have had something to do with it. maybe not. i was permitted t to have a secd opinion it was the choice i wassent going to take that ensured i would get into renation with a bone-marrow
transplant. with the second choice i might not be standing here today. if the cost is too high negotiate down. if there are concerns about quality work with best doctors to have that quality issue conversation. when directorian directoriant mr statement. if you had an opportunity to have a second opinion, would you take that. urge no or vote to delay until those occurred. lastly i would just say i didn't have the benefit of second bin. i was within kaiser until i made a big deal. in i hadn't made a big deal they could have flipped a coin. i urge you to vote no on this.
thank you. >> i am representing sciu10-1 retirees and the csf. the feedback from members that utilized this service has been positive. what i found when i speak to pre-retirees, they are not aware of 24 benefit. this is an option and benefit. the other thing that occurred to us most people who are going to utilize best doctors are getting the kind of diagnosis that might be unusual. it is not the go to the doctor with the flu. they are not calling to find out if they have the flu or allergy. it is something much more serious and meads something.
i think it is not going to be something that is minor and we are only going to fix your wrist as i did for tendonitis. when it is more major they are utilizing this. utilization needs to be in context. i am understanding what you mean and i think it is up to our providers to be forthcoming about the options within the plans. when i have listened toy retirees includes one who used it for himself. his father is a retired police officer and used it for his father as well. his father is almost 100 years
old. this was impressive. this was a benefit they were grateful to have. i don't think we expect high utilization. then we have a lot of high claims and dealing with rates higher what this provides. it is that option. when people hear they haveited those who used it and this is overwhelming to me, they all have had very positive responses on you it worked for them. please reconsider your vote. thank you. >> usf retired division. i would like to second. i would like to ask a question
about kaiser. the kaiser representative said if we want a second opinion outside of kaiser like at sanford we could do it at our expense. if we chose to do that and that second opinion brought us information which would lead to a different treatment or more effective treatment than what kaiser had wanted, would kaiser pay for that? we need, i think, in the united healthcare people can go anywhere in the conduct tree. we need the opportunity even if we pay for it upfront of getting the second opinion and if it leads to new information kaiser needs to cover the cost or provide those with cancer, heart
disease, i have paid to go outside of kaiser several times. twice they agreed with what kaiser said. it made me feel better. it made me more accepting. i used best doctors twice and found it immensely valuable. thank you. >> i can address the issue you raise generically and say that obviously every treating provider has to be comfortable with the recommendation because they have to sign off on the prescription. as the infection disease doctor i saw several with lymes disease and went outside of kaiser to doctors who recommended a host of therapies which i was not comfortable prescribing. most of those individuals found
somebody in kaiser to do that. it wasn't an infection disease doctor but they found somebody more kind than i was or whatever. they did take those recommendations. i don't think that kaiser practices medicine just like blue shield doesn't practice medicine sin more united health care. they are providers independently licensed in the state of california. in their best judgment they would give any member the feedback of where those recommendations fall. at least one physician who was included was very appreciative of the recommendations that came from the best doctors expert. i think he did that to prescribe that. there were probably a lot more
examples of that. everyone wants the best thing. the question is it done only at mayo clinic or someone advertising in the paper or handout or who is that? at least our health plans are accountable to their own providers and monitoring the quality and recommendations and should get the feedback one way or the other about that so they can take actions that they need to.
>> withkaiser the way to get action is to file a grievance. if you are not well that is not the easiest thing. i had an experience with kaiser where a specific doctor recommended something to me but the doctor at kaiser to get it i had to file a grievance with kaiser. i filed the grievance and won. if you are really sick it is not easy to go through. >> any others? >> well, i guess i am a little confused that the best doctors isn't here. it would be interesting to hear from them sort of their take on all of this. i would be more comfortable given the public comment about how potentially use full this
service is actually hearing or giving best doctors the opportunity to explain their service. i would be inclined to continue be this item and give them an opportunity to respond. >> i believe they were here at the last meeting, weren't they? >> yes, and i would comment they did not -- we encouraged them not to present the cost savings data because we felt it was not contributing to the conversation. i wanted to calm that out. we also as part of the strategic plan did a request for information on a number of services available out there with 200 plus startups a day in healthcare. i am not sure this was the case when best doctors was selected. there are several other entities
shifting the model. the model best doctor has was their best effort to provide this extern expert opinions that they provided us with. helping members find a doctor abother services. the up take in the utilization everyone i have spoken to including those entities with employers who are having the same struggle with both low uptick of services, they are not budging on the price. we have gone at them several different ways wanting to have a case rate for the most highest level of consultation but there is no -- it is not a pal littable number and they didn't present a way to manage it.
so they knew, i spoke to them myself this week we were having the hearing and made it clear the recommendation and they chose not to attend. i think it is a state of the market more than anything. i don't know that the current model has these cumbersome aspects to it. for the plans neverred and institutions and let alone the practicing physician. those are the things as i said we did build it into the request for information. we are seeing several different
>> even before going to best doctors, they could get a second opinion. >> okay. , any other comments? there is a motion on the floor to approve allowing the existing service agreement with best doctors to expire as scheduled on december 31st, 2019. with this continuation of third-party expert medical opinion service by the 2020 plan
>> we decided we stand appear and talk individually about health plans. for this year's cycle, without a be helpful to start the conversation that we will have about each of the three individual nonmedicare plans by a short presentation that provides an overview of what is happening with the renewals across the plans, what total right member -- rate contributions that we will be looking at, and other information that spans each of the active employee and non medicare retiree health plans on page 2, i described that is the purpose of this material, and you'll focus for the cycle 20 plan is what other plan costs will be, how are they impacting 2020 rating actions, whether they be a self-funded plan like united healthcare, flex flaunted -- funded plan, blue shield plans, or fully insured kaiser permanente plans.
and then baked into our recommendations include a few plan design change suggestions that we believe will be beneficial to members on the united healthcare plans. will be talking about those individual presentations and what those are. so everybody can see the total rate increases that we are going to present today that are shown at the bottom of page 1. both on a before rate stabilization adjustment basis, just purely based on the experience of the plan, and then for those plans were rate stabilization applies, blue shield plans and the u.h.c. p.p.o., what the adjustment is after stabilization. kaiser does not have stabilization adjustment because it is fully insured. you will also note the asterisk footnote at the bottom of the page.
the five-point 9% increase from kaiser, 1% is due to the return of the federal affordable care act help ensure tax for 2020 after was suspended by the federal government for 2019. some commentary on the specific rate actions that i discussed on page 1, for the blue shield plans, to .3% increase, 0.9% for kaiser. they were higher increases in 2019, approximately 90% overall. what we are finding that is especially with the plan, now that we have one full year of actual experience, that the plan is doing well. and so our increases are substantially lower than just general trust -- trend cost expectations for good news on the blue shield plans. for kaiser, we do want to remind everybody that we have a 0.3