HEALTH COMMISSION CITY AND COUNTY OF SAN FRANCISCO

Sonia E. Melara, M.S.W. President Edward A. Chow, M.D. Vice President Cecilia Chung Judith Karshmer, Ph.D., PMHCNS-BC David.J. Sanchez, Jr., Ph.D. David B. Singer Belle Taylor-McGhee HEALTH COMMISSION CITY AND COUNTY OF SAN FRANCISCO Edwin M. Lee, Mayor Department of Public Health Barbara A. Garcia, M.P.A. Director of Health Mark Morewitz, M.S.W. Executive Secretary TEL (415) 554-2666 FAX (415) 554-2665 Web Site: http://www.sfdph.org 1) CALL TO ORDER The meeting was called to order at 4:08pm. MINUTES HEALTH COMMISSION MEETING Tuesday,, 4:00 p.m. 101 Grove Street, Room 300 or Room 302 San Francisco, CA 94102 Present: Sonia E. Melara, MSW, President Edward A. Chow M.D., Vice President Cecilia Chung Judith Karshmer, Ph.D, PMHCNS-BC David J. Sanchez Jr., Ph.D. David B. Singer Belle Taylor-McGhee The meeting was called to order at 4:03pm. 2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF JANUARY 21, 2014. Action Taken: The Health Commission unanimously approved the minutes of the meeting of January 21, 2014. 3) DIRECTOR S REPORT Barbara Garcia, Director of Health, gave the report. The full report can be viewed at: http://www.sfdph.org/dph/comupg/aboutdph/insidedept/dirrpts/default.asp Centers for Medicare and Medicaid Services Verifies SFGH Compliance On January 24, San Francisco General Hospital and Trauma Center reported that the federal Centers for Medicare and Medicaid Services (CMS) has verified the hospital's compliance with its Plan of Correction (POC) to fix the problems that contributed to the tragic death of patient Lynne Spalding Ford, and that the hospital has made significant progress toward a safer and more secure hospital. Her family is in the forefront of our minds as we continue to work to improve safety and security for all our patients. CMS conducted a thorough investigation from October 30 to November 8 2013, following the hospital s selfreporting of Ms. Spalding s death. The survey covered general security, patient safety/security and privacy. The federal investigators returned the week of January 21 to re-survey the hospital. The surveyors completed staff

interviews, observed practice in the patient care areas, and reviewed documents before concluding that SFGH is in compliance with all requirements. Many of the changes outlined in the POC already have been implemented and we can assure Ms. Spalding s family, and all our patients, visitors and staff, that we are a safer organization today. Working in collaboration with the San Francisco Sheriff s Department, which provides security on the San Francisco General Hospital (SFGH) campus, we have made significant improvements in the key problem areas identified during the investigations: general security, patient safety/security and privacy. A full summary of the improvements is available at: http://www.sfdph.org/dph/comupg/oservices/medsvs/sfgh/default.asp under Helpful Links, the top link, SFGH Emergency Information. New San Francisco Health Network Director of Primary Care Congratulations to Dr. Hali Hammer for being named the new Director of Integrated Primary Care for the San Francisco Health Network (SFHN) effective March 17, 2014. Joining Albert Yu, Director for Ambulatory Care, and his team, Dr. Hammer will be responsible for the strategic planning, integration, delivery, and operational performance of all primary care programs which include: SFGH and Community Primary Care, Primary Care- Behavioral Health Integration, Dental Services, Youth Programs, Breast and Cervical Cancer Treatment Program, Family Planning, Primary Care Quality Improvement, and Urgent Care Services. LHH Prepares for the Implementation of ICD-10 Laguna Honda is preparing for the transition to ICD-10 that will occur on October 1, 2014. On February 5, staff participated in a webinar training entitled ICD-10 Coding and Documentation for Long Term Care. Information has been made easily accessible on our Intranet page which now includes an ICD-9/10 Lookup. This has ICD-9 lookup by diagnosis with a crosswalk of ICD-9 to 10 codes. Over the next several months, Laguna Honda will be assisted by a Clinical Documentation Integrity consultant who will be providing analysis of our most common diagnoses and helping us prepare a cheat sheet for coding of our most common diagnoses. In addition, the consultant will be educating providers on documentation requirements for ICD-10. Jail Health Services Jail Health Services (JHS) is pleased to announce that the Forensic AIDS Project, Jail Psychiatric Services, and Jail Aftercare Services have changed their names to more accurately reflect how each program functions as a fully integrated part of JHS. While all contact information (phone numbers and addresses) remain the same, going forward, our program names will be as follows: Reentry Services (formerly Jail Aftercare Services) Behavioral Health Services (formerly Jail Psychiatric Services) HIV and Integrated Services (formerly Forensic AIDS Project) LHH CNS Recognized Clinical Nurse Wound Care Specialist, Fatima Ascano-Martin has been selected from a nationwide group of nurses to participate on an esteemed panel of nursing professionals of the American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association. In February, Fatima will be meeting with 13 other ANCC members in Maryland to help promote excellence in nursing by reviewing the latest advance practice credentialing program in nursing. 4) GENERAL PUBLIC COMMENT There was no general public comment. 5) FINANCE AND PLANNING COMMITTEE Chung, Chair of the Finance and Planning Committee, stated that the Committee reviewed and recommended for approval the February Contracts Report, requests for new contracts with 13 vendors to Page 2

provide as-needed facility maintenance and a contract with the Kiely Group to provide professional consultation and technical assistance services to support the Departments Affordable Care Act RFP Planning Group. She added that the Committee also discussed the SFDPH presumptive eligibility policies and practices. 6) CONSENT CALENDAR Action Taken: The Health Commission unanimously approved the following: FEBRUARY CONTRACTS REPORT REQUEST FOR APPROVAL OF NEW CONTRACTS WITH 13 CONTRACTORS, A & B MECHANICAL, BEN'S ROOFING, COMMERCIAL STEAM CLEANING COMPANY, JDI ELECTRICAL SERVICES, JW CARPET AND FLOORING, KLW CONSTRUCTION, LIBERTY BUILDERS, RODAN BUILDERS, RUBECON BUILDERS, TEC-1 PLUMBING, UNITED CALIFORNIA GLASS AND DOOR, WATERTIGHT RESTORATIONS, AND WILLIAM DECKER AND COMPANY, TO PROVIDE AS- NEEDED FACILITIES MAINTENANCE SERVICES IN 17 TRADES FOR THE PERIOD OF FEBRUARY 1, 2014, THROUGH JANUARY 31, 2017 (3 YEARS). REQUEST FOR APPROVAL OF A NEW CONTRACT WITH THE KIELY GROUP, IN THE AMOUNT OF $223,216, WHICH INCLUDES A 12% CONTINGENCY, TO PROVIDE PROFESSIONAL CONSULTATION AND TECHNICAL ASSISTANCE SERVICES TO SUPPORT THE DEPARTMENTS AFFORDABLE CARE ACT RFP PLANNING GROUP, FOR THE PERIOD OF JANUARY 1, 2014 THROUGH JUNE 30, 2015 (1.6 YEARS). 7) REQUEST FOR APPROVAL OF THE LICENSE AGREEMENT FOR INTERIM SEISMIC SAFETY MEASURES AT THE SFGH CAMPUS Mark Primeau, SFDPH Capital Advisor to the SFDPH Director s Office, gave the presentation. Comments/Follow-Up: Singer asked if any of the older buildings (10-40) on the SFGH campus can be repurposed. Mr. Primeau stated that the SFDPH has been exploring an option to work with a developer who specializes in renovating old hospital buildings and then leasing them to labs for revenue. Chow asked if UCSF research staff will remain in buildings 10-40 until a new research building is completed. Mr. Primeau stated that if the Health Commission approves the interim seismic safety measures, then the UCSF research staff will be able to remain in buildings 10-40. Chow asked for more information on the plan for building 5. Director Garcia stated that the SFDPH is exploring using the building for clinical services. She added that SFDPH staff will eventually move from buildings 10-40. Sanchez asked about the plan for building 80, where many vital community services have been provided. Director Garcia stated that there is planning underway to ensure that the services in building 80, in addition to the other older buildings, will continue to be provided on the SFGH campus. Action Taken: The Health Commission unanimously approved the seismic safetymeasures at the SFGH campus. 8) DPH 2 nd QUARTER FINANCIAL REPORT Greg Wagner, DPH Chief Financial Officer, gave the presentation. Comments/Follow-Up: Singer asked for more information on the 2-4% variance for the Public Health Division. Mr. Wagner stated that projections for the Public Health Division are dependent on current contract spending and amounts of funds that have been encumbered. He stated that the $1.8 million loss of revenue noted in the Page 3

report is due to the postponement of the sale of a piece of SFDPH property that was projected to be sold this year. Although the property will likely be sold next year, the change of timing results in a loss of revenue for this fiscal year. Another variances is due to the California Children Services funding; generally there is negative revenue which is offset by saving in salary and fringe benefits; the SFDPH usually budgets a cushion in its revenue on this line-item to allow the SFDPH to spend the money but if the funds do not come in then the money is not spent and the budget is not negatively impacted. Singer asked the reason why the revenue from the primary care clinics is projected to be reduced. Mr. Wagner stated that the rates of reimbursement have been reduced which account for some of this reduction. In addition, he noted that historical budget statements show a shortfall of revenue for this area. He noted that there is a offset of salary and fringe benefit savings. He also stated that implementation of eclinical Works in the clinics resulted in a planned drop of productivity for a period of time until the clinic staff acclimate to the new system. There is also an increase in the managed care population with more capitated revenue; therefore clinics are using non-standard types of visits that do not generate the higher fee-for-service revenues. Singer asked how the SFDPH manages its budget with the factors that are out of the SFDPH or City s control. Mr. Wagner stated that the SFDPH does not have an operating reserve to deal with the budget fluctuations that are beyond the control of the SFDPH or City; he added that he would like to move towards having an operating reserve. He also stated that an important improvement the SFDPH has made is providing fiscal and client outcome metrics to managers to include them in the accountability of their section/unit s budget. Karshmer asked for more information on which areas with the SFDPH are most impacted by the shift from fee-for-service to capitated rates. Mr. Wagner stated that captitated rates will impact both SFGH and primary care clinics. He added that SFGH currently has most of the capitated revenue. He also stated that ratio of fee-for-service to captivated rate will be changing, moving towards 20-30% fee-for-service and the remainder being capitated revenue. Karshmer asked if primary clinics are provided data for their own clinic and other clinics to give a comparison. Mr. Wagner stated that clinics are given data related to their clinic and the benchmarks set for their clinic so they can gauge their performance. Karshmer requested that the Health Commission be given a chance to review an example of these reports. Karshmer asked if there are plans to address the shortfall in salary and fringe benefits costs for mental health. Mr. Wagner stated last year, the SFDPH, along with the Mayor s Office, focused on fixing the structural issues in the SFGH budget; this year there SFDPH will have to choose to work towards fixing the structural issues in either Jail Health Services, Mental Health, or Health-at-Home. Director Garcia asked Mr. Wagner to briefly update the Health Commission on the State Plan Amendment revenue. Mr. Wagner stated that for the last four years, the SFDPH has expected revenue from the State Plan Amendment, but has never received any funds. He added that when received, these funds will have a large and positive impact on the SFDPH budget. Chow stated that the Jail Health Services budget issues stem from the fact that the Sheriff s Department is not paying the total cost of services related to the work-order between it and the SFDPH. Mr. Wagner stated that the census in the San Francisco jails has dropped substantially which has resulted in a reduction of Jail Health Services staff needed. He added that the level of staffing in the jails is often determined by the MOUs between the City and labor unions that determine staffing ratios. Page 4

9) UNIVERSAL HEALTHCARE COUNCIL REPORT: RESOLUTION Colleen Chawla, Deputy Director of Health and Director of Policy and Planning, and Aneeka Chaudhry, Office of Policy and Planning, gave the presentation, which explained the Universal Heatlhcare Council s findings, and highlighted some of the suggestions offered in the report that pertain to the City Option and Healthy San Francisco. Public Comment: Susan Shargel, Shargel and Company Insurance Services, stated that the Affordable Care Act (ACA) and the SF Health Care security Ordinance are in conflict. A key problem is that employees who have access to health reimbursement accounts (HRA) are ineligible for insurance subsidies through Covered California. Many are not enrolling in insurance because of the cost of unsubsidized premiums. She recommended adding language to the resolution to indicate support for thorough review of the City ordinance requirements that prevent enrollment in Covered California subsidized insurance plans. She also recommended leveraging funds to assist the business community to provide health insurance. Micah Weinberg, Bay Area Council, stated that the implication of having a medical reimbursement account (MRA)on someone s ability to access subsidizes on the exchange is currently unknown. The IRS has yet to determine what the policy will be. He urged the City to obtain a ruling from the IRS in writing. He also encouraged the SFDPH and the Health Commission to not lose focus of the many lessons learned from implementing a service delivery system through the implementation of Healthy San Francisco. Ian Lewis, Local 2, stated that half of all uninsured people will remain uninsured due to the lack of affordable insurance. He added that ACA insurance plans are not subsidized for low-income people living in an expensive city like San Francisco. He stated that he had a different take on the question of whether MRA can be used to subsidize payment of insurance premiums, saying that it is settled based on assurances from the City Attorney that the MRA can be used to buy subsidized insurance. He also urged the Health Commission to do what it can to make sure that any employer loopholes are closed. Michael Petrelis, Sunshine Activist, stated that the public is not getting the information it needs from the Health Commission because its meetings are not televised or the video posted online. He added that the information being discussed at this meeting impacts many people in the City. He added that conducting outreach can be assisted by broadcasting the Health Commission meetings to the public; the slides in the presentations need explanations and context. He urged the Health Commission to find a way to televise its meetings or to move to City Hall. Comments/Follow-Up: Singer asked for clarification on when the SFDPH will understand how consumers have interacted with the ACA insurance options to know how to shift and optimize the SFDPH service delivery system. Ms. Chawla stated that it will take up to two years to fully understand the impact of the implementation of ACA. She added that Healthy San Francisco enrollment data and SFDPH clinic experience will be good information to use to gauge the impact of ACA implementation in San Francisco; due to the influx of state and federal data systems related to the implementation of ACA, there will likely not be informative data from the state or MediCal for some time. Chow asked for clarification on the differences between HRA and MRA. Ms. Chawla stated that the HRA is a benefit for an individual through his/her employer; the MRA is a public benefit through the City of San Francisco. For the City MRA, an employer contributes to the City Option and the City determines an individual s eligibility for the account. She stated that the City has been advised by the City Attorney s Office that the City MRA can be used to subsidize insurance premiums. She also noted that more people will now be eligible for the MRA, and gave the following example: Page 5

If a San Francisco resident made $30,000 a year and did not have health insurance provided by his/her employer, the employer previously may have contributed to the City Option and the person would have been enrolled in Healthy San Francisco. Since the implementation of ACA, this individual is now eligible for subsidized health insurance, which makes them ineligible for Healthy San Francisco. Instead, the individual s employer contributions would now go to a City Option MRA, which the employee may use to help pay for insurance premiums. Chow asked for clarification on the City Option and added that the SFDPH should thoroughly study the Health Care Security Ordinance including the City Option. He added that the Universal Health Care Council Report s recommendation should be used as a framework to make the Health Care Security Ordinance fulfill its intent. Chow asked for information on the process for individuals who were enrolled in Healthy San Francisco but who are now eligible, through ACA, for health insurance. Director Garcia stated that the SFDPH is studying many options. She added that the SFDPH developed a limited waiver for some HIV positive individuals to keep them enrolled in Healthy San Francisco to ensure continuity of care for them while more permanent solutions are studied. Chow requested that as solutions are found, the SFDPH should be developing guidelines to help the public understand the complex nuances of the system. Melara recommended exploring the possibility of giving incentives to small businesses so that they will provide health insurance for employees. Taylor-McGhee asked if the Universal Healthcare Council had a operating budget. Director Garcia stated that the Council was managed through in-kind support of existing SFDPH staff. Taylor-McGhee asked for more information on the budget and process of outreach and education to the public to encourage enrollment in available health insurance programs. Ms. Chawla stated that the Mayor s Office has spearheaded a program to enlist many City Departments to encourage enrollment in ACA insurance for those eligible. She also stated that 70% of San Francisco s uninsured adults were enrolled in Healthy San Francisco. The SFDPH is able to email, text, call and/or mail information to this group as part of this outreach effort. In addition, Ms. Chawla stated that the SFDPH applied for a grant to conduct outreach to populations who are difficult to reach such as people who are incarcerated or families will multiple immigration issues. Chung stated that she sits on the Presidential Council on HIV/AIDS, which is looking into how ACA implementation is impacting people with HIV throughout the country living in states with or without Medicaid expansion. Sanchez stated that there will be constant changes as the ACA implementation continues to roll out; he is appreciative of the community collaboration that makes San Francisco such a high quality service system. Karshmer stated that the Universal Health Care Council s guiding principles should be included in the resolution s Whereas section. The Health Commission will vote on the resolution at its February 18, 2014 full Health Commission meeting 10) OTHER BUSINESS Singer congratulated the SFDPH staff for having three articles in Public Health Reports, a public health journal. The articles are: Partner Services as Targeted HIV Screening Changing Paradigm, A Public Page 6

Health Framework for Developing Local Preventive Service Guidelines, and Epidemiology of Viral-Hepatitis- HIV Syndemic in San Francisco: A Collaborative Surveillance Approach. Melara requested that in the near future, the Health Commission be given relevant information to consider its options regarding posting the audio and/or video of its meetings online. Chow requested that either the full Health Commission or the Community and Public Health Committee be given an update on Emergency Medical Services with a focus on the paramedics. 11) JOINT CONFERENCE COMMITTEE REPORTS Sanchez, LHH JCC Chair, stated at that the January 28, 2014 JCC meeting, the Committee reviewed the second quarter Gift Fund Report and approved an expenditure for a Laguna Honda Hospital resident. The Committee also heard presentations on the Rehabilitation Services and the annual Health at Home Report; Commission Sanchez recommended that the Health at Home Report be made to the full Health Commission at a future meeting. The JCC also approved policies and procecures and, in closed session, approved the LHH Credentials Report. 12) COMMITTEE AGENDA SETTING This item was not discussed. 13) CLOSED SESSION A) Public comments on all matters pertaining to the closed session B) Vote on whether to hold a closed session (San Francisco Administrative Code Section 67.11) C) Closed session pursuant to Evidence Code Sections 1157(a) and (b); 1157.7; Health and Safety Code Section 1461; and California Constitution, Article I, Section 1 BHATIA VS CCSF D) Reconvene in Open Session Action Taken: The Health Commission voted not to disclose the discussions held in closed session. 14) ADJOURNMENT The meeting was adjourned at 6:21pm. Page 7