Minutes of the Health Commission Meeting Tuesday, August 19, 2003 at 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The meeting was called to order by President Chow at 3:05 p.m. Present:  Commissioner Edward A. Chow, M.D., President Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Lee Ann Monfredini Commissioner Harrison Parker, Sr., D.D.S. Commissioner Michael Penn, Ph.D. Commissioner John I. Umekubo, M.D. Absent:  Commissioner David J. Sanchez, Ph.D. 2) APPROVAL OF THE MINUTES OF THE REGULAR MEETING OF JULY 15, 2003 Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Penn, Umekubo) approved the minutes of the July 15, 2003 Health Commission meeting. Commissioners’ Comments Commissioner Chow noted that an omission from the minutes of July 1, 2003 had been brought to the Commission’s attention. These minutes have been approved and finalized at the July 15, 2003 Health Commission meeting. However, Commissioner Chow stated for the record that Dr. Katz commented on July 1 about the Blue Ribbon Committee charged with studying the Mental Health Rehabilitation Facility. Dr. Katz mentioned in the meeting that he is chairing the Committee and that it will meet in the second week of September. Dr. Katz noted that he would provide an update about the Committee to the Commission later in July. Dr. Katz noted that the update is happening this month instead as part of the Director’s Report. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE (3.1) Central Administration-Policy and Planning - Request for approval to retroactively accept and expend 52 recurring grants from the State of California for FY 2003-2004. (3.2) AIDS Office-HIV Health Services - Request for approval of a modification of a sole source contract with Mission Neighborhood Health Center, in the amount of $14,157, for a total contract amount of $84,597, to provide HIV treatment outreach and counseling, testing and referral services targeting HIV-positive Latinos/as living in and around the Mission District, for the period of January 1, 2003 through September 29, 2003. (3.3) AIDS Office-HIV Prevention - Request for approval of a retroactive contract renewal with Aguilas, Inc., in the amount of $334,418, to provide HIV prevention education services, for the period of July 1, 2003 through June 30, 2004. (3.4) AIDS Office-HIV Prevention - Request for approval of a retroactive contract renewal with Black Coalition on AIDS, in the amount of $144,169, to provide HIV prevention education services targeting the African American high-risk population, for the period of July 1, 2003 through June 30, 2004. (3.5) AIDS Office-HIV Prevention - Request for approval of a retroactive contract renewal with Iris Center, in the amount of $212,137, to provide HIV prevention services, for the period of July 1, 2003 through June 30, 2004. (3.6) AIDS Office-HIV Prevention - Request for approval of a retroactive contract renewal with San Francisco AIDS Foundation HIV Prevention Project, in the amount of $591,696, to provide HIV prevention and needle exchange services targeting injection drug users, for the period of July 1, 2003 through June 30, 2004. (3.7) AIDS Office-HIV Prevention - Request for approval of a retroactive contract renewal with South of Market Health Center, in the amount of $128,801, to provide HIV prevention services, for the period of July 1, 2003 through June 30, 2004. (3.8) CHP-AB 75 Project - Request for approval to accept and expend retroactively a grant allocation in the amount of up to $3,929,439, from the State Department of Health Services through its California Healthcare for Indigents Program, to provide reimbursement for health services delivered to indigent persons, for the term of FY 2003-2004. (3.9) CHP-Homeless Program - Request for approval of a retroactive sole source contract renewal with Central City Hospitality House, in the amount of $567,618, to provide drop-in and self help services for the homeless, for the period of July 1, 2003 through June 30, 2004. (3.10) CHPP-Injury Prevention Planning - Request for approval to accept and expend a grant from the California Office of Traffic Safety, in the amount of $439,455, to prevent DUI and resultant traffic injuries for the period of October 1, 2003 through December 31, 2005, and contracts with the San Francisco Study Center in the amount of $45,000 per year and with O’Rorke Media and Public Relations in the amount of $20,000 per year for the same time period. (3.11) CHPP-Health Promotion - Request for approval of a retroactive contract modification with the Regents of the University of California (UCSF), in the amount of $86,500, for an increased contract total of $289,297, to provide evaluation services to the SevenPrinciples Project, for the period of September 30, 2002 through September 29, 2003. (3.12) CHPP-Health Promotion - Request for approval of a retroactive contract modification with Booker T. Washington Community Services Center, in the amount of $200,000, for an increased contract total of $497,000, to provide community action and outreach/education services regarding infant mortality among African Americans, for the period of September 30, 2002 through September 29, 2003. (3.13) CHPP-African American Health Initiative - Request for approval of a retroactive new contract with Bayview Hunters Point Health and Environmental Resource Center, in the amount of $518,342, to provide asthma and cancer health education and wellness services to residents of the Bayview Hunters Point community, for the period of July 1, 2003 through June 30, 2004. (3.14) CHPP-Immigrant Health - Request for approval of a retroactive contract renewal with International Institute of San Francisco, in the amount of $64,032, to provide refugee preventive health services targeting documented refugees and asylees, for the period of July 1, 2003 through December 31, 2003. (3.15) CHSS-TB Control - Request for approval of a retroactive sole source contract renewal with UCSF at San Francisco General Hospital, in the amount of $228,000, to provide physician and radiologist services to patients referred to the SFGH Tuberculosis Clinic, for the period of July 1, 2003 through June 30, 2004. (3.16) CHSS-TB Control - Request for approval of a retroactive sole source contract renewal with the Regents of the University of California, in the amount of $78,655, to provide QuantiFERON TB testing services targeting patients being screened for tuberculosis, for the period of January 1, 2003 through December 31, 2003. (3.17) BHS-Mental Health - Request for approval of a retroactive contract renewal with Westside Community Mental Center, Inc., in the amount of $1,712,544, to provide mental health and substance abuse treatment service to CalWORKS program participants, for the period of July 1, 2003 through June 30, 2004. (3.18) BHS-Mental Health - Request for approval of a retroactive contract renewal with Westside Community Mental Center, Inc., in the amount of $1,866,892, to provide a Single Point of Responsi-bility program for severely mentally ill adults, for the period of July 1, 2003 through June 30, 2004. (3.19) BHS-Mental Health - Request for approval of a retroactive contract renewal with Richmond Area Multi-Services, Inc., in the amount of $2,786,270 per year, for a total contract value of $8,358,810, to provide mental health services targeting adults, for the period of July 1, 2003 through June 30, 2006. (3.20) BHS-Mental Health - Request for approval of a retroactive contract renewal with Richmond Area Multi-Services, Inc., in the amount of $1,580,506 per year, for a total contract value of $6,322,024, to provide mental health services targeting children and adolescents, for the period of July 1, 2003 through June 30, 2007. Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Penn, Umekubo) approved the Consent Calendar of the Budget Committee. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. Establishment of the Blue Ribbon Committee for the Mental Health Rehabilitation Facility Dr. Katz announced the formation of the Blue Ribbon Committee for the Mental Health Rehabilitation Facility (MHRF). The objective of the Blue Ribbon Committee is to recommend an optimal programmatic design and funding mechanism for the MHRF. The Committee will complete its work by December so that its recommendations can be included as part of the budget presentation to the Health Commission. Dr. Katz has attached the membership roster to the Director’s Report. DPH has been incredibly lucky that such a knowledgeable, experienced, and diverse group of individuals has agreed to serve on this Committee. Included in the membership are a former county mental health director, a current assistant county administrator, the San Francisco Aging and Adult Services Director, the President of the Family and Friends of the MHRF, a nurse and an activity therapist from the MHRF (appointed by their respective unions), a university psychiatrist working at San Francisco General, a community psychologist, a community social worker, a university-based nurse, and a union based researcher. Ms. Garcia Deputy Director of Community Programs, Ms. Sharon McCole-Wicher, the nurse-administrator over the MHRF, and Dr. Jimmy Jones, the Medical Director for Behavioral Health also serve. Dr. Katz will chair the meetings that will occur every other Wednesday at 3:00 p.m. at the MHRF starting September 10th. The meetings will be open to the public and there will be a public comment period at each of the meetings. The minutes from the meetings and distributed materials will be maintained on the web. People who cannot make it to the meetings will be able to submit their comments in writing to the Committee or through the web. The Committee will be staffed by Anne Chang, LaFrancine Tate, and Gloria Rodriguez. Tour of Primary Care Community Health Centers In August Dr. Katz began a tour of the primary care community centers by working at the Southeast Health Center. He saw urgent care/drop-in patients during five afternoon sessions, and was extremely pleased with how well the Center is running, and proud of the work being done by its staff. Dr. Katz’s major concern about Southeast Health Center is that there are two few primary care providers to fulfill the need of the community. Because providing a primary care “home” is a major goal of the Health Department, Ms. Garcia and Dr. Katz will be looking towards moving resources in the coming months to fulfill this need. Dr. Katz looks forward to the next stop on the tour: urgent care/drop-in at Silver Avenue Health Center. By working at each of the centers he hopes to get a better sense of both the uniqueness of the populations served and the common challenges faced by the centers. State Budget On August 2, 2003 Governor Davis signed California’s $100 billion budget for 2003-04 with General Fund spending budgeted at $7 billion less than 2002-03. This is the fourth time in 50 years that General Fund spending has been reduced compared to the previous year. The adopted Budget is already estimated to result in an $8 billion deficit in 2004-05 due largely to the reliance of this year’s spending plan on one-time measures and the shifting of current financial obligations into future years. Despite these future year concerns, cuts to health services were less severe than originally anticipated. The final budget did not include the Governor’s Realignment II plan and protected the 1931(b) and Aged and Disabled Program expansions from reductions previously proposed. Further, though Medi-Cal provider rates were reduced five percent, long-term care, hospital inpatient and outpatient, and federally qualified health centers were exempted from the reduction, resulting in minimal impact on the Department. Reductions to the Department’s revenues are estimated at approximately $2.3 million, coming from the Proposition 99 County Healthcare for Indigents Program (-$1.6 million), the HIV/AIDS Therapeutic Monitoring Program (-$500,000), and mental health managed care (-$200,000). In addition to the direct financial impact of the items listed above, the budget also assumes significant savings resulting from the disenrollment of a large number of Medi-Cal beneficiaries as a result of the implementation of county performance standards and semi-annual status reports. This is likely more of a budgeting technique that allows the State to recognize enough savings to balance the budget, rather than an actual reduction in expenditures. So, it is unlikely that the full savings attributed to these items will be realized by the State. However, if the State's estimates are taken at face value, it is estimated that more than 11,500 Medi-Cal beneficiaries in San Francisco will lose their health care coverage and that Medi-Cal revenues to DPH will be reduced by $2.2 million. What DPH is unable to estimate is how many of these 11,500 newly uninsured people would seek services at DPH for which the Department would not be reimbursed. The Governor has directed the Department of Finance to work with the Legislature to find ways to address the structural deficit that will continue in future years. The Budget Bill signed by the Governor already contains new powers allowing the Administration to cut spending in this year, to transfer up to five percent of the appropriation for an item, and to move money within funds to avoid deficiencies. CHDP Gateway As of July 1st, , the statewide Child Health and Disability Prevention Program (CHDP) became a “Gateway” to provide access to Medi-Cal or the Healthy Families Program for over one million uninsured children through an automated pre-enrollment process. CHDP is a State-funded program that provides for periodic health assessments to low-income children, regardless of immigration status. Under the new Gateway program, CHDP providers will be able to immediately determine financial eligibility for CHDP health assessments and pre-enroll children into temporary Medi-Cal. All children eligible for CHDP will automatically receive two months of full-scope Medi-Cal coverage regardless of whether they ultimately apply for Medi-Cal or Healthy Families benefits. Since the program’s inception, 324 San Francisco kids have been enrolled. TB Shelter Guidelines DPH has adopted Tuberculosis (TB) Shelter guidelines based on the recommendations of the San Francisco TB Taskforce on Homelessness. Originally written in 2000, the revised guidelines, which are attached, call for mandatory TB screening of all individuals staying at any shelter for more than three days within a 30-day period. The guidelines also recommend the adoption of a “Cough Alert” policy. These new policies will be more effective in preventing transmission through early detection and recognition of TB disease. These guidelines are especially timely in addressing ongoing TB outbreaks in shelters in San Francisco and a 65 percent increase in the number of TB cases among homeless persons. HIV Health Services Awarded Grant DPH’s HIV Health Services office has been awarded a Title III Capacity Building Grant from the federal Health Resource Services Administration to target primary care providers with a Cultural Competency Training Plan to improve services for the transgender community, particularly transgender individuals of color. DPH received one of 14 grants awarded nationwide, and one of only two Title IIII capacity building grants awarded to California. In addition, this is the only award focused on services for the transgender population. DPH received the maximum award of $150,000 for a two-year capacity building effort. With this grant, DPH in coordination with the AIDS Education Training Center will implement an innovative training program to improve provider knowledge of transgender health issues. The goal is to increase provider understanding of the health needs and obstacles to care for the HIV positive transgender population and to increase transgender access to primary care services. The grant was written by Christopher Gartner, Administrative Analyst. Nutrition Services, Chinatown Public Health Center There will be a “Nutrition and Cancer” workshop in Cantonese on August 23, 2003, from 1:00 p.m. to 3:30 p.m. at Cameron House, 920 Sacramento Street, featuring healthy eating guidelines, food labels, healthy cooking tips and food tasting. There will also be a program on nutrition and exercise for children 6 years and older. Admission is free, but advance registration is required due to limited space. HIV Prevention Awards Each year the STOP AIDS Project honors individuals from the community who have made significant contributions to the fight against HIV/AIDS. Dr. Katz announced that Tracey Packer, Manager of HIV Prevention and Community Planning from the AIDS Office, is this year's recipient of the Sam B. Puckett Memorial HIV Prevention Award. Tracey is being recognized for her "reliability, knowledge and passion in ensuring parity, inclusion and representation in San Francisco's HIV Prevention Planning Council for more than 10 years." Tracey will be honored at a special fund-raising dinner on September 15th. The Health Commissioners joined Dr. Katz in congratulating Tracey on this very special award. COMMUNITY HEALTH NETWORK SAN FRANCISCO GENERAL HOSPITAL CREDENTIALS REPORT August 2003 Health Commission - Director of Health Report (From 8/11/03 MEC and 8/19/03 HC) 8/03 7/03 to 8/03 New Appointments 21 25   Reinstatements 1 Reappointments 39 22   Delinquencies 0 0   Reappointment Denials 0 0 Resigned/Retired 22 18 Disciplinary Actions 0 0 Restriction/Limitation-Privileges 0 0 Changes in Privileges   Additions 6 7   Voluntary Relinquishments 0 1   Proctorship Completed 6 7 Current Statistics - as of 7/1/03 Active Staff 423 Affiliate Professionals (non-physicians) 160 Courtesy Staff 510 Total Members 1093 Applications in Process 31 Applications Withdrawn Month of January 2003 2 2 (07/03 to 8/03) SFGH Reappointments in Process Feb. 2003 to May 2003 149 MHRF BLUE RIBBON COMMITTEE MEMBERSHIP LIST Linda Chafetz, R.N., DNSc, Professor Department of Community Health Systems University of California, San Francisco 2 Koret Way San Francisco, CA 94143-0608 415/476-2726 Barbara Garcia Deputy Director Community Health Programs 1380 Howard Street, 5th Floor San Francisco, CA 94103 Jennie Hua, SEIU Local 21 Vocational Program Coordinator  Mental Health Rehabilitation Facility 887 Potrero Avenue San Francisco, CA 94110 415/206-6357 Shawn Dubin, Alternate SEIU Local 21 Mental Health Rehabilitation Facility 887 Potrero Avenue San Francisco, CA 94110 415/206-5828 James R. Jones, M.D. Medical Director Behavioral Health 1380 Howard Street, 5th Floor San Francisco, CA 94103 415/255-3401 Derek Lam, M.S.W. Executive Director Department of Aging and Adult Services 875 Stevenson Street, 3/F San Francisco, CA 94102 415/355-6789 Emily Lee, M.D. Department of Psychiatry San Francisco General Hospital, 7A 1001 Potrero Avenue San Francisco, CA 94110 415/206-8391 Lynn Lively, L.C.S.W. Project Director Baker Places 785 Market Street, Suite 650 San Francisco, CA 94103 415/977-1440 Piers N.P. Mackenzie, Chairperson Family and Friends of the MHRF C/o 268 Avila Street San Francisco, CA 94123 415/567-0734 Sharon McCole-Wicher, RN, MS Director of Behavioral Health Services at SFGH San Francisco General Hospital, 7M18 1001 Potrero Avenue San Francisco, CA 94110 415/206-6569 Melanie Myers, Researcher SEIU Local 250 Research Department 560- 20th Street, 3rd Floor Oakland, CA 94612 510/869-2229 Sandra Nathan Deputy County Executive Santa Clara County 70 W. Hedding Street, 11th Floor Santa Clara, CA 95110 408/299-5107 John Nickens, Ph.D. Clinical Director Progress Foundation 368 Fell Street San Francisco, CA 94102 415/861-0828 Philippa Rutgaizer, R.N. SEIU Local 790 Mental Health Rehabilitation Facility 887 Potrero Avenue San Francisco, CA 94110 415/206-6374 Charlene Silva Director of Aging and Adult Services San Mateo County 225 - 37th Avenue San Mateo, CA 94430 650/573-3910 Soleng Tom, M.D. Medical Director Alliance for Community Care, San Jose 957 Crane Avenue Foster City, CA 94404 650/574-1066 Commissioners’ Comments: Commissioner Chow asked, in regard to the attached guidelines, “TB Infection Control Guidelines for Homeless Shelters,” is the only change that someone staying in a shelter more than three days would have a TB screening? Dr. Katz replied that this was not the only change, but the most significant change. Another change is the “Cough Alert” policy. Commissioner Guy noted that the last time the Commissioners received a report on the impact of Tuberculosis in San Francisco the homeless shelter population was prioritized because of increased incidence. This update shows important advancements for this population. Commissioner Penn asked if Dr. Katz has an endpoint for the Blue Ribbon Committee. Dr. Katz explained that the Committee would meet every other Wednesday throughout September, October and November. He intends to schedule, with approval of the Health Commission President and Vice President, a presentation at the first January Health Commission meeting. This would be appropriate timing for the City Budget. This year’s funding for the Mental Health Rehabilitation Facility is from the generosity of staff who have given up raises and DPH will not have this funding next year. The Committee will use a consensus building process. There may be multiple recommendations, but the Committee will present to the Health Commission the recommendations that are decided on. Commissioner Umekubo asked about the State’s regulations concerning long term care residents, is it required that they get tested for TB? Dr. Katz answered that it was a regulation. Commissioner Umekubo asked about the rationale behind this, why would elderly residents need to get this test when they are usually also given a chest X-ray upon admission. Dr. Katz explained he is not sure exactly what prompted the State to make this recommendation. However, he noted that the risk is quite low, but the consequences quite serious. The State has chosen to err on the side of over testing because the consequences of a missed diagnosis are so high. Public comment: Mr. Brian Green thanked Dr. Katz for speaking about the Blue Ribbon Committee. He is concerned about this Committee as well as the premature discharge of patients. It is a fact that 40 percent of the patients were discharged from the MHRF to a greatly reduced level of care and nothing has been done to bring them back. He wanted to bring this to the Commissioners’ attention. The Commissioners should have his e-mail outlining these items in their in-boxes. 5) PRESENTATION OF THE DEPARTMENT OF PUBLIC HEALTH EMPLOYEE RECOGNITION AWARDS FOR THE MONTH OF AUGUST Vice President Roma Guy presented the Employee Recognition Award to: Team Awardee Division Nominated by Lowell Sabisaje, MHRW San Francisco General Hospital, Enrie Manzano, Public Health Mental Health Rehabilitation Facility Team Leader 6) 4TH QUARTER REVENUE AND EXPENDITURE REPORT Gregg Sass presented the DPH Preliminary Financial Results, beginning with San Francisco General Hospital: Year-end projections show a surplus of $11.4 M. Revenues are projected to be $15.0 million over budget (after adjustment for SB855 IGT payments) primarily due to: $4.5M in one-time revenues related to the OP Medi-Cal Settlement and other third party settlement adjustments; $1.2M in additional SB1255 revenue; $2.5M in reduced provisions for bad debts; and $6.8M in additional reimbursement that is on-going in nature and includes $0.75M in new federal matching payments under AB915; $2.5M in additional Medi-Cal Capitation; and various other differences in expected payments from third parties. San Francisco General Hospital: Expenditures are projected to be over budget (after adjustment for SB855 IGT payments) by $3.6M primarily due to: $1.7M in salary and fringe benefit expenses, $1.2M of which was for Health Service Agency retiree benefit subsidies for the Department of Health posted by the Controller to SFGH as a lump sum; $0.6M in materials and supplies; $1.0M in costs of services of other City departments including $0.4M in workers compensation, $0.3M from the DPW and $0.2M for costs of institutional police. Laguna Honda Hospital: Year-end projections show a surplus of $3.5 million. Revenues are projected to be $3.4M higher than budget primarily due to: $1.8M in Medi-Cal revenues due to a $5 per day increase to the SNF rate; $1.1M increase in the DP/NF Medi-Cal supplemental payment due to timing differences and increased federal participation; and $0.5M associated with improved recovery of bad debt and reductions in contractual adjustments. Laguna Honda Hospital: Expenditures are projected to be $0.2M less than budget primarily due to: $0.3M savings in salaries and fringe benefits; $0.2M savings in contractual services; and $0.4M over budget in materials and supplies. Primary Care: Year-end projections show a deficit of $50K. Revenues are projected to be $0.5M less than budget primarily due to differences in the close out of capitation revenues. Expenditures are projected to be less than budget by $0.4 million primarily due to $0.9M favorable variances in non-salary expenditures offset by $0.5M in unfavorable variances in personnel costs. Health at Home: Year-end projections show a surplus of $0.3 million. Revenues are projected to be close to budget. Expenditures are projected to be $0.2M less than budget primarily due to savings in contractual services. Jail Health Services: Year-end projections show a deficit of $1.3 million. Revenues are projected to be close to budget. Expenditures for jail health services are $1.4M higher than budget primarily due to a deficit in salary and fringe benefits (-$2.1M) from the ongoing under-funding of nursing services offset by savings in contractual services ($0.5M) and materials and supplies ($0.1M). Public Health: Year-end projections show a surplus of $0.4M. Revenues are projected to be $3.0 million less than budget primarily due to: $1.9M surplus in other patient revenues in Disease Control programs. This surplus is offset by a deficit (-$2.3M) in Disease Control fees/miscellaneous revenues; $0.7M deficit in MAA/TCM revenues. FY 02-03 revenues are higher than prior year revenues. However, current projections indicate that the FY 02-03 budget was over estimated; $1.5M deficit in CCS revenues that will produce an equivalent expenditure savings; and $2.8M deficit in miscellaneous revenues primarily in Disease Control programs that is offset by a surplus in patient revenues, as noted above. Public Health: Expenditures are projected $3.4M less than budget primarily due to savings in salaries and fringe benefits ($1.7M), professional services ($1.4M) and equipment ($0.2M). Mental Health: Year-end projections show $2.0M deficit in Medi-Cal revenues that will produce an equivalent expenditure savings; $2.4M deficit in Short Doyle (Community Mental Health Service) revenues that will produce an equivalent expenditure savings; $2.3M deficit in Short Doyle Medi-Cal revenues that will produce an equivalent expenditure savings; $4.7M surplus in other state revenues primarily due to SB90/AB3632 revenues that were held in reserve for prior year audit disallowances in a deferred credit account. Mental Health: Expenditures are projected to be $5.8M less than budget primarily due to underutilization of contractual services. Work order funds of $4.6M from DHS for expenses to the state CalWORKS program that were included in the 3rd quarter report were transferred to SFGH to cover operating expenses Substance Abuse: Year-end projections show a surplus of $0.8 million. Revenues are projected to be $0.2 million higher than budget. Expenditures are projected to be $0.6 million less than budget primarily due to savings in salaries and fringe benefits ($0.4M), professional services ($0.5M) and rent ($0.1M) offset by a deficit in projects (-0.4M). In conclusion, the Department is forecasting a larger than expected surplus for the fiscal year, that is primarily the result of favorable revenues at SFGH and LHH. Favorable revenue variances include one-time items such as $4.7M in SB90/AB2632 deferred credits in Mental Health, $4.3M in prior year settlements at SFGH, and $0.5M in DP/NF timing differences at LHH. There are also recurring sources of revenue at SFGH and LHH, most of which have been budgeted for the 2003-2004 year. Surplus revenues have enabled the Department to accommodate cuts in our General Fund and at the same time avoid deep cuts in service to patients. These financial statements are preliminary and it is expected that changes will occur through the annual audit process that extends into November of 2003. Commissioners’ Comments Commissioner Parker noted that this was an outstanding report, very clear and concise. Commissioner Parker pointed out that jail health seems to be a chronically under funded. He asked Mr. Sass to explain why this is the case. Mr. Sass explained that the Department does know what it costs to run this operation. The Department’s initial budget did include sufficient dollars to pay for the services. The City ultimately did not fully fund the jail health programs. This is how it usually works, so the Department may very well overrun this budget again next year. It is a structural problem. Commissioner Parker recommended that the Department address this issue in advance by working with the City. Dr. Katz said that the Department intends to continue to provide the level of care that is now being provided. The Department has one of the few accredited jail health programs, providing more than is required because it is the right thing to do. The Department uses the same standard of care for those in jail as is used for everyone in the health care system. However the will on the City level does not appear to be there to fund jail health services on this level. Commissioner Chow commended Mr. Sass on his report and on the job that he has done throughout the year. He noted that the Department has kept all promises made to the City regarding the budget. Dr. Katz noted that variances have been made very small, but the Department cannot predicate in all cases what the State and Federal government will pay. The variances are somewhat predictable at this stage, and the Department has a CFO that does a good job anticipating. Commissioner Guy shared her appreciation with Laguna Honda Hospital because they did a good job reducing their deficit. Commissioner Umekubo commended Mr. Sass on revenue enhancements. Mr. Sass noted that he was impressed with Department staff; he thought they could not do more in this regard, but they did. Commissioner Guy pointed out that jail health is a known structural problem, but the Department needs to keep asking for what it needs and to make costs clear to the City. The public needs to hear what the problems are, so that they can keep the Board of Supervisors accountable. Commissioner Monfredini said that she was very impressed with this report and the work that has been done. 7) UPDATE ON STATE HEALTH INSURANCE EXPANSION PROPOSALS Colleen Johnson presented today’s report on the State’s various legislative attempts to expand health insurance to more California residents. She explained that the City has already taken a position on several pieces of legislation. The Department cannot take a position on its own. The purpose of her report is to talk overall about expansion proposals and to introduce a resolution supporting the City’s position. Pending State Bills: Single Payer: SB 921 (Kuehl) provides universal health care coverage for all Californians under a new California Health Care Agency. This bill would consolidate existing public health care program funding to finance the program. It may also be partially financed through increases in income, payroll, tobacco, and/or other taxes. The cost of implementation is unknown. CCSF in support of this bill. Arguments in support establish universal health insurance for all residents stabilize growing health care spending to employers and consumers streamline current fragmented system of care Arguments in opposition government systems less efficient than private business single payer system would cost more than the current private system Incremental: AB 30 (Richman) would expand health insurance coverage under Healthy Families to uninsured, employed, childless adults with incomes below 200% FPL and be available to eligible employees of employers with more than 50 employees and 50 percent of employees earn less than 200 percent of minimum wage (i.e., $13.50/hour). The bill allows for premium cost sharing (25% employer, 25% employee, 50% federal government). The estimated general fund cost is between $195 million to $351 million. Arguments in Support Will expand health care coverage and reduce the number of the uninsured. Arguments in Opposition would divert funds from children’s health insurance to childless adults not intended to be served by SCHIP Employer-Based: SB 2 (Burton-Speier) is considered “pay or play” because it requires that employers provide health insurance to employees and dependents or pay a user fee to enable the State to serve as a purchasing agent to pool these fees to cover uninsured employees. CCSF is in support of this bill. AB 1527 (Frommer) also establishes a “pay or play” but places requirement on employers with more than 50 employees. It also establishes a premium assistance program for Medi-Cal or Healthy Families and provides an incentive mechanism for small employers. AB 1528 (Cohn) is the Healthy California Act of 2003. It creates a minimum set of health insurance benefits for all Californians and establishes both an individual and an employer mandate Arguments in Support Builds upon California’s existing employer-based health insurance system Most large employers already provide coverage and requiring all employers to do so would promote fairness among employers Arguments in Opposition Will discourage new businesses from locating in California and provide an excessive burden on small businesses Primary reason employers do not offer insurance is the exorbitant cost of health care, which this bill does not address The current political climate may provide a unique opportunity to expand access to health care coverage and reduce the number of uninsureds. It is likely that Legislature will pass employer-based expansion this year. The Commission’s resolution will provide direction for the Department to continue to work towards increasing access to health care coverage. Public Comments: Dr. Christina B-Salem spoke in support of SB921. She is from Planning for Elders, Senior Action Network and Health Care for All and expressed her anger that the U.S. is ranked 37th in a list of WHO countries that provide adequate health care. There are 36 countries ahead of the U.S. Dale Milfay from Health Care for All spoke in support of SB 921. It is a Catch 22 nightmare to get treatment for her mentally ill son due to conflicts about who is responsible for his care. SB 921 would end this maze and save money at the same time. Her son has Kaiser and Medi-Cal. When her son is taken to SFGH for a psych. emergency her claim is denied for going out of network. A single payer system would eliminate problems like this. Susan Cieutat, a nurse at SFGH and from SEIU spoke in support of SB 921. Ms. Cieutat studied economics of health care and health care delivery. She noted that it is obvious to anyone who knows this issue that the only solution is universal health care. Our current system preys on people who have the misfortune of having a debilitating illness or accident. She acknowledged the savings of getting timely treatment. The Lewin Group may have not even taken this savings into account when they analyzed SB921. She asked the Commissioners to educate themselves about health care systems in other parts of the world. SB921 is not just a good piece of legislation, but also a moral imperative. Harry Kershner from Health Care for All spoke in support of SB 921. He noted that the current health care system is broken and needs to be fixed. Karen Lindsey from Health Care for All spoke in support of SB 921. Ms. Lindsey said that she has been sick for 16 years and for the first few years of the illness she had no insurance. She was told to go to SFGH to get tests but they would not run them because she was uninsured. Now she has Medi-Cal through disability. She would like to get a part time job, but would lose Medi-Cal. She asks that the Commissioners support 921 so she can have health coverage and work. Jay Lyon spoke in support of SB 921. He uses City health centers for his care and is uninsured. John Shearer, M.D., a Family Practitioner and the President of the California Physicians Alliance, spoke in support of SB 921. The CA Physicians Alliance, with 1,300 members Statewide, enthusiastically endorses SB 921. It is in their view model legislation. Betty Kallo, from Health Care for All, spoke in support of SB 921. Ms. Kallo is a senior. SB 921 would remove profit from health care. There are many seniors in San Francisco. Some have to buy prescription drugs or food. Many seniors use emergency rooms because they don’t have their own doctors. Mark Stout, from Health Care for All, spoke in support of SB 921. Mr. Stout is self-employed. He currently pays for Kaiser out of pocket. If he gets a job he fears what will happen if he loses the job and has to find insurance again on the market. He will never get insurance again due to a pre-existing condition. Vi Huynh, from Health Care for All, spoke in support of SB 921. Ms Huynh is currently unemployed and is trying to get teaching job but it is challenging with school cutbacks. An employer-based mandate only covers people who are employed and that would not help her. She has applied for Medi-Cal, but may not be accepted and needs medical care. She cannot sleep at night worrying about this, as she has medical conditions that need attention. Ed Kinshley, from SEIU 790, spoke in support of SB 921. Mr. Kinshley is a medical social worker at SFGH and a representative of SEIU. He noted that 6,000 workers in San Joaquin at the other public hospital in San Jose are on strike because of problems with their health care costs. He thanked the Commission for discussing this legislation. The union supports SB 921. Anne Chen, from Health Care for All, spoke in support of SB 921. She noted that the safety net of Medi-Cal is no longer a safety net for everyone. Many people are slipping through the cracks. She has seen people die before they get Medi-Cal. Emerito Querol said that he thinks the Commissioners should approve of health insurance coverage for all San Francisco residents. Don Bechler, the Chair of Health Care for All, spoke in support of SB 921. The problem is that neither the nation nor California has a real health care system. Instead we have many different programs and plans trying to create a system. There are different classes of care for different classes of people. SB 921 would create a real system. Rory Michaelis spoke in support of SB 921 because it guarantees access and removes profit from health care. No one chooses to get ill. He is thankful for being insured when he was ill, but others are not so lucky. Dan Eichelberger, from the California Green Party, spoke in support of SB 921. The Green Party supports a single payer system. Mr. Eichelberger asked the Commission to bring the U.S. into the 21st century and endorse health care for all. Susan Evans, from Health Care for All, spoke in support of SB 921. Ms. Evans is a nurse with masters degree works with children and adults. She has been advocating for universal health care since 1994. Robert Damron, from APWU, BAUAW, 911 Truth Alliance, spoke in support of SB 921. Mr. Damron said that it is the future. Privatization is a crime against humanity, as profiteers are only interested in the bottom line. Jeffery Harding, from Health Care for All, spoke in support of SB 921. Mr. Harding is a social worker with older adults in San Francisco. He has seen what it is like for seniors to navigate health coverage. Mr. Harding listed the health services that would be available under SB 921. Mary Magee, from Health Care for All and Local 790, spoke in support of SB 921. Ms. Magee has been a nurse at SFGH for 16 years. She asked the Commission to endorse SB921. Ms. Magee pointed out that one of the most dramatic features of SB 921 is that it covers everyone. Elizabeth Milos, a self-employed medical interpreter, spoke in support of SB 921. Her son has Healthy Families, but she has no health insurance. Self-employed women are at a high risk of not being served by the health care system. Frances Payne, from Neighbor to Neighbor, spoke in support of SB 921. Ms. Payne reminded the Commission that a short time ago Vicente Fox signed into law a universal health care bill in Mexico. If Mexico can do it, then the U.S. can too. Bridget Harrison, a UCSF medical student, spoke in support of SB 921. Universal coverage is good for preventive care and primary care. Lack of insurance promotes overuse of the emergency room. Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Penn, Umekubo) approved amending the proposed resolution by making one correction to the first whereas, to say “17% of the City’s population.” Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Penn, Umekubo) adopted Resolution #14-03, “Supporting State Efforts to Increase Access to Health Care Coverage for the Uninsured,” (Attachment A), with the amendment. Commissioners’ Comments Commissioner Guy noted that the Commission has taken a lot of responsibility since the Department’s Strategic Plan to advance universal health coverage goals in San Francisco. Clearly, health coverage and access are important issues to voters. If the legislature does make incremental improvement it will not be comprehensive, and this continues the current fragmented system. The Department needs to continue to be vigilant. The Department should voice interest in universal health coverage and encourage City lobbyists to keep this on the list of priorities. Commissioner Chow noted that the resolution does not support one particular approach, but instead supports whatever bill will move coverage expansion forward. 8) DCYF CHILDREN’S SERVICES ALLOCATION PLAN Nani Coleretti, the Department of Children, Youth and Families (DCYF) Budget and Planning Director and Tajel Shah, DCYF’s Assistant Director of Technology and Communications Strategy presented the Children’s Services Allocation Plan. Ms. Coleretti and Ms. Shah presented a power point presentation to the Commission, which illustrated the information given to them at the meeting. This is the first year that DCYF has worked with other Departments on this process. It focuses on fiscal year 2002-03, showing that City Departments allocated about 282 million to children and youth focused programs in San Francisco. Health and Wellness, where the Department categorizes the bulk of its programs, is a primary theme. According to this report, the Department of Human Services (DHS) contributes the most in terms of dollars, with DPH next, then DCYF, and other Departments follow. According to this report, in FY 2002-03, DPH contributed $78,535,258 to programs (listing over 100 programs) that serve children and youth ages 0-17. Ms. Shah did clarify that DHS has put a small number of their large programs into the Health and Wellness theme, including foster care funding. DCYF is looking at allocating these dollars differently. Commissioners’ Comments Commissioner Guy asked how much DHS funding for foster care is. Ms. Shah did not know today, but could provide that information. Commissioner Guy is concerned that this distorts the Health and Wellness theme. Commissioner Chow noted that it was an extensive database that DCYF created. Commissioner Chow asked Dr. Katz to speak about this process and to answer the questions DCYF is asking about the allocation of resources. Dr. Katz noted that DPH, DHS and DCYF are now working very well together, which was not always the case in the past. Dr. Katz said that he feels that a focus on prevention is the right place to start for children if there is to be a real impact in the life of the person. Commissioner Chow said that this process would help look broadly at where needs are and where gaps are. Commissioner Chow asked how much the Children’s Fund is? Ms. Coleretti answered that it was $25 million per year or $75 million over three years and another $10 million in general fund. Commissioner Chow asked if DCYF was going to do a RFP process for all Departments? Ms. Coleretti said that they were still deciding how to do that based on the planning process. Commissioner Chow warned against an internal RFP process as it increases bureaucracy. Commissioner Guy pointed out her concern that the data collection was apples and oranges between City departments. She advised DCYF to look closely at this issue, though she recognized that DCYF had already identified this as a concern. Commissioner Guy also warned against stressing outcomes too strongly, if you only stress outcomes then people make false promises. Commissioner Guy suggested process objectives to look at on an ongoing basis. Commissioner Guy also mentioned counseling around stress and that DCYF needs to look at this as an issue. She recommended that they look at the Department’s maternal and child health report card, and their findings in terms of the younger children. She also recommended that DCYF coordinate with the Department’s Adolescent Health Coordinator. Commissioner Guy stressed the importance of funding for the health and wellness centers in schools. Commissioner Umekubo liked the methodology for DCYF’s allocation plan; it is very logical. Commissioner Umekubo was struck by the need for counseling in the schools. He thought there were good counseling programs in schools, but this does not appear to be the case. This is a place to look at for funding. Commissioner Monfredini complimented Ms. Coleretti and Ms. Shah on the report and delivery. Commissioner Monfredini pointed out that at age eighteen this work is not done. It is important to consider continuity. Commissioner Parker recommended that DCYF consider all of the components that have been discussed and the complete environment of the child. Continuity and comprehensiveness is key. Commissioner Penn thanked them for the comprehensive report. He asked about the importance of one-time costs vs. investment. Ms. Coleretti noted that DCYF stresses investment that goes beyond dollars in the interest of creating systems change. Commissioner Penn also asked how confidants are Ms. Shah and Ms. Coleretti that DCYF is collecting all of the data. Ms. Coleretti said that they know they are not capturing the entire pie. In addition to the work they are doing with City departments, DCYF is doing a parallel process with foundations to see what the foundations are doing in San Francisco for children and youth. Commissioner Penn noted that a priority should be parental support. The numbers are low in this area. Commissioner Chow expressed that the Wellness Centers are a good priority. He answered yes to all of DCYF’s questions. He noted another idea is to expand Healthy Kids to age 25. Commissioner Parker asked about the finding that 46 percent find San Francisco a child-friendly city. What is DCYF going to do about this finding? Ms. Coleretti said that there are two main reasons for parents being unhappy with San Francisco, the school system and high housing costs. DCYF cannot control the latter, but can support families and can help with schools. Commissioner Chow asked DCYF what sort of feedback they would get from community stakeholders and Departments and Board and what will their report look like. Ms. Coleretti said that basically DCYF would have an allocation plan that will show what areas their money will be invested. They will work collaboratively with Departments to allocate funding. 9) RESOLUTION REGARDING PROPOSITION 54 Frances Culp, Health Program Planner, presented this report and draft resolution. This report provided an update on the new ballot initiative (Proposition 54) being sponsored by University of California Regent Ward Connerly’s American Civil Rights Coalition entitled Classification by Race, Ethnicity, Color or National Origin also referred to as the Racial Privacy Initiative (RPI) or the Information Ban. Proposition 54 would prohibit the collection, analysis or use of information pertaining to race, ethnicity, color or national origin by state and local governments. Actions taken to maintain federal funding are exempted, as are medical research subjects and patients, though classification of public health data is not. Proposition 54 is scheduled to appear on the October 7, 2003 special election ballot. The sponsors of Proposition 54 have asserted that there will be little or no obstruction in the realm of public health and health services. However, exemptions for medical research and to comply with federal requirements do not provide nearly enough protection to continue core public health functions. The sponsors have said that even if these exemptions are too limiting there is a mechanism to get special approval through the State Legislature. This would require a two-thirds majority approval by the Legislature, which seems at best a significant and unnecessary burden and at worst an impossibility. It has also been argued by supporters of Proposition 54 that this initiative would protect people from being forced to choose racial classifications, but in fact all such reporting is currently entirely voluntary already. Research today shows us that there are disparities within almost all health indicators, with many racial and ethnic groups suffering far below the norm in health care access, likelihood of early diagnosis and adequate treatment and rates of specific diseases. With this knowledge, it is more important than ever to collect the very information this initiative would ban. Proposition 54 will have a profound negative impact on the ability of DPH to collect and disseminate information integral to understanding and responding to disparities in a number of areas. Clearly this initiative would interfere with the ability to fulfill DPH’s mission to protect and promote the health of all San Franciscans. The censoring of data critical to promoting and protecting public health may be setting a dangerous precedent not only for California, but also for the nation. Public Comment James Bryant, President of the A. Philip Randolph Institute distributed a paper on “Racial and Ethnic Data Collection and Use in Health Care: Examples of Projects that Might Be Affected by Proposition 54.” He noted that the presentation was right on the head of the nail. Proposition 54 is an effort to disenfranchise everyone. He urged the Commission to oppose the proposition, and the A. Philip Randolph Institute would be happy to carry it out to the community. Commissioners’ Comments Commissioner Monfredini said that not all Arnold Schwarzenegger voters plan to vote for Proposition 54. The problem is that many voters do not have information about Proposition 54. What else can the Department do to educate the public on the initiative? Ms. Culp noted that DPH clinic directors and other providers have been asking about what they can do to educate the public and the Department can share the resolution and report. Commissioner Guy advised Ms. Culp to put the resolution and other information on the DPH website. Commissioner Guy asked if reporters or journalists have asked the Department’s opinion. Dr. Katz said that the Chronicle Editorial Board called and asked for DPH’s opinion and much of Dr. Katz said made it into the editorial. Dr. Katz also noted that it helps DPH to have a Commission approved resolution opposing Proposition 54. Commissioner Parker noted that the values of Proposition 54 might be acceptable in an ideal, perfect world. Yet the proposition fails to address who we are, there is a hidden agenda. He said that the Department should not be hesitant about addressing that hidden agenda. Commissioner Monfredini agreed that the hidden agenda is there, but does not want to cloud the issue at hand. Commissioner Chow said that simply on the face of it the Proposition does not work for public health. The key issue for the Commission is how it affects the Department. Ms. Culp noted that the health related issues resonate most with voters. Ms. Colleen Johnson noted that local health officers are putting out a position paper. Commissioner Chow encouraged the Department to take the opportunity to speak out against Proposition 54. Passing a resolution and setting policy will allow the staff to speak out on behalf of the Department. Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Penn, Umekubo) approved amending the proposed resolution by making one addition to the last further resolved, to say “that the Health Commission directs the Director of Health to provide the Board of Supervisors, the Mayor’s Office, and the public with information...” Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Penn, Umekubo) adopted Resolution #15-03, “Opposing Proposition 54,” (Attachment B), with the amendment. 10) PUBLIC COMMENTS There was no public comment. 11) ADJOURNMENT The meeting was adjourned at 6:57 p.m. Frances Culp, Acting Executive Secretary to the Health Commission