Minutes of the Health Commission Meeting Tuesday, May 3, 2005 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 Commissioner Monfredini at 3:15 p.m. Present: Commissioner Lee Ann Monfredini, President – left 4:50 p.m. Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Edward A. Chow, M.D. Commissioner James M. Illig Commissioner David J. Sanchez, Jr., Ph.D. Commissioner Donald E. Tarver, II, M.D. Commissioner John I. Umekubo, M.D. 2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF APRIL 19, 2005 Action Taken: The Commission approved the minutes of the April 19, 2005 Heath Commission meeting with one correction. Item 3.2 on the Budget Committee Consent Calendar was removed from the agenda at the request of DPH staff, and this was not noted in the minutes. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner James M. Illig chaired and Commissioner Chow and Commissioner Sanchez attended the Budget Committee meeting. (3.1) DPH-BHS – Request for approval of a resolution approving an extension of the terms of the Fiscal Year 2004-05 contracts. Secretary’s Note – the resolution was corrected to say Department of Public Health contracts, instead of Behavioral Health contracts (line 2 of the paragraph that begins “now, therefore, be it resolved). Commissioners’ Comments Commissioner Illig asked if the resolution covers all DPH contractors. Mr. Leung replied that organizations with multi-year contracts are not part of the resolution. In addition, those agencies that are on a different contract year are not included, nor are some for profit contractors. Commissioner Illig noted that he asked Anne Okubo to provide him with a list of contractors who have contracts that total over $5 million. Mr. Leung is preparing this information for him. Commissioner Chow noted that he had inquired about Westbay Filipino Services, considering the agency was tangentially involved with an organization accused of Medi-Cal fraud. Dr. Katz assured him that the agency has provided services as required by their contract, and their monitoring reports are acceptable.   Secretary’s Note - Commissioner Illig abstained as it pertains to CHW and Project Open Hand; Commissioner Sanchez abstained as it pertains to the Regents of the University of California; Commissioner Chow abstained as it pertains to NICOS; Commissioner Umekubo abstained as it pertains to Catholic Healthcare West; Commissioner Tarver abstained as it pertains to Baker Places. (3.2) BHS-Mental Health – Approval to accept and expend retroactively a grant from the California Endowment in the amount of $121,047 to elevate the level of cultural competency in the delivery of client services through advanced training of staff and providers, for the period of April 1, 2005 through March 31, 2006, and for approval to modify contracts with Instituto Familiar de la Raza and the San Francisco Study Center for $40,000 and $55,000, respectively, for the same period of time. Commissioners’ Comments Commissioner Chow expressed some concerns regarding cultural competency, including the fact that there has been some loss of leadership in community-based organizations. Yet San Francisco has a wealth of resources and best practices. He also noted that the Health Commission and Health Department established the CLAS standards as guidelines, not mandates, and San Francisco should modify this guidelines as appropriate. Ms. Yee replied that they would be utilizing their community providers, many of whom have best practices, and learn from them what should be incorporated. Commissioner Chow is confident that Ms. Yee will be cognizant of the fact that organizations, particularly the small organizations, struggle to comply with this requirement and all the documentation that is required. Commissioner Sanchez said that as part of this effort the Department interacts with a whole set of communities and subspecialties, and there have been certain mandates from various agencies to provide culturally competent services. A critical component for success is that program managers are aware and trained in these areas. This proposal is a great start. Commissioner Illig commended the Department for working with contractors to get this grant. Contractors are looking for best practices and examples of good cultural competency reports. Commissioner Illig hopes that as the Department moves forward with its cultural competency program, Department-run programs should also be required to report on their efforts. Ms. Yee replied that this has been discussed in the Department’s Cultural Competency Committee, and they will be moving forward on this. Commissioner Illig commented that Instituto Familiar de la Raza’s (IFR) board, with only five members, is small. Ms. Estella Garcia from IFR replied that two board members have been added, and they will bring another member on in a few months. This would bring the total number of board members to eight. Commissioners’ Comments (at the Commission meeting) Commissioner Guy asked if the curriculum includes outcomes. Ms. Yee replied that their goal is to give meaning to the CLAS standards. The desired outcome is to have contract managers and analysts who review the reports, as well as the contracts who write the reports, to have a true understanding of what cultural competency means. The curriculum they are proposing includes basic understanding of CLAS standards, but very quickly moves into understanding how to write goals and objectives, understanding cultural differences, and other elements. All three counties that participate in this grant are expected to produce best practices. Commissioner Guy asked when the Health Commission, through the Joint Conference Committee, could look at the curriculum and outcomes. Ms. Yee said the goal is to have a product in March 2006. Commissioner Tarver asked that there be consideration to longer-term planning beyond the term of the grant, for cultural competency for Department programs. (3.3) AIDS Office-HIV Research – Request for approval to accept retroactively and expend a subcontract from PHFE Management Solutions, in the amount of $51,934, for the period of July 1, 2004 to June 30, 2005. (3.4) CHPP-Health Promotion – Request for approval of a contract renewal with San Francisco Study Center, Inc., in the amount of $912,346, to provide fiscal sponsor services for the Tobacco Free Project Community Capacity Building Training Center, for the period of July 1, 2005 through June 30, 2006. Commissioners’ Comments Commissioner Chow asked how many people these programs serve, and whether the Department is seeing reduced rates of smoking as a result of the program. Ms. Lau Smith said they do case studies on all the policy-level efforts to see if the capacity of the organization is increasing, capacity of the advocates has increased and if we are achieving policy-level change. At the end of the evaluation cycle they will be able to identify where they were most successful. Ms. Smyly added that the community action model was highlighted in the American Journal of Public Health. Commissioner Chow recommended that the CPS JCC receive a report after the current round of projects is evaluated. Action Taken: The Commission approved the Budget Committee Consent Calendar. For Item 3.1, Commissioner Illig abstained as it relates to CHW and Project Open Hand; Commissioner Sanchez abstained as it pertains to the Regents of the University of California; Commissioner Chow abstained as it pertains to NICOS; Commissioner Umekubo abstained as it pertains to Catholic Healthcare West; and Commissioner Tarver abstained as it pertains to Baker Places 4) DIRECTOR’S REPORT Mitchell H. Katz, Health Director, presented the Director’s Report. Federal Budget Update After weeks of contentious negotiations, Congress last week narrowly passed a $2.6 trillion spending plan for FY 2006. The compromise will reduce Medicaid program spending by approximately $10 billion over five years – approximately half of what had been proposed by the House and by the President's budget. In addition, the budget resolution creates a bipartisan commission that would "find ways to eliminate fraud and abuse in the state reimbursement component of Medicaid." Although the budget resolution is technically non-binding, it serves as a guideline for Congress as it makes spending decisions for FY 2006. The Congressional committees with jurisdiction over Medicaid will be developing policy proposals to achieve savings in the coming months. Some of the Medicaid savings proposals that are on the table include revising pharmacy pricing, changing the rules on asset transfers, and restricting Intergovernmental Transfers (IGTs), which in California fund, among other things, safety net hospitals. However, it is anticipated that cuts will not begin until 2007, after the Medicaid commission has delivered its final report in December 2006. The commission will deliver an interim report to Congress by Sept. 1. Dr. Katz will continue to keep the Commission apprised of these activities. Joint Accreditation of Health Care Organizations Visits SFGH The Joint Accreditation of Healthcare organizations and the Institute of Medical Quality/California Medical Association completed their unannounced survey of San Francisco General Hospital the week of April 18th. SFGH successfully passed the survey and was awarded the three-year accreditation. SFGH was reviewed on three separate manuals: Hospital Programs, Long Term Care, and Behavioral Health. In the exit interview attended by Health Commission President Monfredini the surveyors praised SFGH for its clinical care and commitment to patient safety. The organization should be commended for their teamwork and exemplary efforts of all the departments. World Asthma Day In observance of World Asthma Day, Karen Cohn, Chair of the San Francisco Asthma Task Force, joined Supervisors Sophie Maxwell and Fiona Ma, Dr. Shannon Thyne of the SFGH Pediatric Asthma Clinic, and Natasha Madaris, a parent of a 4-year old boy who died from asthma in San Francisco at a press conference at City Hall earlier today. The event focused on raising asthma awareness throughout the City where more than one in 10 San Franciscans suffer from asthma. A new public service ad unveiled at the press conference urges parents and kids to "Take Asthma Seriously." Hypertension in Hispanic Community The American Society of Hypertension's 20th Annual Scientific Meeting is scheduled to take place in San Francisco the week of May 14th. This year's program will feature an exclusive Spanish language press briefing on May 18th. Laura Brainin-Rodriguez, Registered Dietitian with Nutritional Services, will be one of the guest speakers. DPH applauds the Society's efforts to reach out to the City's Hispanic community where hypertension and vascular health impacts a significant number of patients. SFGH Physician Recognized by American Gastoenterological Association The American Gastroenterological Association (AGA) has named SFGH’s John P. Cello, MD the recipient of its 2005 Distinguished Educator Award for his accomplishments during his career in gastroenterology. Dr. Cello is a professor of medicine and of surgery at the University of California, San Francisco and is also director of medical education for the Division of Gastroenterology at San Francisco General Hospital. Also with the university, he was chief of gastroenterology, hepatology and clinical nutrition at San Francisco General Hospital for 20 years. Commissioners’ Comments Commissioner Monfredini congratulated San Francisco General Hospital for passing the JCAHO survey. This was an extraordinary team effort. Each of the surveyors mentioned how competent Gene O’Connell is and how well the SFGH executive team works together. The Health Commission is very proud. Ms. O’Connell said the whole hospital worked together to make sure they were successful. Commissioner Illig asked if scores are given with the new methodology. Ms. O’Connell said it is pass/fail. The surveys did identify a few areas that need to be fixed within 90 days. Commissioner Guy said it is astounding that, even though the hospital has weathered budget cuts, it continues to provide such a high level of care. Commissioner Chow reiterated the importance of passing the JCAHO survey, and how fortunate San Francisco is to have such dedicated staff. Staff could have been demoralized over the last few years of budget reductions, but they work through adversity. 5) FY 2004-2005 3rd QUARTER FINANCIAL REPORT Valerie Inouye, CHN Chief Financial Officer, presented the 3rd Quarter Financial Report. This report presents the third quarter financial projections of revenues and expenditures for the Department of Public Health for fiscal year 2004-2005. Projections include a revenue surplus of $25, 666,000 and expenditure deficit of $15,432,000, after adjusting for SB855 IGT transfers to reflect SB855 disproportionate share revenues net of related transfers. Based on this data, the Health Department is projecting a year-end surplus of $10.2 million for FY 2004-05. The mid-year budget cuts have the effect of reducing DPH’s budgeted spending authority by $3.5 million. The Department is therefore required to return a surplus of $3.5 million to the General Fund at year-end. In addition, DPH has committed to return $3.2 million in projected surplus for FY 04-05 as a carry forward in the FY 05-06 base budget. The projections indicate that DPH will exceed those two requirements by $3.5 million. This remaining surplus contributes to one-time efficiency investments of $12 million proposed by the Department. DPH anticipates the need for a revenue-funded supplemental appropriation to address structural problems in the current year and fund certain one-time expenses anticipated for this fiscal year.   DEPARTMENT OF PUBLIC HEALTH - FY 2004-05 REVENUES EXPENDITURES TOTAL Division Revised Budget Current Projection Surplus/(Deficit) Revised Budget Current Projection Surplus/ (Deficit) Surplus/(Deficit) SFGH $ 543,668,000 $ 542,406,000 $ (1,262,000) $ 543,668,000 $ 533,984,000 $ 9,684,000 $ 8,422,000 SB855 Adjustment (98,225,000) (73,473,000) 24,752,000 (98,225,000) (73,473,000) (24,752,000) - SFGH Adjusted $ 445,443,000 $ 468,933,000 $ 23,490,000 $ 445,443,000 $ 460,511,000 $ (15,068,000) $ 8,422,000 Laguna Honda 154,265,000 154,920,000 655,000 154,265,000 155,375,000 (1,110,000) (455,000) Primary Care 42,187,000 44,293,000 2,106,000 42,187,000 42,772,000 (585,000) 1,521,000 Health at Home 7,665,000 7,478,000 (187,000) 7,665,000 7,687,000 (22,000) (209,000) Jail Health 22,078,000 21,980,000 (98,000) 22,078,000 21,980,000 98,000 - Public Health 91,447,000 91,147,000 (300,000) 91,447,000 90,546,000 901,000 601,000 Mental Health 172,286,000 172,286,000 - 172,286,000 172,282,000 4,000 4,000 Substance Abuse 65,105,000 65,105,000 - 65,105,000 64,755,000 350,000 350,000 SUBTOTAL $ 1,000,476,000 $ 1,026,142,000 $ 25,666,000 $ 1,000,476,000 $ 1,015,908,000 $ (15,432,000) $ 10,234,000 Mid-Year Reduction Target $ (3,500,000) Carryforward Assumed in FY 2005-06 Budget (3,231,440) NET DPH $ 3,502,560 (1) The Revised Budget in the table above includes: Annual Appropriation Ordinance for DPH, carry forwards from prior year, Inter Governmental Transfer (IGT) for SB855, Transfer In and Project Related expenses. Commissioners’ Comments Commissioner Tarver asked if there are plans of correction for areas that do not meet revenue expectations. Ms. Inouye said that each entity is responsible making sure that the problems that led to the revenue deficits are addressed. Commissioner Illig said the revenue enhancement at SFGH and Primary Care should be highlighted and applauded. He also noted that the Department is doing a better job collecting bad debt from people who receive care and have the ability to pay. Commissioner Chow asked if the budget includes one-time appropriations to fix the problems that were identified during the power outage at SFGH last Fall. Ms. Inouye replied that funding to fix these issues is part of the one-time efficiency money. Ms. O’Connell added that some repairs and maintenance have already been done, but the real fix is to replace the power plant, which is in the proposed budget. 6) APPROVAL OF A REVENUE SUPPLEMENTAL APPROPRIATION Valerie Inouye, CHN Chief Financial Officer, said the Department is requesting approval of a revenue supplemental appropriation of $17.8 million for expenditures that exceed budget at San Francisco General and Laguna Honda hospitals. Surplus revenues of $16.7 million at San Francisco General Hospital will be used to fund the supplemental appropriation request. These revenues include $8.5 million in Other Patient revenue and $8.2 million in higher than expected revenues for Medi-Cal SB1255 revenues. Surplus revenues at Laguna Honda Hospital due to a projected favorable adjustment to the computation of Distinct Park Skilled Nursing supplemental payments will be used to fund the supplemental appropriation request. This is offset by a $129,000 negative variance resulting from delay in implementing paid parking reflected in Fees and Miscellaneous revenues. An additional $455,000 will be transferred from San Francisco General Hospital to Laguna Honda Hospital. Expenditures of $16.7 million in excess of budget at San Francisco General Hospital are due to unfavorable variances in Personal Services & Fringe Benefits, Non-personal Services and Materials and Supplies. Expenditures are projected to be $1.1 million more than budgeted at Laguna Honda Hospital due to unfavorable variances in Personnel Services and Fringe Benefits and Materials and Supplies. The supplemental appropriation request for the two hospitals is fully funded from revenues and will not require additional general funds. The on-going issues that have produced the excess expenditures have been addressed in the FY 05-06 budget via program initiatives and increases to specific budget line items. Action Taken: The Commission approved the revenue supplemental appropriation. 7) STD PREVENTION AND CONTROL UPDATE Jeffrey Klausner, M.D., MPH, Director, STD Prevention and Control, presented an update on STD Prevention and Control Services. STD services include The San Francisco City Clinic – 23,000 patient visits in 2004 Detention screening services – 12,000 persons age 15-35 screened per year St. James Infirmary – occupational health clinic for sex workers Magnet – Gay and bisexual male sexual health centerDisease control and investigation Field-delivered therapy Health education, provider training Sex club outreach and monitoring HIV testing, counseling and partner services HIV medical care Special projects and research Dr. Klausner highlighted some of the epidemiologic trends in select STDs in San Francisco. After a dramatic decline in syphilis infections in San Francisco from the 1980s, there have been increases over the past six years. In 2004, San Francisco was the city with the highest syphilis rate in the country. Almost all cases are in men. The public health response in San Francisco has been strong, and includes enhanced surveillance, expanded clinical and lab services, health provider education, community health promotion, addressing select risk factors and evaluation. As with syphilis, gonorrhea decreased dramatically from the early 1980s to 1996, and since then has remained elevated but relatively constant. The epidemiology of gonorrhea reflects two different transmission networks within San Francisco, one among men who have sex with men (MSM) and one among African Americans young adults. Gonorrhea is the second most common reportable disease nationally and in San Francisco. Compared to other cities, San Francisco has markedly higher rates than other places. In response to these high rates of gonorrhea, San Francisco has launched several screening programs for both gonorrhea and chlamydia, including at HIV testing sites, in the jails, at Magnet and at the sex worker safety clinic. In general over the past five years gonorrhea rates have been level or have declined, most dramatically in young adults age 15-19. Importantly, these declines are most pronounced in high-risk groups, including African Americans. Drug resistance in gonorrhea treatment remains a public health problem in San Francisco and is carefully monitored. Chlamydia remains the most commonly reported disease in San Francisco. San Francisco has the most comprehensive screening program and does the most testing. The highest rates are among African Americans and lowest rates are among API. Citywide chlamydia screening programs have been associated with significant decreases in the positivity rate. The most dramatic increase in the youngest age groups. Another way to look at the outcome of a decrease in gonorrhea and chlamydia rates is in Pelvic Inflammatory Disease, which has declined over the past few years. Dr. Klausner discussed the intersection between STDs & HIV. DPH has been monitoring the number of new STDs among people with HIV in San Francisco since 1995. These types of data have caused a reconsideration of HIV/STD prevention policy resulting in a shift of prevention efforts towards people with HIV infection. The rate of STDs among persons living with AIDS in San Francisco has increased, and HAART users were more likely to have an STD than non-HAART users. Dr. Klausner said that survey data show that a variety of MSM populations report recent methamphetamine use. Dr. Klausner said that in conclusion: San Francisco has high rates of STDs relative to other cities and California; unique epidemiology of STDs in MSM and young African-American heterosexuals; and programmatic interventions demonstrate reductions in morbidity in select groups. Commissioners’ Comments Commissioner Monfredini asked if the higher rates of STDs in San Francisco are a function of increased reporting. Dr. Klausner said San Francisco does a lot more testing than other areas, and this might be a factor in higher rates. However, San Francisco has a high positivity rate. Commissioner Tarver asked if the screening sites provide the entire spectrum of tests. Dr. Klausner said not all sites cover 100 percent of the spectrum, for example some sites might not provide throat swabs or rectal swaps. Commissioner Chow asked Dr. Klausner if he knows why gonorrhea rates have declined in young people, and can the decline be attributed to DPH efforts. Dr. Klausner replied that maintaining an STD treatment program in the detention facilities has impacted the rates of gonorrhea and chlamydia. In addition the YUTHE program, which is a peer-based program in the Bayview and other areas, as well as work with faith-based organizations, has raised awareness about sexual health and encouraged people to get screened and treated. Commissioner Chow said, given these successes, why haven’t the syphilis rates gone down. Dr. Klausner said syphilis is in a different population and a different approach is needed. Commissioner Illig clarified that STD Prevention and Control provides medical care to people with HIV. Dr. Klausner replied that City Clinic provides ongoing primary HIV care for approximately 125 individuals with HIV. Some people consider the City Clinic their health care home. Also, many clients are diagnosed with HIV at the City Clinic, and the Department felt it was important to provide services at the same site. Commissioner Chow asked when San Francisco might fall out of first place for syphilis rates. Dr. Klausner replied that in the first quarter of 2005 there has been a significant decline in syphilis, and if this holds for the second quarter, San Francisco may no longer be number one. Dr. Klausner said that the positivity rates for chlamydia continue to go down, which is encouraging. Commissioner Guy said STDs are a very important public health concern. She asked Dr. Klausner what he thinks works and also what the Health Commission needs to pay attention to. Dr. Klausner said what works is a combination of community mobilization, partnering with the community, and developing a contingent of community advocates. The most effective thing to do is empower the community to demand the right kinds of tests and the right kind of treatment. Secondly, the technical expertise of health departments to do surveillance and epidemiology is needed. At the national level, the CDC STD division has been decimated by the current administration, and it is another year of rescission. There needs to be a national dialogue about how we value our public health system. Commissioner Umekubo asked what some of the trends are with bacteria resistance. Dr. Klausner replied that 60% of cases are resistant to Azithromycin, and there hasn’t been any drug development for new antibiotics for syphilis. There has been no resistance with chlamydia. DPH has one of the only HIV drug resistance monitoring programs in the country. Commissioner Umekubo thanked Dr. Klausner for sending private providers the information on Azithromycin. Commissioner Tarver asked what kinds of programs are targeted toward African American MSM, and if the Magnet Clinic would be expanded. Dr. Klausner said that it was only this past fall that San Francisco required patients to identify the gender of the sex partner, and this is one of the limitations of the epidemiology. They have to infer based on geography or case interviews for syphilis. Last fall they co-sponsored a variety of different programs on the down low and try to support efforts to get the word out. They continue to work with San Francisco AIDS Foundation, Black Brother Esteem and other groups that want to serve gay men of color, to help them with grant proposals, support minority AIDS initiatives and provide data. 8) BEHAVIORAL HEALTH UPDATE The report was continued to the May 17, 2005 Health Commission meeting. 9) PUBLIC COMMENT/OTHER BUSINESS Anthony Hunter, representing Jelani House, commented on the possibility of losing services in the Bayview. This community is in crisis and should not lose any resource of any kind. Susan Murphy, president of the Silver Avenue Health Clinic Community Advisory Board. This clinic has served her entire family. A 20 percent budget reduction equates to 7,000 to 8,000 patients not being served. At Silver Avenue, 2,000 visits would be cut. Anonymous, spoke in support of the Silver Avenue Clinic. The clinic is very compassionate and nurturing. Closing this clinic and others is a death sentence. Please reconsider the decision, and keep this center open. Dr. Barry Zevin, speaking as a private citizen, is concerned with the plans to cut more from primary care. He reminded the commission that the keys to health care in this country remain primary care. The health problems are not going to decrease, and the number of patients needing services is not going to decrease. Services need to be expanded, not cut. James Strouse said there is no other place in the world that provides services like Tom Waddell. A lot of people will be killed if it is closed. Dulavi Khan said these proposals are all about finances. Schools, clinics and hospitals are being closed for poor people. There are so many cultures in California. The governor and president need to fund programs. Jim said there are people who would be dead but for the services at Tom Waddell. The services are very cost effective. If only 560 Tom Waddell patients end up at San Francisco General Hospital, all the savings from the cut will be wiped out. Cutting humane care is very false economy. Rudy Pedraza said he deserves to be seen and heard, and these budget cuts tell him that he no longer matters. He receives personal, compassionate treatment at Potrero Hill clinic. Fred Kirksey, a patient at Tom Waddell, loves Tom Waddell as a clinic and a family. Jane Kiskiras said Maxine Hall is her rock. DPH has the best doctors in the world, and the best the best technology. We have a health care delivery problem and we need a new paradigm. LaVonne McIntosh spoke against cuts to the primary care clinics. San Francisco exists in a macrocosm where general welfare is null and void, and the people have no say. She and others will protest. Jay Ordman spoke as a client of SFGH and Castro Mission Health Center. San Francisco has a world class health system in process and please do not stop this. He loves his primary care medical team. The leaders in this city have to tell the people that they need to have this health care team. Sandra Elizondo, member of the Potrero Hill Clinic Advisory Board, spoke against the cuts to the Potrero Hill clinic. The consequences of closing or reducing services at this clinic and others would be drastic. SFGH will not be able to deal with all the people that cannot go to primary care clinics. Patricia Gray, principal of Balboa High School, said 2/3 of her students are in need of public assistance in some respect. Her students come from four housing projects and if they do not have health care, they do not come to school and do not learn. She makes a good salary and she had to switch health insurers because she could not afford the co-pay. Imagine what it is like for people who are low income. Find other ways to reduce the budget. JoAnn Sanders, from Silver Avenue Clinic, said Dr. Goldberg at this clinic is an angel. The clinic provided excellent care for her foster children, and she receives care there as well. All the staff there is hardworking. Please do not cut the services to the clinics. Otto Duffy, Tom Waddell Advisory Board, spoke in support of primary care. San Francisco should be leading the way in numbers of insured people. Primary care has already gone through so many budget cuts. Right now patients get 15 minutes every six weeks, which is not enough for health maintenance. Ruth Gravitt spoke in support of Silver Avenue Health Center, where her doctor has been an angel of mercy. She said if her relationship with her physician is not disrupted, she will try to give back to the city what they have done for her. James Greenblat said right now it takes him three to four months to get an appointment, and he has to wait between one and three hours on the day of his appointment. If the Silver Avenue clinic is closed, senior citizens, children, families, men and women will be impacted. Ruben Garcia, Union Representative with Local 790, said Primary Care should be the priority, and he was surprised to see the Health Commission move primary care cuts from the contingency list to the base budget list. San Francisco needs all the clinics. San Francisco General Hospital Emergency Department has one of the worst backlogs, and this will get worse if the people who cannot get into primary care go to the hospital instead. The Health Commission needs to tell the Mayor that the Health Department needs more money. 10) ADJOURNMENT The meeting was adjourned at 5:50 p.m. Michele M. Seaton, Executive Secretary to the Health Commission Health Commission meeting minutes are approved by the Commission at the next regularly scheduled Health Commission meeting. Any changes or corrections to these minutes will be reflected in the minutes of the next meeting. Any written summaries of 150 words or less that are provided by persons who spoke at public comment are attached. The written summaries are prepared by members of the public, the opinions and representations are those of the author, and the City does not represent or warrant the correctness of any factual representations and is not responsible for the content.