Minutes of the Health Commission Meeting

Tuesday, January 17, 2006
at 3:00 p.m.
101 GROVE STREET, ROOM 300
San Francisco, CA 94102

1) CALL TO ORDER

Commissioner Monfredini called the meeting to order at 3:15 p.m.

Present:

• Commissioner Lee Ann Monfredini, President
• Commissioner Roma P. Guy, MSW, 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 JANUARY 10, 2006

Action Taken: The Commission approved the minutes from the January 10, 2006 Health Commission meeting, with amendments. The minutes will reflect the following changes:

• Page 3 “methadone” changed to “methamphetamine”
• Page 4 Added, for Item 3.10, “Susie Reichert, Senior Administrative Analyst for Community Programs/Placement” and “Commissioner Tarver requested Canyon Manor’s Financials.”
• Page 14 Under “Commissioners’ Comments,” added, “Commissioner Guy supports the discussion about the community trust fund taking place at the Community Health Network Joint Conference Committee (CHN JCC), primarily because this committee has a broader overview of the policy issues the Health Commission wants to examine and has members from across the Department. This does not preclude a presentation to the Laguna Honda Hospital Joint Conference Committee as well. In addition, several community members were de-linking the idea of the community trust fund from Laguna Honda, which is another reason she thinks the initial discussion should take place at the CHN JCC.”
• Page 12 Commissioner Chow clarified that Congress has not yet voted on whether the Medicare physician fee reduction will not continue into 2006.

3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE

Commissioner Illig chaired and Commissioner Sanchez and Commissioner Chow attended the Budget Committee meeting.

(3.1) BHS – Request for approval of a retroactive contract renewal with Westside Community Mental Health Center, Inc., in the amount of $3,603,817, with an annual contract amount of $2,402,544, for a total contract of $3,892,122, which includes a 12% contingency, to provide substance abuse treatment services, for the period of July 1, 2005 through December 31, 2006.

Secretary’s Note – Commissioner Tarver abstained from voting on this item.

Commissioners’ Comments

• Commissioner Illig asked what steps have been taken to improve the program, and what issues still exist. Mr. Stillwell said by and large the methadone program is okay. The agency spent a lot of time selecting a physician, so the concern has been met there. The continuing concern is with the two outpatient programs. They are currently being put out to bid through the RFP process. Dr. Boles, Executive Director of Westside Community Mental Health, said that productivity is slightly better than 2003-04, but there is still a productivity issue. Dr. Boles brought on new staff that is dually-diagnosed trained. The agency is retooling and retraining staff, and retooling the program. Quality of care will improve, and he hopes to increase productivity as well. Westside’s new model is what the agency is proposing in its response to the new RFP.
• Commissioner Sanchez asked if the agency feels it has reached a place where it has adequate staffing to begin to show measurable improvements and qualitative pathways. Is the agency fully staffed? Dr. Boles said they are fully staffed, confident that the level of training will meet program need. Now the focus is on bringing in clients. The outstanding question that he has is that they have integrated services but non-integrated funding.
• Commissioner Chow said Westside has a long history of service, and it is distressing to see that the agency has had difficulty meeting productivity goals. He asked for a six-month status report to the Health Commission through the Community Health Network Joint Conference Committee. Commissioner Chow said that, given the move toward 18-month contracts, the annual amount must be clearly articulated in the contract documents so that any reduction or increase can be easily identified.

(3.2) BHS – Request for approval of a retroactive new contract with Rebekah Children's Service, in the amount of $168,000, with an annual contract amount of $112,000, to provide mental health services for children, for the period of July 1, 2005 through December 31, 2006.

Commissioners’ Comments

• Commissioner Chow asked if it remains the case that DPH needs to place adolescents out of county due to lack of facilities in San Francisco. Helaine Weinstein, CBHS, said this is true.
• Commissioner Sanchez said that it would be good to look at what kids are being served over time and where. Gilroy and other suburban areas are so different from urban life, and it would be interesting to track success when placed back into an urban environment.
• Commissioner Illig said that the contract with DPH is for day treatment services, and asked who pays for the residential portion. Ms. Weinstein said the agency that places the child pays for the placement. In the case of this contract, it is the Human Services Agency. For Thunder Road (the next contract), it is primarily the Department of Juvenile Probation, although they are open to all referrals.

(3.3) BHS – Request for approval of a retroactive new contract with Adolescent Treatment Centers, Inc. dba Thunder Road, in the amount of $165,000, with an annual contract amount of $110,000, to provide mental health services for children, for the period of July 1, 2005 through December 31, 2006.

Action Taken: The Health Commission approved the Budget Committee Consent Calendar. Commissioner Tarver abstained from voting on Item 3.1.

The Health Commission requested a six-month update to the Community Health Network Joint Conference Committee on the Westside Community Mental Health contract.

4) DIRECTOR’S REPORT

Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report.

State Budget
On January 10th, Governor Schwarzenegger released his proposed budget for FY 2006-07. The $125.6 billion proposal includes $97.9 billion in general fund expenditures and a $1.2 billion (4%) spending increase for health and human services programs. The bulk of these increases cover rising Medi-Cal caseloads and higher health care costs. However, $72 million is included to increase enrollment of children in the Medi-Cal and Healthy Families programs through public awareness campaigns and simplification of the application process. Approximately $20 million of these funds would be earmarked for counties to support local outreach and enrollment efforts. An additional $9.6 million is proposed to streamline enrollment in the Healthy Families program through increased use of online applications. The Administration estimates that these funds will facilitate enrollment of approximately 300,000 uninsured children.

The budget proposal also includes $45.8 million in new State funds for disaster response programs, a $28.5 million increase for the AIDS Drug Assistance Program (ADAP) and $19 million to hire more inspectors for nursing homes, hospitals and other health facilities. Reimbursement rates for long-term care facilities, like Laguna Honda, that serve Medi-Cal patients are also increased by 5.4% in the budget.

Despite the defeat of Proposition 76, the Governor again proposed language giving the Director of Finance authority to make mid-year budget cuts. Reductions would be limited to 25% of the affected appropriation. The new State fiscal year begins on July 1st. The budget bill will now go to the Assembly and Senate Budget Committees for review. Passage of the budget requires a two-thirds vote in both chambers.

Chronic Diabetes Initiative Recognized
Silver Avenue Health Center, Chinatown Public Health Center, Potrero Hill Health Center and Family Health Center at SFGH were honored at the December 2005 California Association of Public Hospitals Annual Meeting for their successful completion of the year-long Chronic Care Learning Communities (CCLC) Initiative Diabetes Collaborative. The recognition was sponsored by CAPH - Safety Net Institute and included nine California county health system clinics.

The San Francisco CCLC teams redesigned care for their diabetes pilot groups by adopting a diabetes registry, promoting patient self management, expanding staff roles, and developing multilingual group medical visits and group diabetes education classes. Several clinics started Yoga and Tai Chi classes in order to develop a “Wellness Center” clinic model. Monthly reports tracked care measures, showing improved rates of interventions to prevent long-term complications (foot exams, retinal exams, lipid control).

The four CCLC teams and Ocean Park Health Center’s diabetes team will continue the care redesign and reporting of care indicators in 2006, and will meet together periodically to spread improvement in chronic disease care in SF DPH.

New Program Manager for Laguna Honda Replacement Program
Dr. Katz announced that John Thomas has been appointed as the new Program Manager for the Laguna Honda Hospital Replacement Program replacing Michael Lane. John Thomas brings 19 years of experience and expertise with the City and County of San Francisco. He came to the City with a degree in Civil Engineering and spent his first seven years working for the Department of Public Works on the Embarcadero Roadway Replacement. Mr. Thomas worked for MUNI as a Senior Project Manager since 1996. During the last four years, he managed MUNI's Central Subway Project, which is Phase 2 of the Third Street Light Rail Program. DPH is very fortunate to have John join our team on the Laguna Honda Hospital Replacement Program.

Community Health Network San Francisco General Hospital Credentials Report, January 20066

	01/06		07/05 to 01/06
New Appointments	9		108
Reinstatements	0		0
Reappointments	48		227
Delinquencies:	0		0
Reappointment Denials:	0		0
Resigned/Retired:	9		76
Disciplinary Actions	0		0
Restriction/Limitation-Privileges	0		0
Deceased	0		0
Changes in Privileges
Additions	6		32
Voluntary Relinquishments	7		21
Proctorship Completed	23		71
Proctorship Extension	0		6
Current Statistics – as of 01/1/06
Active Staff	469
Courtesy Staff	581
Affiliate Professionals (non-physicians)	190
TOTAL MEMBERS	1,240
Applications In Process		21
Applications Withdrawn Month of January 2006		0	2 (07/05 to 01/06)
SFGH Reappointments in Process Feb. 2006 to May 2006		231

Commissioners’ Comments

• Commissioner Monfredini welcomed Mr. Thomas to the Department and looks forward to his input in moving forward on this very important project.
• Commissioner Chow asked if the Governor’s budget intends to change the MediCal fee for service reimbursement rates, which were reduced by five percent last year. Mr. Sass said this reduction did not have that great of an impact on DPH, and where it does affect the fee for service side, public hospitals are getting an FFP supplemental. Commissioner Chow asked if there are any reductions in capitation. Mr. Sass is unaware of any changes. Dr Katz said the 5% reduction is not scheduled for change, so will continue for this year. He added that while the San Francisco Health Plan would see a reduction, it decided not to reduce capitation to its medical groups. Commissioner Chow asked if other primary care clinics would implement the diabetes chronic care initiative, and other model programs that are found to be successful. Dr. Katz said it would become part of the standard way DPH cares for patients with diabetes, and will likely be the way DPH cares for all chronic diseases.
• Commissioner Illig said there was a lot of discussion around State funding for seismic repairs, and asked if the Governor’s budget includes this. Dr. Katz said there is nothing for seismic improvement in the Governor’s bond. There continue to be suggestions that the Legislature will offer a separate proposal. Commissioner Illig asked if the increase in long-term care reimbursement rates is above and beyond what DPH received this year. Mr. Sass said as he reads it, the increase of next year is expected to be about half of last year’s, and is one of the better pieces of good news. Commissioner Illig asked if there is any expansion in Governor’s budget for community-based care under MediCal. Mr. Sass said not to his knowledge.
• Commissioner Guy asked if the Governor’s proposal to expand the number of children who receive health insurance would have positive consequences for San Francisco. Dr. Katz said not really because the money is only available for outreach. There may be children in San Francisco who are eligible for MediCal but not enrolled, and this money might help capture these people.

5) EMPLOYEE RECOGNITION AWARDS FOR THE MONTH OF JANUARY

Commissioner Guy presented the Employee Recognition Awards for the month of January. 25 years ago, she worked with Ms. Biblowitz in Togo, Africa. She greatly appreciates Ms. Biblowitz’s ongoing advocacy around public health issues.
 

6) ELECTION OF HEALTH COMMISSION PRESIDENT AND VICE PRESIDENT FOR 2006

Commissioner Guy nominated Commissioner Monfredini to serve as President of the Health Commission. She supports Commissioner Monfredini because of her commitment to and leadership for long-term care, the Laguna Honda Hospital rebuild and the rebuild of San Francisco General Hospital. She appreciates that Commissioner Monfredini has maintained her voice on the strategic priority of funding the integration and modernization of primary care and primary prevention.

Commissioner Chow seconded the nomination. He has worked with Commissioner Monfredini for many years, and for all the reasons Commissioner Guy cites, it is fitting that Commissioner Monfredini serve another year as president. She acts on behalf of the residents of San Francisco and is emotionally committed to all patients who are part of our system. It is extremely important that the Health Commission continues to be an objective voice about the health care needs of San Francisco.

Commissioner Sanchez echoed the above sentiments, and moved that the nominations be closed.

Action Taken: The Commission elected Commissioner Monfredini to serve as President of the Health Commission for 2006.

Commissioner Tarver nominated Commissioner Illig to serve as Vice President of the Health Commission. Commissioner Illig is distinguished by being force of nature—highly opinionated, keenly intelligent and compassionate. Commissioner Illig will continue to work effectively with fellow Health Commissioners, department staff, the Mayor’s Office, Board of Supervisors, community partners and others.

Commissioner Chow seconded the nomination of Commissioner Illig, whom he has had the opportunity to work with on the Budget Committee and Laguna Honda Hospital Joint Conference Committee. He will be an effective leader.

Commissioner Sanchez moved that the nominations be closed.

Action Taken: The Commission elected Commissioner Illig to serve as Vice President of the Health Commission for 2006.

Commissioner Monfredini thanked everyone for their nice comments. She and Commissioner Illig will be working side by side over the coming year for the good of the whole of the Department, and there will be no opportunity to put a wedge between this team. They will be hard working team who, working closely with Dr. Katz, will forward the mission of the Health Department.

Commissioner Illig thanked his fellow commissioners. He is looking forward to a closer working relationship between the Health Commission and the Mayor’s Office, and better communication among the Health Commissioners. There are health policy decisions being made, and the Health Commission needs to be at the center of these decisions, be it the rebuild, the HMA report, and other issues.

Commissioner Guy said that it is important to note that in the latest round of nominations, the usual protocol was not followed and next year the Health Commission should put in writing rules around how officers are nominated, committee assignments are made, and other issues.

Commissioner Monfredini announced that there will be new committee assignments and she and Commissioner Illig will be contacting commissioners about desired assignments.

7) FY 06-07 BUDGET: STRUCTURAL, INFLATIONARY, REVENUE, REVENUE-NEUTRAL AND REGULATORY ISSUES

Gregg Sass, Chief Financial Officer, presented the structural, inflationary, revenue, revenue-neutral and regulatory issues that are part of the FY 2006-2007 budget proposal. In this planning process, the Department moved toward an integrated approach to the budget process. Following the issuance of the Health Management Associates report, the Department moved quickly on a key recommendation to establish and Integrated Steering Committee of senior administrative and clinical leadership from the Department’s delivery system. This leadership group is functioning as the Executive Budget Planning Committee for the Department. Key initiatives under development include:

• Integrated plan to coordinate placement of long-term patients in the most appropriate and cost effective settings; and
• Initiatives to restructure the primary care delivery system to expand capacity, increase productivity and improve financial performance.

Mr. Sass described the citywide budget, which has a total projected shortfall of $80 million. The shortfall projection assumes that the City will resume payment for the 7.5% employee share of retirement contributions in accordance with negotiated labor agreements, but that no wage increase would be provided for the nearly forty employee groups whose contracts will be open for negotiation next year. To the extent that wage increases are provided, the cost of funding those increases would add to the projected shortfall.

Mayor’s Budget Instructions state that departments must absorb half the cost of restoring the employee pickup. For DPH, the projected cost of this restoration is $14.26 million and therefore the amount we must absorb is $7.13 million. The Mayor’s instructions also require Departments to submit a list of expenditure savings worth 3% of the Department’s reduced general fund subside in the event additional reductions become necessary. This translates to an additional reduction of $7.8 million. Finally, departments should propose one-time investments and expenditures equal to 3% of general fund.

Mr. Sass said that before the Health Department can begin to address the requirement to decrease its general fund, it must take into account unavoidable increases in the cost of doing business that result from structural, inflationary and regulatory issues. Mr. Sass described the components of each area. Total regulatory issues amount to $2,414,573. Total inflationary issues amount to $9,049,803. Total structural costs are $14,247,535. Revenue neutral programs are new services that are funded entirely through revenues linked to the service. In this budget, DPH proposes to include 22 initiatives. Total Revenue Neutral Programs net the Department $315,067. And finally, the Department continues to explore opportunities to increase revenues. Mr. Staff said they have identified increased revenues at SFGH, CBHS, LHH, Primary Care and Environmental Health that total $28,364,023.

The full report, which includes a list of all structural, inflationary and regulatory issues, revenue-neutral programs and increased revenues, can be found on the DPH website at www.sfdph.org/budget/.

Mr. Sass said the net effect of all inflationary, regulatory, structural, revenue neutral and revenue increases results in a surplus of $2,967,178. This surplus could be put towards the Mayor’s Budget instructions to absorb $7.13 million for restoration of the retirement pickup and $7.8 million for the three percent general fund savings target.

Dr. Katz gave a big picture overview of the budget. The first scenario is always the worst scenario. Given past years, an $80 million shortfall is an improvement, and the revenue picture might get better. In terms of DPH’s budget, the Health Department’s general fund has decreased despite the extent of health care inflation. That the Department has been able to manage this with relatively little service disruption is commendable. Dr. Katz said the Department sent a letter to all agencies asking them what their increases are. The two responses to this information are either to provide funding for the increases or decrease services. The Health Commission will be presented with policy issues at the next stage of the budget process. Dr. Katz is very pleased with the revenue neutral proposals. Dr. Katz was troubled to see how much the increased cost of doing business eats into additional revenue.

Commissioners’ Comments

• Commissioner Monfredini said this is a kinder picture than past years, but there are still challenges. She asked if there was any wiggle room around the addition of an agricultural commissioner. Dr. Katz said this is a state-mandated positions.
• Commissioner Illig said that these structural issues are policy decisions, and he is going to be weighing these items with the budget cuts that will be proposed. The Health Commission needs to address the policy decision around whether the Department hires staff as soon as it gets money. He will pay particular attention to the structural issues. He thanked Dr. Katz and Mr. Sass for including a budget estimate on the cost of a contractor COLA, however he is disturbed that it is only for general fund contracts.
• Commissioner Tarver said it is clear that there are some policy considerations around the structural issues that are presented here. He is pleased to see that there are opportunities to increase revenues. He said there might be opportunities to increase fees. The Chief Operating Officer position will increase effectiveness, and could be considered cost-recovery. He also asked about the dialysis unit. Mr. Sass said staff is going through all line items again to fully examine all underlying assumptions, including whether or not certain items should be considered structural fixes. Dr. Katz said the LHH dialysis unit in the budget next year. Commissioner Tarver asked if the Department has a three-year budget plan. Dr. Katz said many people have called for this, but the city can only appropriate a year at a time. Commissioner Tarver thought that Medicare Part D would be a plus for the Department. Dr. Katz said Part D Medicare saves money for people who are Medicare only, but costs money for people who are Medi-Medi, primarily due to the co-pay. The co-pay must be paid, and DPH’s policy is to currently not to charge co-pays. Commissioner Tarver is still waiting for information about how many long-term care beds DPH has, and what types of beds. He asked if there is the opportunity to increase the number of community-based facilities, be it another MHRF or more Broderick houses, that DPH could use rather than buying L facility beds.

Public Comment

• Richard Healey, Executive Director, Conard House, thanked the Department for including the cost of a COLA in the budget projections. Ms. Garcia spoke to the Human Services Network last week about the effort to identify contractor cost of doing business, and it will be interesting to see the result of the surveys.
• Eve Meyers, San Francisco Suicide Prevention, thanked the Department for including contractor cost of doing business at the front end of the budget discussions.

Commissioners’ Comments (continued

• Commissioner Sanchez thanked Dr. Katz and all the staff that has been involved in the process of developing this model that will be used to develop the budget. It is very revealing and brings to the Health Commission’s attention how far ahead of other counties San Francisco is in health care delivery.
• Commissioner Umekubo is pleased to see that the Integrated Steering Committee is working well. He is very excited about the heart failure clinic. Heart failure is the number one diagnosis for admission and if patients could be screened and treated before having to be admitted, this could save money over the long term.
• Commissioner Chow complimented the continuation of this budget format, which allows the Commission the opportunity to review the foundations of the budget. He is pleased that a number of the revenue-neutral programs really move the Department into preventive primary care, and he encouraged a continuation of this type of creativity. Colon cancer screening and the breast and cervical cancer navigator program are two examples. Commissioner Chow asked for additional information on the following issues: the Chief Operating Officer, and how this position could benefit the Department; how many nurses are necessary to comply with state mandated nursing ratios; what is the rationale for needing 6.75 additional pharmacists, and is this truly a JCAHO; and a better understanding of what is meant by position adjustments/corrections. He asked when the next phase would be. Dr. Katz said staff would provide answers to these questions. He said that 6.5 FTE pharmacist equates to one pharmacist for a 24-hour operation. CMS quite really critical of the pharmacy. The COO will come to the Commission as a new initiative. The issue that needs the most global work is the discussion around the use of residential beds, and the types of patients that DPH needs placements for. In terms of process, this will come back to the Health Commission some time in February.
• Commissioner Guy said the way the Commission has discussions around assumptions is important. For example, she would not be checking all the assumptions around the cancer navigator, because she has been involved in this project and evidence shows it works. She does not want to check out the assumption whether or not there is a Health at Home. Four years ago DPH and the Health Commission began the discussion around the assumptions about the rebuild of San Francisco General Hospital. Many assumptions are not going to be managed and decided upon by the time we need to submit the budget. There are various kinds of assumptions—regulatory, evidence-based, etc.—and there needs to be an understanding of this as we move into the next round. Another important discussion that needs to take place is how the budget fits into the Strategic Plan. It would add value if the Commission could look at budget initiatives in terms of how they fit into the DPH mission and our strategic plan.
• Commissioner Illig asked what is included in the 31% fringe benefit. He also asked if the 15 percent retirement contribution is on top of the 31% fringe benefit. His point is that it is expensive to hire civil service employees, so he wants to have policy discussions around whether civil service is the best way to treat our patients. Mr. Sass will provide the Commission with a list of what is included in fringe benefits.

8) PUBLIC COMMENT/OTHER BUSINESS

None.

9) ADJOURNMENT

The meeting was adjourned at 5:45 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 noted 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.