Minutes of the Health Commission Meeting Tuesday, May 2, 2006 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 Illig at 3:10 p.m. Present: Commissioner James M. Illig, Vice President Commissioner Edward A. Chow, M.D. Commissioner Roma P. Guy, M.S.W. Commissioner David J. Sanchez, Jr., Ph.D. Commissioner Donald E. Tarver, II, M.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Lee Ann Monfredini, President 2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF APRIL 18, 2006 Action Taken: The Commission (Chow, Guy, Illig, Sanchez, Tarver, Umekubo) approved the minutes of the April 18, 2006 with the correction of three typographical errors. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Sanchez chaired and Commissioner Tarver and Commissioner Chow attended the Budget Committee meeting. Items for Discussion and Approval (3.1) CHN-SFGH – Request for approval of a contract modification with Nurse One Staffing, LLC, to increase the contract amount by $125,000, from $100,000 to $225,000, to provide supplemental, temporary per diem and traveling nursing personnel services under a state of health emergency for San Francisco General Hospital, for the period of December 1, 2005 through June 30, 2006, per San Francisco City and County’s Administrative Code, Section 21.15, Emergency Procurement Procedures. (3.2) PHP-STD Prevention & Control – Request for approval of a retroactive renewal contract with UCSF-Stonewall/Magnet Project, in the amount of $128,800, which includes a 12% contingency, to provide STD & Syphilis testing and treatment to gay men and other men who have sex with men, for the period of January 1, 2006 through December 31, 2006. (3.3) Central Administration – Request for approval of the Fiscal Year 2006-2007 Patient Rates Ordinance. Action Taken: The Commission (Chow, Guy, Illig, Sanchez, Tarver, Umekubo) approved the Budget Committee Consent Calendar. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Health Director, presented the Director’s Report. Department Response to Incident at Ella Hill Hutch As the Commissioners are aware, a tragic shooting occurred on April 27th at Ella Hill Hutch Community Center in the Western Addition. At the time, several youth in the gym were participating in ‘Safe Haven’ activities when shooters entered and killed a 22-year-old part-time employee of the center. The DPH/CBHS Crisis Response Team and Westside Critical Incident Response Team (CIRT) responded. Ella Hill Hutch Community Center has been temporarily closed. DPH, the District Attorney Office and Westside Community Services are assisting family and the community. Agencies, schools, and housing complexes in the nearby vicinity were contacted to let them know that mental health and support services are available. Westside Community Services is providing debriefing services to the Ella Hill Community Center staff. The Ella Hill Hutch Community Center is projected to re-open tomorrow. Charlie Morimoto is coordinating the Department’s response to this terrible tragedy. Contingency Budget Update On April 24, 2006, the CHN Joint Conference received additional data from the Department on the costs associated with residential substance treatment programs and heard testimony from treatment providers. Although a final resolution has not yet been reached, the Department is committed to developing an alternative methodology for determining rates if the contingency cut is required to balance the City’s budget. Homeless Prenatal Program Last week the Homeless Prenatal Program (HPP) held an open house at its new headquarters at 2500 18th Street @ Potrero. Mayor Gavin Newsom and other dignitaries were present to inaugurate "HPP's" new home. The Executive Director, Martha Ryan and HPP's staff were host to over 300 guests. The Homeless Prenatal Program serves homeless families with young children, providing case management, life skills learning, access to medical care, and move-in assistance for families moving into permanent housing. They will be able to offer much more at the new facility in the way of job readiness and health to clients. The Homeless Prenatal Program is one of the DPH's partners in many endeavors, especially in improving the outcomes of pregnant women and their infants. The website, http://www.homelessprenatal.org, provides information about the program and its needs. Shape Up San Francisco On April 26th the Mayor hosted a Shape Up Summit and launched his “Shape Up San Francisco” Challenge. The Chronic Disease Prevention Consortium organized the event. The Summit focused on the policy level solutions to address physical inactivity and poor nutrition. The Mayor's remarks set the tone for the City’s ongoing work on chronic disease prevention. The Summit was well attended by City Department heads and leaders from the business, non-profit and health care sectors. The Summit was just the beginning of the Mayor's 18-month Shape Up initiative, and laid the groundwork for future chronic disease prevention work in San Francisco. Many thanks to Kaiser Permanente who funded the Summit and to Christina Carpenter, who serves as staff for the Chronic Disease Prevention Consortium. Immunization Coalition Observes 10-Year Anniversary Dr. Katz congratulated the San Francisco Immunization Coalition on its 10-Year Anniversary Celebration. In observing its first decade of promoting childhood immunization, the Coalition last night hosted a fund raiser and campaign kick-off at AT&T Park featuring national immunization advocate and Former First Lady Rosalynn Carter. Mrs. Carter, president and co-founder of Every Child By Two, stressed the importance of timely childhood immunizations and urged the adoption of computerized immunization registries. This event also helped to commemorate National Infant Immunization Week and Toddler Immunization Month. A running theme in this year’s immunization awareness efforts is the concept of “Community Immunity,” also known as herd immunity. The Coalition’s goal is to achieve maximum immunization, thereby protecting the vulnerable from becoming sick. The Coalition’s next high visibility campaign, focusing on parents and communities with lower immunization rates, features San Francisco Giant’s infielder and father of two, Ray Durham. The Coalition’s website can be found at www.sfimmunize.org. Chronic Alcoholism Conference The Department of Public Health, in collaboration with St. Francis Memorial Hospital, will be sponsoring a day long conference on May 19th entitled, Chronic Alcoholism: Homelessness, Health and Hope. The goals of the conference are to establish community-wide recommendations to reduce hospitalizations and improve health practices for chronic alcoholics. Representatives from Federal and State Health Organizations as well as local experts will participate. Carnival Participation The Department of Public Health will provide health screenings and health education activities at the Healthy Lifestyle Pavilion for this year’s Carnival on May 27th and 28th. The Carnival is one of San Francisco's most revered community events with over 450,000 attendees. This year’s theme is Suenos de la Ninez (Land of Childhood Dreams). Dora the Explorer will be the Grand Marshall of the Parade. Dorothy Washington Nursing Scholarship Fund A reminder that this Thursday, May 4th we will be holding the second SFGH Gala Fundraiser dinner event at the Ritz-Carlton Hotel benefiting the Dorothy Washington Nursing Scholarship Fund. Keynote Speaker is Kamala Harris, District Attorney. Understanding Racism and Health Disparities The African American Health Initiative is sponsoring a workshop for DPH mangers and leaders on Friday, June 16th entitled, “Understanding the Impact of Race and Racism on Health Inequities and Health Disparities.” We are fortunate to have Melanie Tervalon, MD, who has presented hundreds of thought-provoking workshops across the nation, facilitate the workshop. Dr. Tervalon is one of the leading theorists and practitioners in “cultural humility.” Training is being coordinated through the Health Education Training Center. We welcome the Commissioners’ interest and attendance at this upcoming event. Commissioners’ Comments Commissioner Illig said there was a very interactive discussion at the Joint Conference Committee about the residential substance abuse programs, and he looks forward to future dicussions with staff and contractors. 5) CONSIDERATION OF A RESOLUTION REGARDING BROWN AND TOLAND Commissioner Chow and Commissioner Sanchez both have been advised by the City Attorney not to participate in this hearing. They asked their colleagues to entertain a motion to recuse them from the discussions. Action Taken: The Commission (Guy, Illig, Tarver, Umekubo) approved a motion to recuse Commissioner Chow and Commissioner Sanchez from participating in this hearing. Public Comment Dr. Fiona Wilson, Brown and Toland Medical Group (BTMG), has been working collaboratively with the Department of Public Health CHN around chronic disease management and she works with providers on best practices, irregardless of payor class. BTMG’s strategy is to acknowledge the work of its most productive physicians through the preferred physician program. Dr. Stan Padilla, Chief Medical Officer, BTMG, said BTMG has met with Chinese Community Health Care Association (CCHCA) and Chinese Hospital and the outcome was a letter of intent about physicians participating freely in both organizations. There is no reason to proceed with the resolution if it is based on exclusivity because exclusivity is just not there. The preferred network is an attempt to recognize and fortify the group that is the most active. The offer did not target the Chinatown physicians, but did include them. Richard Loos, Chinese Community Health Plan, said the issue of exclusivity has been an issue from the beginning. CCHCA, CCHP and Chinese Hospital’s initiative around this is to preserve the mission and the services. The letter of intent was signed, but this only bought time to come to a long-term solution. Eric Leung, M.D., President, CCHCA, asked for the Commission’s support for the resolution. The letter of intent is only for six months. If there is no agreement, exclusivity will stand and physicians will have to resign. Michael Lee said he is a long-term member of CCHCA. Most Chinese seniors would like to continue seeing Chinese physicians because of language and cultural access and sensitivity. Commissioners’ Comment Commissioner Umekubo asked BTMG to clarify the exclusivity agreement, and Commissioner Illig asked if exclusivity is part of the current negotiations. Dr. Padilla said BTMG accepts the fact that CCHCA physicians provide services to a unique population. But BTMG wants physicians in both organizations to have equal benefits. Commissioner Tarver said BTMG is cherry picking Chinese physicians because only some of CCHCA’s physicians were offered the preferred network. Dr. Padilla said the preferred status was only offered to physicians who were already in BTMG and had significant volume and quality parameters. Commissioner Tarver asked if other groups outside of CCHCA are subject to an exclusivity provision. Dr. Padilla said only with respect to HMO and some PPO contracts, not the entire gamut of their practices. Most BTMG physicians are members of other IPAs. Commissioner Guy said the Health Commission is not going to solve the debate about whether exclusivity is or is not still an issue, nor is it the appropriate body to do so. The issue for the Health Commission is that if exclusivity is implemented, it will be detrimental to San Francisco and the Chinese community. She supports giving voice to this fact through the resolution. Commissioner Illig asked why BTMG does not maintain Medi-Cal contracts. Dr. Padilla said the BTMG model is set up to allow the individual physicians to practice as they think most appropriate, and some BTMG physicians do serve Medi-Cal. Commissioner Illig noted that he had another request for public comment, and he would honor that request. Public Comment Rose Pak, Board of Trustees for Chinese Hospital, said this has been one of the most painful issues the board has faced. They have been meeting with BTMG for six months. She has seen the forms BTMG sent to doctors—you sign with them, you resign from Chinese Hospital. They only picked the most vital groups of doctors where Chinese Hospital is the most vulnerable. Chinese Hospital only has two orthopedic surgeons, for example, and these were targeted. Doctors do not like to be put in the predicament of either serving their community or keeping their BTMG patients. Commissioners’ Comments (continued) Commissioner Tarver supports the continuation of Chinese Hospital and opposes any actions that would undermine independent physicians’ ability to provide services. He proposed an amendment to the resolution to reflect this. Commissioner Umekubo said he was at the San Francisco Medical Society meeting where this issue was discussed. He has heard that exclusivity is not an issue, but there is still skepticism and once this is in writing, on paper, and agreed upon by all parties, people will feel a lot better. Commissioner Illig said one of the positive outcomes of this fight is the attention it has brought on the good work of Chinese Hospital and CCHCA, including service to 7,000 members of the San Francisco Health Plan. Action Taken: The Commission (Guy, Illig, Tarver, Umekubo) approved an amendment to the resolution adding the following: further resolved, that the Health Commission appreciates and respects the historic service that Chinese Hospital, CCHCA and independent community physicians provide to the community, and would oppose any undermining of these health services as they would have a detrimental impact on public health. Action Taken: The Commission (Guy, Illig, Tarver, Umekubo) approved Resolution 08-06, “Resolution Urging Brown & Toland Medical Group to Allow Non-Exclusive Affiliation for Physicians of Chinese Hospital and its Medical Group the Chinese Community Health Care Association,” as amended (Attachment A). 6) 3RD QUARTER FINANCIAL REPORT Gregg Sass, Chief Financial Officer, presented the 3rd Quarter Financial Report. DPH is projecting a surplus of $21 million, compared to a second quarter projected surplus of $15.8 million, for a net increase of $5.16 million. The additional surplus includes $4.03 million in SB 90 revenue that was not included in the second quarter report and a negative $2.3 million for a prior period adjustment to revenue under the GME program for 2004-05. The following table summarizes projected financial results for the year: Projected FY 2005-06 Year-End Surplus/Deficit   REVENUES EXPENDITURES TOTAL   Revised Current Surplus/ Revised Current Surplus/ Surplus/ Division Budget Projection (Deficit) Budget Projection (Deficit) (Deficit) Department of Public Health             SFGH 599,459,000 525,660,000 (73,799,000) 599,459,000 517,459,000 82,000,000 8,201,000 SB855 Adjustment (82,000,000)   - 82,000,000 (82,000,000)   - (82,000,000)   - SFGH Adjusted 517,459,000 525,660,000 8,201,000 517,459,000 517,459,000   - 8,201,000 Laguna Honda 168,755,000 178,251,000 9,496,000 168,755,000 170,030,000 (1,275,000) 8,221,000 Primary Care 44,282,000 44,007,000   (275,000) 44,282,000 46,042,000 (1,760,000) (2,035,000) Health at Home 8,550,000 8,550,000   - 8,550,000 7,942,000   608,000   608,000 Jail Health 23,087,000 23,087,000   - 23,087,000 23,180,000   (93,000)   (93,000) Public Health 98,261,000 98,261,000   - 98,261,000 98,291,000   (30,000)   (30,000) Mental Health 195,049,000 199,079,000 4,030,000 195,049,000 193,376,000 1,673,000    5,703,000 Substance Abuse 65,370,000 65,370,000   - 65,370,000 64,936,000   434,000   434,000 TOTAL DPH  $ 1,120,813,000  $ 1,142,265,000 21,452,000  $ 1,120,813,000  $ 1,121,256,000   (443,000) 21,009,000 Mr. Sass highlighted revenue and expenditures for each of the divisions. In conclusion, DPH is projected to return a surplus to the City General Fund primarily as a result of increases in Medi-Cal funding resulting from the Medi-Cal Waiver and increases in Medi-Cal per diem rates at Laguna Honda Hospital. In addition, the continued high occupancy rates at SFGH are contributing to increased patient service revenues. Commissioners’ Comments Commissioner Umekubo noted that in the past, increased census at SFGH actually cost money, but now the opposite is true. He asked if the if the GME subsides have been cut. Mr. Sass replied that GME, SB 1255 and SB 855 have all been replaced by the Medicaid waiver. The CMS portion has not been cut. Commissioner Tarver suggested more frequent financial reports, and that the timing of the presentations be more coordinated vis-à-vis budget proposals, so that commissioners are aware of any additional revenue available to offset cuts. He also said there is an ability, through billing, charging, etc., to further maximize revenues. Mr. Sass said DPH has worked over the years to increase revenue collection. This year, much of the surplus revenue was the result of external efforts and decisions. Commissioner Chow asked where the recently approved supplemental appropriation for Laguna Honda fits into this quarterly report. Mr. Sass said the money for Laguna Honda that was included in the contingency budget approved by the Health Commission at the last meeting was for next year’s budget. However, they are discovering that costs resulting from the licensing surveys are already impacting the budget this year. Commissioner Chow asked if DPH is using revenues from SFGH to fund Primary Care. Mr. Sass said there was a $1.7 million supplemental appropriation for Primary Care, $700,000 of which was funded by surplus revenue. This surplus revenue was going to be used to offset the overspending in Primary Care, but now is unavailable so they are using other revenues and general fund. Commissioner Guy said that DPH is deficit spending in Primary Care, and this is a significant issue she wants to bring into focus. How will this be addressed? Mr. Sass said DPH has included a structural fix for Primary Care in next year’s budget, which addresses about half of the problem. In addition, a variety of initiatives to restructure Primary Care have been submitted to the Mayor. And the Moss Adams report, which will be presented to the Commission at an upcoming meeting, also includes recommendations. Commissioner Guy asked if SFGH’s census would be adjusted to reflect that it is continually over census. This has taken a tremendous toll on staff, and there should be some discussion about this at the CHN JCC. The overcensus issue may not be a fad—it may be here to stay. Commissioner Illig noted that Medi-Cal rates are not going to be as high in future years as they were this year. He is going to ask the Mayor’s Office if DPH could use $3 million of its surplus revenue on one-time activities, for example a community living trust fund. Mr. Sass noted that DPH has submitted its one-time list at the request of the Mayor’s Office. This will be part of the budget process. Dr. Katz said Commissioner Illig’s approach is a good approach, and it never hurts to ask. He noted that the Board of Supervisors still has not funded the next phase of the SFGH capital work. 7) CONSIDERATION OF A RESOLUTION ESTABLISHING A POLICY OF BUDGET PROPOSALS BEING REVIEWED THROUGH THE JOINT CONFERENCE COMMITTEES Commissioner Illig is proposing this policy to the Health Commission in an attempt to bring budget discussions to the joint conference committee level. This reflects that the Health Commission established the joint conference committees (JCCs), including the Budget Committee, to provide a forum for more extensive, deliberative and interactive communication between commissioners, DPH staff and the public. It is an important policy statement to say that when the Health Commission is going to consider cuts, it will do so outside of the budget cycle, throughout the year, at the JCCs and consider the pros and cons of the proposals, as well as get public input. He has one change, and that is to change the word “must” to “should.” Commissioners’ Comments Commissioner Chow thinks the policy is useful and should be included in the Rules of Order as part of the larger context of how the Health Commission reviews the budget in a way that allows for deliberative and open discussion. He asked that the Commission direct the Budget Committee to develop the implementation of the policy through the Rules of Order, and bring a proposal back to the Health Commission. Commissioner Guy said her goal is for the Health Commission to take a more anticipatory approach to budget consideration. She sees this being done through the JCC structure. Commissioner Sanchez would like to rethink other opportunities for increasing dialogue and public input, for example committees of the whole on topics such as budget surpluses, budget priorities and others. Committees of the whole have been positive protocols to solicit input and develop ideas in conjunction with staff. He hopes that this is part of the discussion. Commissioner Umekubo supports the resolution. He would like regular financial reports to be reinstituted at all of the JCCs. Commissioner Chow said to date the Budget Committee has had a limited scope, but it has the ability to help shape how the Health Commission looks and fiscal and budget issues, and develop protocols around this. He suggested that the Budget Committee develop a skeleton framework and bring this forward to a Committee of the Whole. Commissioner Tarver said there are forums for dialogue within the Department about budget and policy that did not previously exist. The Commission wants to vet proposals before they come to the full Commission, and different proposals would be vetted at different committees. Action Taken: The Commission (Chow, Guy, Illig, Sanchez, Tarver, Umekubo) amended the resolution to change “must” to “should, and to add: further resolved, that the Health Commission charges the Budget Committee to return with a protocol for how this policy will be implemented. Action Taken: The Commission (Chow, Guy, Illig, Sanchez, Tarver, Umekubo) approved Resolution 09-06 “Establishing a Policy of Reviewing Budget Proposals Through the Joint Conference Committees Prior to a Full Hearing at the Health Commission,” (Attachment B). 8) REPORT ON CHRONIC CONDITIONS OF CALIFORNIANS-SUMMARY OF FINDINGS RELATED TO SAN FRANCISCO This report was continued to a future Health Commission meeting. 9) PUBLIC COMMENT/OTHER BUSINESS None. 10) ADJOURNMENT The meeting was adjourned at 5:30 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.