Minutes of the Health Commission Meeting Tuesday, December 5, 2006 at 3:00 p.m. 101 GROVE STREET Room 300 San Francisco, CA 94102 1) CALL TO ORDER Vice President Illig called the meeting to order at 3:17 p.m. Present: James M. Illig, Vice President Edward A. Chow, M.D. Roma P. Guy, M.S.W. Donald E. Tarver, II, M.D. Absent: Lee Ann Monfredini, President David J. Sanchez, Jr., Ph.D. John I. Umekubo, M.D. 2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF NOVEMBER 14, 2006 Action Taken: The Commission approved the minutes of the November 14, 2006 Health Commission meeting with two additions. In item 9 Section B, page 11, Mitchell H. Katz, MD, Director of Health was not present in the Closed Session. In item 9 Section D, page 11, the Health Commission voted not to Disclose Any or All Discussions Held in Closed Session. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Chow chaired and Commissioner Tarver attended the Budget Committee meeting. The Budget Committee requested that items 3.8, 3.9, 3.10, 3.11, 3.12, 3.13, 3.15 and 3.20 be moved from the “For Approval” section of the agenda to the “Discussion and Approval Section.” Items for Discussion and Approval 3.1 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Shanti Project, in the amount of $1,837,371, which includes a 12% contingency, to provide HIV Prevention Services – Prevention with Positives Services to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.2 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Walden House, in the amount of $1,057,218, which includes a 12% contingency, to provide HIV Prevention services - Health Education and Risk Reduction Services and Prevention with Positives services to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.3 AIDS Office-HIV Prevention – Request for approval of a renewal contract with UCSF AIDS Health Project, in the amount of $2,594,336, which includes a 12% contingency, to provide HIV Prevention Services - Health Education and Risk Reduction services, REACH Program and Counseling, Testing & Linkages services to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.8 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Iris Center, in the amount of $476,000, which includes a 12% contingency, to provide HIV Prevention Services - Health Education and Risk Reduction Services for Youth services to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.9 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Larkin Street Youth Services, in the amount of $172,794, which includes a 12% contingency, to provide HIV Prevention services – Counseling, Testing, & Linkages services to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.10 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Mission Neighborhood Health Center, in the amount of $963,760, which includes a 12% contingency, to provide HIV Prevention Services – Counseling & Testing, and Health Education and Risk Reduction, to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.11 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Mobilization Against AIDS International, in the amount of $439,600, which includes a 12% contingency, to provide HIV Prevention services - Health Education and Risk Reduction Services for Youth services to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.12 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Native American AIDS Project, in the amount of $436,144, which includes a 12% contingency, to provide HIV Prevention services - Health Education and Risk Reduction Services to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.13 AIDS Office-HIV Prevention – Request for approval of a renewal contract with New Leaf Mental Health Services, in the amount of $679,999, which includes a 12% contingency, to provide HIV Prevention Services - Health Education and Risk Reduction Services for White and African-American men between the ages of 30 and 50 who have sex with men who use methamphetamine, poppers and/or other substances (both intravenously and non-intravenously) - in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.15 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Continuum HIV Day Services, in the amount of $158,056, which includes a 12% contingency, to provide HIV Prevention Services – Prevention with Positives, to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2008 (1.5 years). Items for Approval 3.4 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Ark of Refuge, Inc., in the amount of $420,000, which includes a 12% contingency, to provide HIV prevention services – Prevention with Positives, to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.5 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Bay Area Young Positives, in the amount of $346,265, which includes a 12% contingency, to provide HIV prevention services – Prevention for Positive Youth in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.6 AIDS Office-HIV Prevention – Request for approval of a retroactive contract renewal with Better World Advertising, in the amount of $215,503, which includes a 12% contingency, for social marketing services and Web Site Translations services addressing methamphetamine use, for the period of November 1, 2006 through June 30, 2007 (8 months). 3.7 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Girls After School Academy, in the amount of $168,000, which includes a 12% contingency, to provide HIV Prevention Services - Health Education and Risk Reduction services to behavioral risk populations in San Francisco, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.14 AIDS Office-HIV Prevention – Request for approval of a renewal contract with Harder + Company Community Research, in the amount of $440,447, which includes a 12% contingency, to provide Technical Assistance & HIV Planning Council Support services, for the period of January 1, 2007 through June 30, 2009 (2.5 years). 3.16 AIDS Office-HIV Prevention – Request for approval of a renewal contract with UCSF Women’s Specialty Clinic, in the amount of $373,027, which includes a 12% contingency, to provide HIV Prevention Services – Prevention with Positives services, through the Sexuality and Empowerment Program, to behavioral risk populations in San Francisco, for the period of January 1, 2007 through December 31, 2008 (2 years). 3.17 AIDS Office-HIV Prevention – Request for approval of a retroactive contract with PHFE Management Solutions, in the amount of $537,600, which includes a 12% contingency, to provide Fiscal Intermediary Support for the Evaluation Technical Assistance & Capacity Building Program services, Qualitative Evaluation Program services, and Referral Tracking services, for the period of July 1, 2006 through June 30, 2007 (1 Year). 3.18 PHP-Housing& Urban Health – Request for approval of a retroactive renewal contract with Lutheran Social Services, in the amount of $455,656, which includes a 12% contingency, to provide money management and third-party rent payment services to residents of the Direct Access to Housing sites, for the period of July 1, 2006 through June 30, 2008. (2 years) 3.19 PHP-Housing & Urban Health – Request for approval of a retroactive renewal contract with Baker Places, Inc., in the amount of $229,461, which includes a 12% contingency, to provide Supportive and Case Management Services for the Direct Access to Housing tenants at the Empress Hotel, for the period of September 30, 2006 through June 30, 2007. (9 months) Action Taken: The Commission removed item 3.20 from the Consent Calendar and approved items 3.1 through 3.19. 3.20 DPH-Central Administration – Request for approval of a retroactive new contract with the San Francisco Community Health Authority, in the amount of $810,817, which includes a 12% contingency, to provide consultant planning and design services related to the Health Access Program, for the period of October 1, 2006 through June 30, 2007 (9 months). Tangerine Brigham presented item 3.20. She stated the contract was to assistance with pre-planning and design activities for the eventual launch of the Health Access Program. A key partner in this process is the San Francisco Health Plan. Members or enrollees will become members of the San Francisco Health Plan, possibly doubling the number of members. SFHP will have to look internally at its operations and structure to ensure that it actually has the capacity to serve these new members. These funds will help the Health Plan to start this process. The Health Plan is also putting many of its own resources into the process. Commissioner Comment Commissioner Chow stated that he appreciated the explanation that Tangerine Brigham gave earlier and asked her to go into more detail regarding how this will fit into the future. Also what roles will the health department and commission fit into ensuring the success of this program? Tangerine Brigham stated that DPH and SFHP will be partnering on this. The contractual relationship does not stop with this particular contract. Certainly when this program is up and running we will have an ongoing relationship with SFHP, similar to the relationship DPH currently has with SFHP in other programs such as Healthy Kids. Commissioner Tarver added that Ms. Brigham sat on the committee to select the first vendor through the SFHP. He also stated that he wanted to build a relationship with the HAP pre-planning process and the CHN JCC to keep abreast of issues and developments of the HAP. He also wanted to touch base regarding medical home and ensuring that behavioral health services are thought of on par with medical services. Much of what he reads about the HAP is focused on primary and specialty care, and he would like to see that the HAP stays close to the original intent which was also to focus on preventative care. Perhaps for some, the best medical home may be a behavioral health center and not a primary care clinic. He also added that cultural competency is rich on the CBHS side and much less so on the CHN side. He stated that CBHS involves client choice and information, and involves specific demographic factors beyond language and race. He hoped that the HAP will also use this approach. Tangerine Brigham responded that she would be presenting to the CHN next week, and that the department has several roles and we will make sure we fulfill them. In regard to medical home and behavioral health, we have a behavioral health workgroup that is led by CBHS to work on the issues that Dr. Tarver raised. In respect to cultural competency, we will ensure that that is taken into account. Commissioner Illig also stated that Dr. Katz will be presenting to the Health Commission regarding HAP before going to the BOS. Ms. Brigham responded that this is scheduled for January 16th. Action Taken: The Commission approved item 3.20. Public Comment Michael Petrelis requested that the Health Commission be broadcast on television and also commented on item 3.6 (contract with Better World Advertising) stating that he sent a letter to Daniel R Levinson, Inspector General of HHS, demanding a performance audit and a fiscal audit of all contracts the CDC has given to Better World Advertising for the HIV Stops with Me social marketing campaign. He stated that we really need to have independent eyes to look over the reports that Better World have been submitting to CDC, look over all the receipts submitted, and also to look at the seven other cities where HIV Stops with Me. His two page letter cites an audit from September of 2005 conducted by HHS. A disturbing finding was wide spread deficiency throughout the award phase. He stated that his letter is posted on petrelisfiles.com. 4) DIRECTOR’S REPORT Anne Kronenberg, Deputy Director of Health, presented the Director’s Report. Keynote Speaker New America Foundation Summit Mayor Newsom was scheduled to speak today in Sacramento at the New America Foundation Summit on the City’s Health Access Program, but at the last minute had a conflict. The Mayor asked Dr. Katz to fill in for him, so he drove up to Sacramento this morning and will miss much of today’s Health Commission meeting. The Summit’s focus is the high cost of health care and the need to creatively develop plans to increase health access for the uninsured and underinsured. Ryan White CARE Act Moving Toward Reauthorization The Ryan White CARE Act took a step toward reauthorization today when the bipartisan Congressional committee accepted Senator Ted Kennedy’s proposal. Essentially the Senator’s proposal would extend the CARE Act for three years and maintain communities’ funding levels at no less than 95 percent of what they received in 2006. For San Francisco this would mean a loss of $1.5 million from our current allocation over the three years of the bill, for a total loss of $4.5 million. The proposal provides a transition period for states, like California, with immature names-based reporting systems, while directing funds to communities with emerging AIDS caseloads. It includes an absolute repeal of the law after three years in order to force the issue of restructuring to meet the current needs of emerging communities working to provide AIDS care. This proposal, which is significantly more favorable toward San Francisco than the one put forward prior to the October Recess, must now be approved by both houses of Congress. Senator Kennedy has expressed his commitment to reauthorization before Congress adjourns later this month. Board of Supervisors Resolution and Ordinance on DPH Contracts At the October 17th meeting the Commission took action to address concerns raised by a new interpretation by the City Attorney of City Charter provisions on contracting. Dr. Katz is happy to report that yesterday the Board of Supervisors Finance Committee approved a resolution to ratify approximately 100 DPH contracts. In approving the resolution, the Board 1) retroactively approved contracts previously approved by the Commission; and 2) prospectively approved 3-year extensions for these contracts. In addition, the Finance Committee recommended approval of an ordinance that will amend the City’s Administrative Code. The ordinance authorizes the Health Commission to designate non-profit professional service contracts as sole source. The sole source designation is for services that are unique to DPH and require specialized personnel or facilities provided by a limited number of non-profits. The ordinance will be heard by the full Board at today’s meeting and is expected to be approved. California Pacific Medical Center Town Hall Meeting On Wednesday, November 29th Dr. Katz spoke at a panel “Got Healthcare? Lucky You.” It was presented by the California Pacific Medical Center Program in Medicine and Human Values and the San Francisco Medical Society. His presentation on the Health Access Program was well received. Commissioner’s Comments: Commissioner Chow: In regard to the Ryan White Care Act, was the 3-year absolute repeal a compromise? Will we have an extensive role in looking at how things should be? Anne Kronenberg responded that this was a compromise, but that it was the best thing we had seen and that the hold harmless provision was still in place and that was where we would have lost a lot of money. She also stated that James Loyce was present to elaborate. James Loyce added more specifics to the Director’s Report including that over the 3 years of this bill, SFDPH will receive 95% of the 2006 budget and that this Act counts AIDS cases were they are, as opposed to previously reporting where they were tested. In addition, this Act maintains funding for pharmaceuticals. We will continue to engage in the development of a new Ryan White Care Act. Outstanding questions include whether it will reflect national reporting? Will there be a 5 year or 10 year band? We also want to ensure that aging AIDS cases aren’t dropped. When he was in Washington DC, people with AIDS diagnosed beyond 5 years ago presented asking if they were not important. HRSA will be coming up with a severity of need application and HHS will have to come up with a clear definition of severity of need. We will have an active role in this definition. Finally, there is a four-year transition plan for submitting data to the CDC. Even if we are ready in 4 years, if the state is not ready and the other counties are not ready we will have some problems. Commissioner Illig asked if the hold harmless was the same in total formula or the entire allocation. Mr. Loyce responded that they are interpreting the language to mean the entire allocation as it is not specific to Title 1. He also added that he thinks the supplemental applications won’t be important after 2007. Commissioner Illig asked if 70% of Title 1 still needs to go to medical care. Jimmy Loyce responded that it is still in there, but the language around medical outcomes has loosened some. He stated that you need to be able to link your services to a medical outcome, and we believe that we can link our services to an improvement in the Pearson’s medical status. Commissioner Tarver stated that we saw a number of prevention contracts come through the budget committee today and that 3 years is not a long time for the whole Ryan White Care Act to be reevaluated. HIV prevention can be tied to actual health outcomes and it seemed there were questions that there were CDC PEMS measure that has been dropped for over a year, and the department has its own measures that looks at avoiding or preventing transmission in various at risk populations. Jimmy Loyce responded that the HIV Health Planning workgroup does not see this as a reprieve from their charge and they also do not think that 3 years is a great deal of time. They have expectations that they will be completing their work in a very short order. Commissioner Guy stated that 3 years is nothing and that she appreciates that the work we started will continue. She asked if this 3 year time limit was related to the politics of the next presidential election. Is this a coincidence? Jimmy Loyce stated that is was not. 5) PRESENTATION OF THE CHARITY CARE REPORT AND CONSIDERATION OF A CHARITY CARE RESOLUTION Anne Kronenberg, Deputy Health Director, Director, Office of Policy and Planning and Alicia Neumann, Senior Health Planner, Office of Policy and Planning presented the 2005 Charity Care Report. The 2005 Charity Care Report presented the following information about charity care in San Francisco: Compliance with the Charity Care Ordinance. Charity care needs and resources. Summary of charity care provided. Analysis of charity care provided. Summary of additional community benefits. Analysis of additional community benefits. Compliance with the Charity Care Ordinance Data on San Francisco Charity Care primarily comes from local hospitals, most of which report in accordance with San Francisco Ordinance 163-01. All hospitals report problems with two aspects of the ordinance; providing zip codes for applicants who are denied charity care yet may receive care through other means, and providing information about hospitals to which patients may be referred subsequent to receive charity care. Charity Care Needs and Resources To present a context for charity care in San Francisco, the Department of Public Health reports community health need by insurance coverage and health resources by reported characteristics. While Medicare and Medi-Cal patients utilize a high percentage of total care, as expected, those who are uninsured and otherwise publicly insured do not receive as much care as might be expected. Charity Care Resources Charity care resources for San Francisco include clinics, private practices, and these hospitals: CPMC, UCSF, SFGH, Chinese, Kaiser, St. Francis, St. Luke’s, and St. Mary’s. CPMC, UCSF and SFGH operate the largest hospitals in San Francisco. The final report will contain more information from the hospitals about their unique characteristics and approach to Charity Care. Charity Care Summary The San Francisco Department of Public Health measures hospital charity care by: The number of applications. The number of unduplicated patients. The number and type of services. The cost of expenditures. Summary: Charity Care Applications All applications are handled within programs designed to find people coverage whenever possible. A denied application does not mean that care was not received; rather that the person most likely was eligible for another program. Also, all hospitals use a sliding scale of payment for patients who do not meet charity care guidelines, but come close. Accepted applications were down 18,000 from 2004 primarily due to SFGH improving eligibility. Applications denied were the same as 2004. Summary: Charity Care Patients Patients were down slightly due to decreases at SFGH and St. Luke’s, and increases at UCSF and St. Mary’s. Patients are up 27,000 from 2001. Summary: Charity Care Services Total services were down 7,000 due to decreases at SFGH and St. Luke’s and increases at St. Mary’s and UCSF. Emergency services were up from 13% of total to 19% of total. Outpatient services were down from 82% of total to 76% of total. Inpatient services were unchanged at 4-6% of total. A change in service types provided is occurring at specific hospitals. Summary: Charity Care Expenditures How charity care is calculated: cost to charge ratio equals patient expenses / patient revenue. The higher the ratio, the closer the costs and charges. Chinese and SFGH charge less relative to cost than Saint Francis and CPMC. Physician costs play a large role – hospitals can speak to other elements. Summary: Charity Care Expenditures Increase of $8 million primarily from SFGH, which is now including SF Behavioral Health Center; CPMC and St. Mary’s also up. Charity Care Analysis The San Francisco Department of Public Health analyzes hospital charity care by: Location. Size. Benefit from Non-Profit tax status. Analysis by Location The San Francisco Department of Public Health analyzes hospital charity care by location according to: District. Hospital and Supervisorial District. Hospital zip code. Supervisorial District with income data. Location: Applications by Supervisorial District The highest number of charity care applicants come from Districts 6, 9, and 10, which correspond to the SOMA/Tenderloin, Mission and Bayview/Hunter’s Point Neighborhoods. Location: Applications by Hospital and District SFGH has high number of applicants from all districts. UCSF has high number from outside SF, as does Saint Francis. Location: Applications by Hospital Zip Code Patients will travel to receive charity care – SFGH received thousands of applications from residents located near other hospitals. Location: Applications by District with Income Data Districts 6, 9, and 10, which correspond to the SOMA, Mission and Bayview/Hunter’s Point Neighborhoods have the highest number of residents both applying for charity care and in poverty. District 11 has the lowest per capital income of all districts, with 10% of charity care applicants. Analysis by Hospital Size The San Francisco Department of Public Health analyzes hospital charity care by size according to: Number of unduplicated patients. Average daily census. Staffed beds. Expenses and income. Size: Charity Care per Unduplicated Patient CPMC and Kaiser spend the most per patient. All hospitals’ per patient expenditures have decreased from 2004, UCSF most dramatically from $2415. Size: Charity Care by Staffed Beds and ADC There is a lack of correlation between hospital size and charity care provided. After removing SFGH, the picture becomes even clearer. Size: Charity Care by Expenses and Income SFGH and St. Mary’s provide the greatest percentage of Total Operating Expenses as charity care. St. Luke’s and UCSF with negative return on income, provide charity care relative to net income. This shows a lack of correlation between hospital profit and charity care. Benefit Analysis Only one hospital, St. Luke’s provides charity care in excess of its estimated tax benefit. CPMC receives a benefit of $45 million dollars. The historical trend shows that the gap between tax benefit and cost of charity care provided is fluctuating. Additional Community Benefits All of these benefits are reportedly limited to organizations that serve low-income populations; however, all of this information is self-reported and some hospitals have difficulty separating low income from other activities. Commissioners’ Comments Commissioner Illig disclosed that he is on the board of St. Mary’s Hospital and has no fiduciary role in that position. Commissioner Guy stated that this is a hard report, and thanked the leadership from the health department. She also acknowledged that this process had a rocky start and that everyone did a great job coming to common ground. On the question of whether the Medi-Cal shortfall chart is included or not, she stated that it is true there have been some discussions and that no agreements have been come to. She asked how this reflects the original intent of the legislation and stated that she would not like to return to a place of political contention. Commissioner Chow stated that he would like to commend everyone for coming to the table, whether it was legislated or not, and that what charity care really means is getting down to the needs of underserved, seeing that those who are underserved are really cared for. He added that any additions to the report should be credible and be an accepted community marker. He also asked that PHI be invited to help come up with these standards. Commissioner Tarver stated that the report itself is a very commendable expansion of what he saw last year. He also stated that he is still learning about this ordinance and that as everyone knows he is a community psychiatrist in the CBO environment and that he also has a private practice with clients receiving Medi-cal, Medi-care, etc. He acknowledged that some part of doing business also involves public relations. He stated that he does join the chorus that this is good work but that when he hears about something like reporting a Medi-Cal shortfall, he sees this as most distant from Charity Care. He stated that these funds are a method of payment and that they do not get to be included in Charity Care because they aren’t what you think you deserve. Lastly, he stated that if we expand the definition of charity care it needs to be inclusive of what is no longer funded and that he would like the department to create an analysis of what is the level of charity care that should be provided and that we task providers with standards we have set based on a similar set of criteria. Commissioner Illig stated that San Francisco is very lucky to have non-profit hospitals, and that we don’t have for-profit hospitals that do not have to cooperate. San Francisco’s hospitals have come to the table on specific health issues. As far as measures that everyone can accept, PHI does offer some. He also stated that he is disturbed to hear that a representative of St. Luke’s is not in the working group. He also stated that in an ideal world there would be no charity care due to HAP starting July 1st. He stated he is looking forward to future reports, and would love to see how hospitals are welcoming HAP patients, which to him, is the future of charity care. Commissioner Chow asked if in future reports they will be able to break out St Luke’s from CPMC. Henry Yu, Controller for CPMC stated that they would be reported separately. Public Comment Dr Martin Brotman stated that CPMC is committed to serve their fair share of charity care patients. To this end CPMC has extended their definition of charity care to 400% of the poverty level, double the standard in able to open their doors as wide as they can. They also decided to partner with the Community Clinic Consortium. They have a community grants program that funded 19 community programs last year. In addition they provide an African American breast health project that focuses on screening and education. They have a health chaplains program in the lower income areas. They also partner with Galileo Health Academy to help develop careers in health. They also have another program at St. Luke’s focusing on lowering the incidence of hospitalization and emergency visits. They are also fully funding and opening a primary care clinic in the Bayview/Hunters Point. Dr Matthew Spitzer, St. Anthony’s Free Clinic, wanted to point out an example of their work with CPMC. St. Anthony’s is a Free Clinic serving people from the Tenderloin and Civic Center areas. They receive a community health grant from CPMC that supports a collaborative for diabetes care, nutrition counseling and expanding their access to specialty care. He also stated that they agree with the items in the resolution supporting standardized reporting and evaluation of charity care granting. Dr. Berman from South of Market Health Center, wanted to comment on the role of CPMC. 65% of their patients are uninsured and getting specialty care appointments can be very difficult. A patient came in trying to get primary care with symptoms of colon cancer, and attempted unsuccessfully to get a timely appointment. When the CPMC grant came through he was able to get an appointment and was able to go to SFGH and see an oncologist. Catherine Ronan Karrels and Michael (student) of De Marillac Academy, a school located in the Tenderloin, which opened 6 years ago and has a relationship with CPMC stated that in their counseling program, CPMC has assisted with both academic and personal counseling. In the Health Champions program, they have worked with the students and their families to improve community heath. Michael stated that Health Champions has changed his eating habits and allowed him to go on a 5k run, which he wouldn’t have done without Health Champions. Barry Lawlor of St. Mary’s Medical Center thanked Alicia and Anne for facilitation and leadership during this process. He also commented on the issue of how some of the charity care ends up clustered around the emergency and in-patient realm and while that can be seen as a failure of preventative care, the clinic he runs (the Sister Mary Philip Health Center) is a shining example helping to keep clients healthy and preventing the exacerbation of other health conditions. He also asked the commission to consider as a provider of services to a 3rd of our patients, to consider the MediCal shortfall as a donut around charity care. Father John Hardin, St. Anthony Foundation, appreciated Dr Tarver focusing on looking at the total individual. Their clinic is 100% funded by private sources, with a 2.1 million budget, over 11,000 patient visits in over 9 languages. Many of their patients have dual and sometimes triple diagnosis. He had a meeting with the Chief of Staff of HHS, who stated that CPMC programs are a model for charity care. They have also been able to provide respite care for around $200 a day for over 50 people. Linda Bien, President/CEO of North East Medical Services, wanted to applaud everyone that is working on the charity care initiative particularly focuses on primary care. Community health clinics in particular focus on the idea of prevention and help to reduce the cost of health care at its most expensive point. NEMS is comprehensive in its out-patient services and relies heavily on CPMC for in-patient services. This year marks our 20th anniversary working with CPMC with pregnant women, 10th year working with Health Families and Health Kids, serving over 9,000 patients. CPMC has been responsive to their linguistic and cultural needs and continues to work closely with them striving to provide the best patient care. She also supports CPMC’s efforts to revitalize St. Luke’s as there are many clients who need their services. Darren Ow-Wing, Community Educational Services, who operates Galileo Health Academy, stated that CPMC agreed to participate in the Health Academy. The first year was a failure and CPMC stuck with it and helped them do it a better way. Every student, either an A or F student, gets 32 hours of mini-internships at the hospital. Every student is also being trained as an EMT with City College. Because of the success of this program, it will be expanded to Mission High School. Sydney Liu-Hanoaka, a senior at Galileo Academy, has an internship at Haight Ashbury Free Clinic through the Health Academy. She now aspires to work in the mental health field which she was not previously interested in. Gladys Sadlin of Mission Neighborhood Health Center was here to speak particularly about the tremendous help from CPMC regarding eye care. They have been able to refer people for eye exams and eye care. Without this help somebody would have to take care of these clients. They have been able to regain the ability to take care of themselves and their children will be able to continue to work and contribute in the private sector. Kent Woo of NICOS Chinese Health Coalition is a member of the CPMC Community Benefit Advisory Committee and Chinese Community work group. Through the health fair sponsored by CPMC, they were able to serve more than 2000 clients. They have also received support for their Health Families/Health Kids programs as well as their enrollment services. They also go the extra step by ensuring families can navigate the health care system. Dick Hodgson of Community Clinic Consortium would like to thank Anne for her leadership and Alicia for her analysis and her patience as well. He feels that community benefit services are charity care. These services are seeking to avoid hospitalization and that this is a good thing. He also stated that it needs to be acknowledged that Kaiser has provided lots of community assistance, St. Francis has supported Glide and of course UCSF has provided all types of support. Dr Nadine Burke stated that what CPMC does really well is to create innovative ways to work on behalf of the poor. Best practices are not always captured by standard measures. One thing CPMC is constantly associated with is excellence in quality of care. This is part of the reason she is so excited about the project she is working on which is Bayview Child Health Center, which has a goal of reduced hospitalization for diabetes and obesity. Charles Range, Director of South of Market Health Center, stated that they serve a number of South of Market clients without a city contract. It is amazing to him that a private clinic came to them and asked what help they may need. As a result they were able to get a grant to provide services to the uninsured. CPMC should get all the praise that the city can give for what they do for San Francisco. He stated that CPMC has an attitude of coming to you to see if you need help. Nikku Dhesi, psychoanalyst at St Anthony Free Medical Clinic, stated that his position is funded by the CPMC grant. He feels that he has been able to help both clients and providers by providing behavioral health services at St. Anthony Free Medical Clinic. He states that he has seen a higher level of compliance since also being able to provide mental health services. He also stated that there is a cost-benefit such as providing clients alternatives to the emergency room. David Grant of Senior Action Network provides counseling and benefit assistance to over 100,000 Medicare beneficiaries through the HICAP program. Charity care is very important but feels that including the issues of MediCal shortfall and other similar issues in the Charity Care Report confuses the issues of how to provide better health care for low income people in San Francisco. further conclusion of reimbursement of, thank Charity Care, Ron Smith of the Hospital Council of Northern California thanked Anne and Alicia and stated that they have done an exceptional job of leading this group. He also stated that the hospitals of San Francisco have heard you and are responding with a wonderful array of programs. He also stated that he would like to have Alicia’s last chart regarding the MediCal shortfall be put into report. He stated that the press does not look at the whole situation; they only look at the charts. He stated that hospitals don’t have the recourse of tax payer money and that adding this final chart gives context. Rhody McCoy of African American Health Disparity Project, Prostate Health Initiative is here for two reasons, one to talk about commitment regarding the Prostate health initiative. In addition, he wanted to bring attention to the funding of the prostate health initiative, as CPMC has continued to step up to the plate, most recently evident in their goal to educate 2,400 African American men regarding prostate cancer, and to screen 2,400 African American men as well. So far they have screened up to 200 men the first year. Jeffery Sterman, Kaiser Permanente stated that one of the things you have in front of you is some of the reports from Kaiser who continues to be committed to charity care. He stated that they continue to do the knowledge transfer to community clinics, increasing access to health care, commitment to chronic disease management and violence prevention. He stated that they are the founder of Operation Access and that they have gone ahead and increased their number of surgeries. They have also provided 2 million in grants for community programs and lent their actuaries to the HAP project. He invited the Health Commissioners to attend a day of surgery on Saturday. Meg Cooch, Director of Planning for Elders, an organization who works to improve the quality of life for seniors, stated that she would like the charity care report to remain focused on charity care and that perhaps community benefit should be a separate report. She stated that she felt the BOS was pretty clear in their scope of what of should be included in the report. Susan Moore of UCSF Medical Center stated that UCSF has been an active participate in the working group which has included some spirited conversations and even some disagreements, although she believes this reflects the passion that the participants feel about the issue of charity care. She stated that the issue of charity care is a complex one, which includes a whole spectrum of services that need to be coordinated. In addition, the health care financing system is fragile and failing. She stated that the charity care report is limited in what it is asked to include. She stated that the HAP program or something like it may be a solution. She stated that they would like to work with DPH and HAP to help implement a strong program. Emily Gordon of SEIU – UHW, who worked on the original initiative, stated that she believes there is a valuable aspect to representing all of the community benefit services but that to continue to change the report would detract from the original intent of the document. She stated that the last table should not be in the report at all. She said that they are sympathetic of the issue of MediCal short falls, but feels there needs to be more work around how to evaluate this. Abby Yant of St Frances Memorial Hospital stated that it is important to recognize that while they did come together in a rather spirited manner, they first sat down and discussed where they wanted to go. Where they went was to come together and report on how to serve underserved populations, and they agreed on putting the information that has been submitted into the report. She also stated that she feels it is arbitrary to be arguing over one table and feels that it should be in the report. Judy Li of St Luke’s wanted to share the launch of a new ambulatory health center which has the goal of improving quality and affordability of primary care. She stated that they are the primary provider of health care in the Mission and that there is a high incidence of asthma in the pediatric population. She extended an invitation to tour the clinic. Rosario Anaya, Mission Language and Vocational School stated that St Luke’s have always provided a safety net for the poorest of the poor. She stated that they have being referring families to St Luke’s for care which they have always received. Theresa Brooks read a letter addressed to the Health Commission from Supervisor Sophie Maxwell. The letter stated that the charity care report is a critical tool which allows the city to evaluate the provision of charity care by San Francisco non-profit hospitals and thereby maximize access to health care for all San Francisco residents regardless of ability to pay. She stated that she was concerned that as additional information is added the report the original intent may be subsumed. She strongly urged the Health Commissioners to work with the Board of Supervisors to set up a process to address the question on whether additional information on community benefit should be added to the report, whether there is a need for supplemental or a separate report evaluating community benefit, and how to assess any additional information that is added. Bob Toomey read a letter addressed to the Health Commission from Supervisor Aaron Peskin. The letter included the following; that Supervisor Peskin recognizes that non-profit hospitals, because of their favorable tax treatment, have a special duty to serve uninsured and poor patients and mandated the issuance of the charity care report to ensure the fulfillment of this duty and assist the City in planning appropriate responses to unmet charity care needs. He also stated that we must accurately capture the delivery of charity care in the city as we make our plans for universal coverage. He strongly urged the Health Commission and DPH to open a dialogue with the BOS, the hospital industry and the greater community before including additional information in the Charity Care Report. Jaya Chatterjee read a letter addressed to the Health Commission from Supervisor Tom Ammiano. The letter stated that the currently Charity Care report is mandated by legislation passed by the BOS. The purpose of the report is specifically to evaluate the provision of Charity Care by San Francisco’s non-profit hospitals so as to ensure that San Francisco’s uninsured and poor patients have access health care and to consider additional community benefit items. The letter also stated that Supervisor Ammiano strongly believes that the legislation is clear in its intent to limit the scope of the Charity Care Report to the evaluation of Charity Care under this definition. While we agree that the complete scope of community benefits provided by San Francisco’s hospitals cannot be fully captured by the information included in the current Charity Care report, I strongly encourage the creation of a standardized system to ensure community benefits are measured consistently throughout all hospitals and are targeted to the appropriate population in addition to services provided under the intent of the Charity Care. Action Taken: The Commission adopted the Charity Care Resolution. 6) CULTURAL COMPETENCY PRESENTATION Jason Hashimoto, Director, EEO and Tina Yee, Ph.D., Cultural Competence & Client Relations, Community Behavioral Health Services Update on the San Francisco Department of Public Health Cultural and Linguistic Policy: Introduction of Pilot Evaluation Tool for Reviewing Cultural Competency Reports Background On January 8, 2002 the San Francisco Health Commission unanimously passed a resolution adopting the Culturally and Linguistically Appropriate Services (CLAS) standards as general guidelines to provide a uniform framework for developing and monitoring culturally and linguistically appropriate services. In adopting the CLAS Standards, the Commission acknowledges that the CLAS standards as implemented by the Department of Public Health are intended to be broadly inclusive of diverse racial, ethnic, sexual and other cultural and linguistic groups. The CLAS standards as utilized by the Department of Public Health are intended to serve as general guidelines and not as mandatory requirements. Providers of direct services are required to submit an annual Cultural and Linguistic Competency Report to the DPH section responsible for monitoring the contract with a copy to the DPH EEO/Cultural Competency Office. This report is due on September 30th of each year or within 60 days of the award of a contract if the provider has not previously submitted an annual report. Pursuant to the Department of Public Health’s Cultural and Linguistic Competency Policy, Program Manager/Analysts shall review the annual report utilizing a standardized monitoring tool as part of their regular contract monitoring process. In 2006, the Cultural Competency Task Force implemented a pilot Evaluation Tool. Training – Completed in 2006 The Department received a grant of $ 121,000 from the California Endowment to develop a program to train DPH program managers to evaluate the Cultural Competency Reports. A series of five training workshops were offered and attended by Program Managers and Community Contractors. The workshops are as follows: a. Affirming Cultural Competence b. Assessing Organizational Cultural Competence c. Goals and Objectives for Cultural Competence d. Dialogue on Differences e. Best Practices in Cultural Competence Attachment A was a copy of the training brochure. Pilot Program: Cultural Competency Evaluation Tool The Cultural Competency Task Force developed an evaluation tool for Program Manager/Analysts to utilize in reviewing the Annual Reports. Attachment B is a copy of the Evaluation Tool. The Evaluation Tool covers the three main sections of the Cultural Competence Report: A. Supporting Policies and Procedures B. Contact Information C. Narrative Report Checklists were established for measures reviewed in the Narrative Report, such as linguistic competence, staff capacity, and proposed remedies for potential barriers to service. In addition, the Evaluation Tool was designed to be part of a developmental process between DPH and our contractors. The Evaluation Tool provides space for comments from the Program Manager/Analysts, and allows the reviewer to note areas of strengths or advancements in cultural and linguistic competency as well opportunities for improvement and constructive feedback to assist the contractor. This is a pilot program and the first year that Program Manager/Analysts have been asked to utilize the tool to review the Annual Report. A focus group with Program Managers/Analysts who have used the Evaluation Tool in reviewing Cultural Competency Reports from this year gave us valuable feedback such as inclusion of the fiscal year, and the provision of additional pages where a contractor has more than one program. These changes have been incorporated in the Evaluation Tool in this packet. In 2006, the EEO/Cultural Competency Office provided a Cultural Competence Report format to our contractors, which follows the format of the Evaluation Tool. Attachment B is a copy of the report format. At the informational meetings held for contractors and DPH Program Manger/Analysts on August 30 and September 6, 2006, we stressed the developmental nature of cultural competence. The report format allows Contractors to present advancements in cultural and linguistic competency as well as identify opportunities for improvement and a plan to attain those goals and objectives. After utilizing the Evaluation Tool to review the Cultural Competency Report, the Program Manager should then initiate a dialogue with the contractor to address areas for development. Next Steps Instead of submitting a full report each year, the Cultural Competency Task Force recommends that the Program Manager and Contractor have discussions to prioritize the opportunities for improvement and select three for this year and, perhaps, each subsequent year of the contract. The contractor then need only update its contact information and provide an update on those three items for next year’s report. The opportunities selected should have outcomes that are measurable. The completed Evaluation Tool should be used to outline the opportunities for improvement for the subsequent years of the contract. The shortened Annual Report will continue to be submitted to each DPH Program Manager/Analyst as well as DPH’s EEO/Cultural Competency Office. DPH’s Health Education section will conduct its Goals and Objectives for Cultural Competency workshop in the early part of 2007. This is the same workshop that was offered as part of the Advancing Cultural Competence series. In 2007 the Cultural Competency Task Force with members of the Health Commission plan to address the assessment of cultural and linguistic competency within DPH. In 2007, the Cultural Competency Task Force will collect additional feedback from the Program Manager/Analysts on the usefulness of the Evaluation Tool to review Cultural Competency Reports. In late 2007 or early 2008, the Cultural Competency Task Force will survey the Program Manager/Analysts and our Contractors to assess the new process and how well it is supporting measurable advancements in cultural and linguistic competency. The results will be reported to the Health Commission. Commissioners’ Comments Commissioner Tarver stated that it is wonderful to see this whole instrument. Having sat on the budget committee this year it is often an issue for him regarding programs for what has been submitted because it doesn’t always flow through the program mangers to the Health Commission. It makes sense to him that the new evaluation needs to be sent with the budget packet. The other piece is around silos in each program. He stated that Tina and Jason were the best evaluators and he wants to see how it is evidenced that how collaboration benefits the individual. He stated a lot depends on where they show up and who they show up to. How do the providers know who to plug into for culturally competent services? Tina Yee responded that what they were trying to do in this whole effort is to show that cultural competency is developmental. Part of the training focused on cultural humility. They have focused on the contractors, not our own department and some groups are doing better than others. Next year they hope to address some of that. Regarding questions about the databases, they had to put together a whole set of databases and they believe that it is a really useful way to help our contractors. For assessment, program managers/analysts have the best connection to the people in our programs and they recognize that they are busy. Commissioner Tarver stated that he has a brief follow up, that he doesn’t think this should be entrusted to program monitors alone. When they do it well it is evidenced, when they don’t, there isn’t another level of across the department saying that the monitor is not reflecting what the program is doing. If some how you all can plug in to the whole program over site mechanism so that there is a second path for that. Commissioner Illig stated that he appreciates the effort of the report, but stated that this has been way too complex. The difficulty of assessing cultural competency is like assessing quality, it is not a concrete thing, and it is a broader issue than checklists. This should be something that transcends an entire agency and we need to get to the next step of assessing cultural competency within our own department. With ideal amounts of money, we have translation available 24 hours a day, but it is something the department has not experience. He urged that this working group continue and include a broader section of contractors. One of the best things about the plan, that it is clear throughout that client satisfaction is a good way to evaluate culture competency. He also stated that the culture of poverty is a culture that we don’t connect with well. Tina Yee responded that the contractors have been active. She also stated that she believes our definition of cultural competency includes homelessness and poverty. Commissioner Guy stated that she thinks we do need to go to the next steps, and that she wants to appreciate that they went after the grant and got it so we can move forward with this. She also stated that we need to find a place in our JCC structure; it is not enough to have it come through staff once a year. In terms of the next steps, she does think it is no small thing that we want to explore that internally, and that more staff time needs to be allocated to this. She thinks it is worth while after doing the workshops, to look at how we want to invest in the role that the program analysts have. She stated that she would like to create more understanding and take a risk around a little more flexibility. Commissioner Chow thanked Tina and Jason for working on this and stated they have given less direction and more critique when something happens. When you look at the documentation that they have tried to use as a methodology and then integrate into the regular roles the manager plays. The managers don’t yet see this as an important role in what they do. He thinks that the taskforce’s focus on bite size goals may lead to program managers to integrating it into their work. He stated there is a question regarding whether we are focusing the program or the whole agency. He favors the next steps of looking at the basic documentation, for example, to see if the agency even says they will be culturally competent. In regards to our own apartment, he stated that we have a variety of things we need to do to meet standards. He believes it is good to bring the next steps here, but he wonders what will be the best way to implement a formal process of commissioner review and how we measure are own departments. Dr. Katz responded that he views cultural competency as an integral part of our program management. In that spirit each joint conference has to treat this at that level of attention for both your policy and evaluation. This will cause staff to realize that it’s not something you achieve, but something you constantly work at. Commissioner Guy stated that at least so far, that hasn’t worked, and that somehow either we have to work well within our own compartments, and see how the overview would be. In her experience it goes to the lowest level and stays there, and does not offer any over all accountability. Commissioner Chow requested that this issue be added to the list he is compiling to be looked at for the strategic retreat. Commissioner Tarver agreed that this need further study. 7) CONSIDERATION OF A RESOLUTION SUPPORTING UNIVERSAL HEPATITIS B SCREENING FOR ASIAN AND PACIFIC ISLANDER RESIDENTS OF SAN FRANCISCO Commissioner Chow introduced and Ted Fang, Director of the AsianWeek Foundation presented the Hepatitis B Resolution. Universal Screening for Hepatitis B Residents of Asian and Pacific Islander heritage comprise 34 percent of the population of the City and County of San Francisco and are facing a health care crisis from Hepatitis B infections and liver cancer as follows: a.) One out of 10 APIs in San Francisco has Chronic Hepatitis B b.) 80% of liver cancer is caused by Hepatitis B c.) 1 in 4 APIs living with Chronic Hepatitis B will die from liver disease or liver cancer d.) Due to lack of symptoms, awareness and testing, most APIs are unaware of their infections e.) APIs are 100 times more likely to have Chronic Hepatitis B than Whites (1 out of 10 for Asians, 1 out of 1000 for Whites) f.) APIs have the highest rates of liver cancer for any racial/ethnic group g.) The greatest health disparity between Asian Americans and Caucasian Americans is liver cancer h.) Up to 23,000 women in the United States who give birth each year have chronic Hepatitis B infection, and 70% of them are API. i.) Liver cancer is the second most common cause of cancer death in Asian men living in the US j.) Over half of chronically infected Hepatitis B Americans are API; and The ramifications of this health care crisis could have dire consequences for the entire City and County of San Francisco as follows: a.) 6,000 APIs in San Francisco are projected to die from liver cancer and cancer brought on by Hepatitis B b.) The cost of liver transplants is more than $200,000 per patient c.) Liver cancer usually develops between ages 35 and 65 when people are maximally productive, with family responsibilities d.) It could cost San Francisco $700 million in medical and work loss costs for Hepatitis B related conditions; and The health care crisis posed by Hepatitis B is largely preventable as follows: a.) Hepatitis B is a vaccine preventable disease b.) 70% to 80% of all liver cancers in Asians can be prevented by a Hepatitis B vaccination program c.) Hepatitis B related Liver Cancer is a vaccine preventable cancer d.) The Hepatitis B vaccine was declared the first anti-cancer vaccine e.) Hepatitis B vaccine is safe and has been given to over 500 million people in the world; now therefore The California Liver Cancer Prevention Plan calls for all Asians in the state to be tested and vaccinated by the year 2010 and the San Francisco Department of Public Health has been working actively to educate, screen and vaccinate San Franciscans to protect residents and the city from Hepatitis B and its related illnesses. The Asian Liver Center at Stanford University and the AsianWeek Foundation are working with a network of San Francisco’s community and healthcare organizations to launch a citywide campaign entitled “SAN FRANCISCO: FREE OF HEPATITIS B – Making San Francisco The First City in America to screen/vaccinate all Asian/Pacific Islanders for Hepatitis B (HBV)”. Early pioneering efforts to safeguard the Asian American community from Hepatitis B by participating in national studies demonstrating the effectiveness of use of Hepatitis B vaccines in newborns at San Francisco General Hospital and the San Francisco Chinese Hospital helped lead to the national recommendations for universal administration of Hepatitis B vaccine for newborns. The Chinese and Asian community for over a half dozen years has been educating providers and residents on the importance of screening for Hepatitis B, including collaborative efforts of the NICOS Chinese Health Coalition, the Asian American Network for Cancer Awareness, Research and Training (AANCART) San Francisco Chinese Council of the Chinese Community Health Care Association, the Jade Ribbon campaign of the Asian Liver Center of Stanford University, and the Chinatown Public Health Center. It is the goal of the City and County of San Francisco to be the first city in America to screen and vaccinate all Asian and Pacific Islander residents for Hepatitis B, setting a model that can be implemented throughout the state of California and the entire nation. Commissioners’ Comments Dr. Chow stated that it would be a very positive thing to be part of this effort. Dr Katz added that there are so many health problems that can not be solved and this is an important health problem we can solve. Dr Chow stated that he would like to reposition the 4th whereas to the position of last whereas. Commissioner Guy asked what a program like this would cost. Ted Fang stated that a rough budget is about $700,000. Dr Katz stated that all people coming into SF health services should be providing screening and immunization for Hepatitis B for all clients. Commissioner Tarver stated that it is laudable that this goal was set particularly high at 100%. He also stated that they needed to include other providers in outreach such as behavioral health. He asked whether there is any Asian or API cultural resistance that they have encountered thus far, or is it fairly consistent in people’s cultural belief to receive injections, etc. Ted Fang stated that the community has been supportive, and that this work will lead to the discovery of many new things about the Asian population. Action Taken: The Commission adopted the Hepatitis B Resolution. 8) PUBLIC COMMENT/OTHER BUSINESS None. 9) ADJOURNMENT The meeting was adjourned at 6:40 PM Rebekah R. Varela, Acting 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.