Minutes of the Health Commission Meeting Tuesday, January 22, 2002 at 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The Health Commission meeting was called to order to President Roma P. Guy, M.S.W. at 3:10 p.m. Present: President Roma P. Guy, M.S.W. Vice President Edward A. Chow, M.D. Commissioner Lee Ann Monfredini Commissioner Harrison Parker, Sr., D.D.S. Commissioner David J. Sanchez, Jr., Ph.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Arthur M. Jackson 2) APPROVAL OF THE MINUTES OF THE REGULAR MEETING OF JANUARY 8, 2002 Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Sanchez, Umekubo) approved the minutes of the January 8, 2002 Health Commission meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Sanchez chaired, and Commissioner Monfredini attended, the Budget Committee meeting. (3.1) CHN-SFGH Nursing Operations - Request for approval of new contracts with Code Blue Solutions, LLC, Maxim Healthcare Services and Medical Staffing Network, Inc., and contract modifications with C. W. Healthcare Services, HRN Services, Inc., Medstaff, Inc., Nurse Providers, Inc. and United Nursing International, for a combined total of $1,500,000 for supplemental, temporary per diem and traveling nurse personnel services for San Francisco General Hospital, Community Health Network, for the period of September 1, 2001 through August, 31, 2002. (3.2) CHP-Primary Care - Request for approval of a new retroactive sole source contract with Shanti Project, in the amount of $175,000, to provide LifeLines project services that support women living with breast cancer, for the period of October 1, 2001 through June 30, 2002. (3.3) PHP-Emergency Medical Services - Request for approval to accept and expend a new grant from the California State Emergency Medical Services Authority, in the amount of $912,440, to promote access to trauma care at the Trauma Center, San Francisco General Hospital, for the period of July 1, 2001 to June 30, 2002. (3.4) PHP-AIDS Office - Request for approval to retroactively accept and expend a subcontract from the Regents of the University of California, San Francisco, Office of Research Administration, in the amount of $241,549, for a collaborative study of prevention for HIV-positive persons, for the period of September 30, 2001 to September 20, 2002. Commissioner Sanchez abstained from voting on this item. Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Sanchez, Umekubo) approved the Consent Calendar of the Budget Committee, with Commissioner Sanchez abstaining from voting on Item 3.4. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. Anne Kronenberg Appointment Director of Policy and Planning I am delighted to announce that I have appointed Anne Kronenberg to be the Director of Policy and Planning for the Department. As the Commission is aware, Anne has served as the Director’s Executive Assistant for the past almost eight (8) years. During that time, she has taken on increasingly large programmatic responsibilities. For example, she has served as our First Responder for fires and other City emergencies and disasters, has sat on the SRO Task Force, has served on the Local Homeless Board, and has become the coordinator of homelessness policy for the Department. During this time she has fulfilled her responsibilities as liaison to the San Francisco Board of Supervisors and the Director of External Affairs. In her new role, Anne will continue to be the Department’s liaison with the Board of Supervisors. In this way we will consolidate all external government relations within one office as our Federal and State policy liaisons have traditionally done through the Office of Policy and Planning. She will also continue to supervise our excellent Public Information Officer, Eileen Shields, who will join this larger office. Besides providing excellent supervision to the Office of Policy and Planning, I believe Anne’s appointment will enable the terrific staff of the Policy and Planning Office to contribute to our development of policies around homelessness and emergency preparedness. Special admiration and gratitude goes to Colleen Johnson who has served as the Interim Director of Policy and Planning since the departure of Tangerine Brigham. Colleen has done a fantastic job and has been commended to me by the offices of numerous State and Federal elected officials. She will continue in a leadership position within the Office of Policy and Planning. Governor’s 2002-03 Budget Summary On January 10, 2002, the Governor released his proposed FY 2002-03 State Budget. The $100 billion budget proposes to bridge a $12.5 billion shortfall for the remainder of this fiscal year and 2002-03 through several fund shifts, loans, bond initiatives and federal revenue assumptions. However, the Legislative Analyst has reported that the Governor’s budget is “overly optimistic.” The Governor’s combined current year and budget year revenue estimates are $3.3 billion above the Legislative Analyst’s estimate. Additionally, because the Governor’s proposal relies heavily on one-time solutions and, therefore, pushes a number of expenses into the future, the Legislative Analyst predicts this budget would leave the State with a $4 billion operating deficit in 2003-04. To minimize the impact of the budget shortfall on health programs, the Governor is relying on: the issuance of a $2.4 billion bond backed by Tobacco Settlement Fund revenues, the proceeds of which will be placed in the General Fund to support health programs; $666 million in increased reimbursement from the federal Health and Human Services Agency in the current year, including a $400 million increase in federal share of Medi-Cal as part of an economic stimulus package; and an additional $350 million in federal reimbursements to offset current and prospective state and local government expenditures related to terrorism, including bioterrorism. To the extent these and other revenue assumptions do not materialize, the Legislature will be faced with making additional cuts. Following are the major changes to health programs that the Governor has proposed: Medi-Cal Program Disproportionate Share Hospital (DSH) Program - Increases the State’s DSH administrative fee from the current level of $29.8 million to $85 million. This is estimated to result in reduced revenues at San Francisco General Hospital of approximately $2 million. Co-payments - Establishes co-payments up to the federal maximum for Medi-Cal services and reduces provider rates by that amount. This will make collection of these monies a provider responsibility and will result in reduced provider revenues in the event that not all co-payments are collected. Though the details of this proposal have not been released, it is anticipated that this initiative will have minimal impact on the Department of Health. For outpatient services, most of the Department’s outpatient services are reimbursed based on cost through the Federally Qualified Health Center (FQHC) program, and may not be subject to the co-payments. For inpatient services, this initiative may impact the University of California, San Francisco, more than the Department, as the University receives fee-for-service Medi-Cal reimbursement. Physician Rates - “Temporarily” suspends about half (approximately $155 million) of the physician rate increases approved two years ago. The Governor has said he will protect providers of care for children and long-term care. Hospital Outpatient Rates - The Administration will proceed with the implementation of the settlement of the Orthopedic Hospital Lawsuit, providing $350 million in one-time payments and a 30% outpatient rate increase. Again, because the majority of the Department’s hospital outpatient services are billed under the FQHC program, this is likely to have minimal impact on the Department. Healthy Families Parent Expansion The Governor’s budget postpones the expansion of the Healthy Families program to parents until July 2003. Child Health and Disability Prevention (CHDP) Program The Governor’s budget proposes to shift the CHDP caseload (for a savings of $69.5 million) to the Medi-Cal and Healthy Families Programs. For children ineligible for Medi-Cal or Healthy Families, the Governor proposes an increase of $17.5 million for community clinics, under the Expanded Access to Primary Care program. The details of this proposal have not yet been established and, therefore, the impact on the Department is unclear. The Department currently receives $98,000 to administer the CHDP program in San Francisco. Mental Health The budget proposal includes an increase of $133.7 million for the Early and Periodic Screening, Diagnosis and Treatment services program and a $16.7 million increase in reimbursements for Therapeutic Behavioral Services. The Department will propose program enhancements to children’s mental health services with these additional allocations. However, the Governor is also proposing reductions of $4.2 million in the Children's System of Care Program. Although the distribution of this reduction is not known, the Department’s increase in EPSDT and Therapeutic Behavioral Services will be greater than a reduction in our system of care allocation. Substance Abuse Services The Governor proposes reducing Drug Medi-Cal by $7.6 million in the current year and by $9.6 million in the budget year. Further reductions of $14.8 million are proposed for 2002-03 in non-Drug Medi-Cal services, technical assistance contracts and the drug court program. These reductions are expected to result in a loss to the Department of $200,000 for perinatal drug treatment services and $300,000 for drug court services. Based on other changes made to Drug MediCal in the current year, an additional reduction of $800,000 to the San Francisco allocation is incorporated into next year’s budget. Supportive Housing Citing his support for a housing bond for the November 2002 ballot, the Governor has reduced the supportive housing initiative by $17.5 million. The Department recently completed a $3 million funding application under this initiative that will likely be rejected if this program reduction is implemented. HIV/AIDS Programs The budget includes a $22.4 million increase in AIDS Drug Assistance Program to fully fund the program. The Legislature has been called into special session to address current year budget shortfalls. In regular session, which will run concurrently with the special session, the Legislature will be developing its own budget proposals for the 2002-03 fiscal year. The Department will continue to monitor the State budget process and will work closely with the Mayor’s office and the City’s lobbyist to minimize the impact of the budget deficit on health programs. State Nurse Staffing Ratios This morning, the Governor released proposed nurse-to-patient ratios for California's acute care hospitals. This is the first-ever attempt by a state to establish a predetermined ratio of nurses to patients in the various services of acute-care hospitals. These ratios were developed by the Department of Health Services following more than two years of work and public input. Ratios are proposed for several service areas, including medical/surgical units (1:6, becoming 1:5 after 12-18 months), emergency department (1:4), trauma (1:1), critical patients (1:2), and psychiatry (1:6). Regulations have not yet been drafted for this proposal, so additional specifics are not available. However, the proposed ratios will be subject to the State's normal regulatory process, which includes a 45-day public comment period that is anticipated to begin this Spring and public hearings that could begin as early as June. The Department will certainly be following this issue very closely and will be an active participant in the regulatory process. Healthy Kids Enrollment Events The San Francisco Health Plan launched the Healthy Kids program the weekend of Jan 12th and 13th with three celebration and enrollment events. From the Beacon Center in Chinatown to Mission Dolores Auditorium and the Bayview Opera House, over 2,000 children and families attended. Families submitted applications for Medi-Cal, Healthy Families, and Healthy Kids. The San Francisco Health Plan is currently counting the number of applications for the various programs and following up on incomplete applications, so it does not yet have a count on the increased enrollment in the various programs. The weekend events mark the official kick-off of Healthy Kids and follow Mayor Brown’s proclamation of January 13th as “Healthy Kids Day.” The events also mark the beginning of an extensive outreach and enrollment campaign to insure every eligible child in San Francisco. New Director of Community Substance Abuses Services Hired Dr. Jorge Partida has accepted the Directorship of Community Substance Abuse Services and will join the Department in February 2002. Dr. Partida is a clinical psychologist and has extensive experience with behavioral health systems, family systems, health psychology, gay and lesbian issues, and diversity and culture. In his previous position, Dr. Partida served as the director of the Psychology Program for JFK University’s Graduate School of Professional Psychology. Previous to that, he was the Director of Behavioral Health Services at St. Elizabeth’s Hospital in Chicago and Executive Director of a youth services organization. He has also hosted two weekly Univision television network segments. Women and Children’s Family Services Update At the December 18, 2001 Health Commission Meeting, Community Substance Abuse Services (CSAS) outlined significant fiscal and programmatic issues identified within Women and Children’s Family Services (WACFS). Previously, CSAS had reduced the contract and developed a work plan for the organization. Staff from the Department has met with the WACFS board twice to monitor progress and, according to CSAS, the agency has accomplished the following: Management Infrastructure: Stabilized their fiscal department through the engagement of qualified temporary accounting staff; initiated the evaluation process of the Executive Director (scheduled to be completed by January 31, 2002), and began a management audit. Fiscal: Submitted the FY 00/01 audit by the December 31, 2001 deadline, addressing five prior audit findings. Two findings were new, which corroborated program-monitoring information regarding agency salaries and employee time reports. Program: Responded to all 99/00 monitoring report recommendations with a plan of correction, which will continue to be monitored for completion. The monitoring reports for FY 00/01 reflecting program performance, client satisfaction and agency compliance were mailed to the agency on January 8, 2002. It is expected that specific recommendations will be addressed in writing by February 15, 2002. Newcomers Health Program Awarded California Endowment Grant The Newcomers Health Program--a collaboration of the Community Health Education Section and International Institute of San Francisco--was awarded a $555,000 three-year grant from The California Endowment. This grant will allow the expansion of a Bosnian community health education program begun in 1999 with State funding. The staff of the Bosnian Community Wellness Program will provide health education workshops and psychosocial support groups for Bosnians, in addition to establishing a resource center for Bosnians to learn about and access health and social service information. Staff will also conduct leadership training with community members and offer them opportunities to use their skills from the training in providing services and conducting activities for their community. By the end of this grant period our overall goal is to have built the capacity of this community to improve their own health and well being. Increasing Syphilis Rates Challenge Prevention Efforts Preliminary data for the year 2001 showed a significant increase of syphilis cases in San Francisco. In 2001 there were 186 reported cases compared to 71 cases in 2000. The increase is most significant in the MSM community, which experienced a 9% increase in cases from 2000 to 2001. STD Services continues to work with community partners, sex clubs, adult bookstores and local health departments outside of SF to control the outbreak. Of note, recent cases may be mostly associated with oral sex. While the transmission of syphilis through oral sex is known, and there have been community outbreaks related to syphilis transmission primarily through oral sex, these findings challenge current HIV and STD prevention efforts that support oral sex as "safer sex." Draft Firearm Injury Reporting System Report Presented to the PHP JCC A draft of the San Francisco (SF) Firearm Injury Reporting System (SFFIRS) was presented at the February 2002 PHP JCC. This report is the product of a collective effort among several city agencies involved in the tracking and reporting of data on deaths and injuries due to firearm violence. In 1998, representatives from the Police Department, Medical Examiner’s Office, Emergency Department and Trauma Center at SF General Hospital, the SF Injury Center at the University of California, and this Department agreed to contribute to the development of a shared multi-agency database. Recognizing that the capability to reduce deaths and injuries dues to violence is not based on any single agency, the report goes beyond reporting of standard demographics. The new reporting system will also provide linkage of data regarding both victims and perpetrators from police reports, medical examiner investigations, and hospital records. This centralized database will ultimately enhance our understanding of modifiable risk factors among both victims and perpetrators, promote a unified approached to reducing deaths and injuries due to violence, and serve as a basis for evaluating the impact of prevention efforts. Commissioners’ Comments Commissioner Guy congratulated Anne Kronenberg for her appointment as Director of Policy and Planning, and thanked Colleen Johnson for serving as interim director in addition to her regular duties. Commissioner Chow asked if the Department would be in compliance will the minimum nursing staffing ratios that were announced by the Governor. Dr. Katz responded that the Department’s overall ratios meet the new State requirement. However the Department is in compliance based on team nursing, which is a RN/LVN combination. It is still to be determined whether or not LVNs can play a role in meeting the staffing ratio requirements. 5) PRESENTATION OF THE DEPARTMENT OF PUBLIC HEALTH EMPLOYEE RECOGNITION AWARDS FOR THE MONTH OF JANUARY On behalf of the Commission, Vice President Chow presented the awards to the following: Individual Awardees Division Nominated by Elaina Chin, Pharmacist DPH/Community Health Network, County Jail #2, Jail Health Services Pharmacy Yuki Kubo-Hendricks, Director, Pharmaceutical Services Team Awardees Division Nominated by James Budke, M.D. Laguna Honda Hospital, Nursing and Medical Services, Unit G6 - Chronic Cluster Mary Louise Fleming, Director of Nursing; Mivic Hirose, Associate Director of Nursing; and Terry Hill, M.D., Medical Director Bronwyn Gundogdu, R.N. Rosario Enriquez, RN In addition, Commissioner Chow recognized Diane Keefer and Gail Davis, PHN, both of whom are retiring, for their years of dedicated service to the Department of Public Health. 6) ELECTION OF PRESIDENT AND VICE PRESIDENT OF THE HEALTH COMMISSION FOR 2002 Commissioner Umekubo nominated Commissioner Chow as President of the Commission. Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Sanchez, Umekubo) elected Commissioner Chow as President of the Health Commission for 2002. Commissioner Monfredini nominated Commissioner Guy as Vice President of the Commission. Action Taken: The Commission (Chow, Guy, Monfredini, Parker, Sanchez, Umekubo) elected Commissioner Guy as Vice President of the Health Commission for 2002. Commissioner Monfredini left the meeting at 3:45 p.m. 7) DEPARTMENTWIDE CAPITAL PROJECT UPDATE John Kanaley, Sr. Associate Administrator for Support Services, presented the Departmentwide Capital Project Update. The presentation showed the status of capital projects currently underway within the Department of Public Health and the proposed projects for FY 2002-2003. The Department of Public Health is overseeing approximately $18 million in facility maintenance and capital project funds at DPH sites: $8.3 million at San Francisco General Hospital; $6.9 million at Primary Care centers; $2.6 million at Laguna Honda Hospital; $100,000 at Population Health/Mental Health; and $200,000 at the Community Health Network. In addition, there are a variety of other funded projects including the rebuild of Laguna Honda Hospital. San Francisco General Hospital projects include seismic safety upgrades, ADA restroom remodels, energy upgrades, service delivey and master planning, life safety, the women’s imaging center, the Ambulatory Surgery Center, the Cardiac Cath laboratory, methadone clinic expansion and facility maintenance. Laguna Honda Hospital funded projects include seismic safety upgrades, fire alarm system replacement, an access ramp to the garden and the rebuild of the hospital. Projects that are funded for the Primary Care centers include the Maxine Hall interior remodel, Tom Waddell interior renovations, HVAC and ventilation assessments at all sites and renovations of selected sites for patient care space upgrades. Projects that are funded for DPH Administration include tenant improvements at CHN headquarters, various energy conservation projects, renovation of Vital Records and the relocation of Epidemiology and the Immunization Clinic at 101 Grove. Mr. Kanaley summarized the fiscal year 2002-2003 requests: San Francisco General Hospital - Campus cardkey installation, radiology master planning, nurse call replacement, Vascular IR Suite design, fire alarm replacement phase I, CT upgrade and facility maintenance. Laguna Honda Hospital - Campus cardkey installation, ADA upgrades at main hospital, Clarendon Hall fire alarm, ADA access ramp, MIS cabling upgrade, piping replacement and facility maintenance. Primary Care Centers - Expansion of Potrero Clinic, Tom Waddell fire alarm, North of Market Clinic staff areas and facility maintenance. Population Health and Prevention - Functional upgrades at 101 Grove, door locks and windows at 101 Grove, PHP facility maintenance and Mental Health facility maintenance. Mr. Kanaley then summarized the challenges the Department faces as it moves forward into the next fiscal year. SFGH Rebuild Facility Maintenance - the age of the buildings is becoming a significant cost factor, and inefficient layouts and obsolete infrastructure limit the use of buildings. Capital/Facility Maintenance Funding - recent budget increases will be curtailed, and facility maintenance budgets are below industry standards. Currently the Department’s facility maintenance budget is less than $1 per square foot, and the industry standard is $3.75 to $4 per square foot. Technology Changes Commissioners’ Comments Commissioner Guy stated that having this annual report at this time has been very helpful, and the Commission would like the report to be given on an annual basis. She asked Mr. Kanaley if he thought the current allocation of funds would allow the projects to be completed. Mr. Kanaley responded that the funds they are requesting should be adequate complete the projects they are seeking approval for. In the event the budget appears to be inadequate, the Department will rescope the project to meet the budget. Commissioner Umekubo asked if other sources of funding are available for fuel cell and micro-turbine technologies and solar projects, or is the Department going to have to fund these kinds of projects with its own money. Mr. Kanaley replied that a $100 million solar energy bond was recently approved, and the Department will aggressively seek funding from this bond. Commissioner Chow asked if the findings from the recent Joint Commission mock survey are incorporated into this plan. Mr. Kanaley said the findings from the recent study are not, but all previous life safety findings have been either been corrected or there are plans in progress to correct. At this time San Francisco General Hospital is working with a professional who is preparing a report that might identify additional projects. These will have to be addressed in the following two years. Commissioner Chow asked the status of retrofitting 101 Grove. Dr. Katz stated that there currently is no plan to retrofit the building. The changes that have been made are to make better use of existing space. 8) EVALUATION OF THE USE OF PBM FOR MEDICAL PATIENTS Sharon Kotabe, Director of Pharmaceutical Services, CHN, presented the 12-month evaluation of the use of PBM for medical patients. In October 2000 the Health Commission approved a new method for prescription services which called for a Pharmacy Benefits Manager. PCN was selected as the CHN PBM. Services began in November 2000. The PBM contract had two major goals: to improve access to prescription services to indigent CHN patents; and to improve prescription services for indigent CHN patients. Ms. Kotabe said that patients did take advantage of having more than one access point, and did get prescriptions filled at locations throughout the city. This implies easier access. In addition, total prescription volume has increased 5 percent in the last six months of the contract. With regard to improved service, Ms. Kotabe said that the PBM contract provides seven days a week, 24 hour per day services, plus free delivery at some pharmacies. The wait time was decreased, with approximately 90 percent of patients getting their prescriptions filled in under an hour and the majority waiting no more than 30 minutes. The system has linguistic capability for 18 different languages. In addition, electronic interface allows prescriptions filled anywhere in the network to be transferred to the patient’s electronic medical record. And the PBM implemented systems to obtain “real-time eligibility,” which allows patients to get prescriptions on the same day they are seen by the provider. The PMB pharmacies fill approximately two thirds of the prescriptions and the remaining one third are filled by the SFGH Outpatient Pharmacy. Ms. Kotabe then discussed the attempt to identify patient satisfaction with the PBM network. They did a member satisfaction survey in 2001, but received very few responses. However, they received no negative responses. Ms. Kotabe said the PBM Oversight Committee began meeting in March 2001 and continues to meet monthly. Ms. Kotabe said that, nationwide, pharmacy and pharmaceutical costs have increased 10-15 percent since 1999, and are projected to rise 15-20 percent at least through 2005. The pharmacy budget has been flat for the last three years, but actual expenditures have mirrored the national trends. In order to try to mitigate the impact of the increase in expenses, the Pharmacy Department, working closely with the medical staff, has instituted various measures to decrease costs. The impact of these changes was $3.03 million in FY 01-02. The average cost per prescription is $50.97 for the PBM and $56.68 for SFGH (this includes labor, benefits and indirect costs). Ms. Kotabe described the next steps to deal with increased cost and volume: 10-day supply of discharge prescriptions for Medi-Cal patients 30-day supply for PBM prescriptions from the current 100-day supply (exceptions for prescriptions to treat chronic conditions). This change will not cause the patient to have to go back to the provider. The pharmacy will dispense in 30-day increments with refills. Changes under consideration Single PBM contract for CHN and mental health patients Opportunities offered by SB 340 pharmacy law changes. In this model the patients would not have their choice of any of 100-plus pharmacies in San Francisco. Instead we would match each of our FQHC clinics with a particular community pharmacy. Ms. Kotabe concluded by discussing some of the lobbying and legislative efforts, including 340B pricing for inpatient drug purchases and a demonstration project proposal with the Office of Pharmacy Affairs, the Federal body that oversees 340B pricing. Ms. Kotabe said that overall the Department believes that the implementation of the PBM has been a success from the point of view of increasing access to prescriptions and improving service for our patients. The increased cost and utilization are of concern, and she assured the Commission that the Department will work very hard to keep costs down without decreasing access or services. Commissioners’ Comments Commissioner Umekubo asked Ms. Kotabe to clarify the State and Federal components of the 340B pricing plan. Ms. Kotabe said there are different efforts at the two levels that can accomplish the same goal. Previously, State law prevented the Department from implementing the program on a one clinic one pharmacy basis, such that they could not access 340B pricing without wholesaling. SB 340 allows clinics to get wholesaler license, so they could access the pricing. The Federal demonstration project proposal would allow the Department to maintain the network so patients have access to all network pharmacies, not just one. This cannot be done currently. Commissioner Umekubo asked how much of the increase is the actual cost of the drug and how much is the utilization of the drug. Ms. Kotabe responded that it is difficult to quantify. However, they have attempted to put into place systems so that extremely expensive drugs are not overutilized. The national trend is that utilization drives costs more than the drug cost. Commissioner Sanchez commended the staff for the patient satisfaction responses. Commissioner Sanchez asked for a further breakdown of the costs. Ms. Kotabe responded that the costs for both the PBM and SFGH include direct and indirect costs. Commissioner Parker asked if the increased prescriptions come from an increase in prescription writing on the part of physicians. Ms. Kotabe does not have this data. Commissioner Parker wanted to be clear that all appropriate indirect costs were included in the cost-comparisons, so that the comparison between the PBM and SFGH could be accurate. Dr. Katz will provide the Commission with more detailed information. Commissioner Guy stated that the report clearly shows that the Department achieved the objective of increased access and increased service, but not the objective of cost savings. Commissioner Guy asked if a combined PBM would mean Mental Health would have to decrease the number of pharmacies they use. Ms. Kotabe said that Mental Health would retain its multiple sites. Commissioner Guy said she really wants to examine this from a programmatic level, because the impact on mental health patients might be great. Also, she was still surprised to see that 34 percent of patients are still getting prescriptions filled at the SFGH pharmacy, and asked if this going to remain the breakdown. Ms. Kotabe stated she thinks it will remain at this level. Commissioner Chow said that the low response to the survey is problematic, and perhaps the oversight committee can identify other ways of getting responses back. Ms. Kotabe said they are looking at incentives to help people return surveys. Commissioner Chow asked who the oversight committee reports to, and the response was Dr. Katz. Commissioner Chow asked Fred Hom, one of the Committee co-chairs, to highlight some of the issues raised in the oversight committee. Mr. Hom said that they are working on a report to submit to Dr. Katz with findings and recommendations. In general the oversight committee thought it opened access but that the increased costs is a concern. 9) PUBLIC COMMENT Frederick Hobson told the Commission that he resigned from the Drug Advisory Board, and submitted a packet of information to the Commissioners. He asked the Commission to look into the overwhelming number of contractors on the board, rather than members of the public. In addition, the Board has a history of disrespectful and discriminatory treatment of the LGBT members on the Advisory Board. 10) ADJOURNMENT The meeting was adjourned at 5:05 p.m Michele M. Olson, Executive Secretary to the Health Commission