Minutes of the Health Commission Meeting Tuesday, June 3, 2003 At 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The Commission was called to order by Commissioner Guy at 3:10 p.m. Present: Commissioner Roma P. Guy, M.S.W., Vice President Commissioner Lee Ann Monfredini Commissioner Harrison Parker, Sr., D.D.S. Commissioner Michael L. Penn, Jr., M.D., Ph.D. Commissioner David J. Sanchez, Ph.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Edward A. Chow, M.D. 2) APPROVAL OF THE MINUTES OF THE MEETING OF MAY 20, 2003 Action Taken: The Commission (Guy, Monfredini, Parker, Penn, Sanchez, Umekubo) approved the Minutes of the May 20, 2003 Health Commission meeting with the correction that Commissioner Parker requested inclusion of his comment on Item #8 that the Youth Health Advisor provides an opportunity for fresh, new thoughts to the Commission. The primary purpose of this position is to seek outside input to help solve youth problems. Training this individual for the future is a secondary purpose. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Monfredini chaired, and Commissioners Penn and Umekubo attended, the Budget Committee meeting. (3.1) CHN-Health Information Services – Request for approval of three contract renewals with the following firms: Mediscript Medical Transcription, Pacific Medical Transcription and Transcription Stat, Inc., for a combined total amount of $905,000, to provide as-needed medical transcription services for the Health Information Services, San Francisco General Hospital, Community Health Network, for the period of July 1, 2003 through June 30, 2005. (3.2) AIDS Office-Prevention – Request for approval of a retroactive renewal contract with CompassPoint Nonprofit Services, in the amount of $105,310, to provide organizational development and technical assistance, for the period of April 1, 2003 through December 31, 2003. (3.3) AIDS Office-Prevention – Request for approval of a retroactive new contract with San Francisco Study Center, in the amount of $160,000, to coordinate a community-wide planning process targeting the HIV prevention services provider community and HIV prevention services staff, for the period of March 1, 2003 through June 30, 2003. (3.4) CHSS-Immunizations – Request for approval of a retroactive new sole source contract with Mount Zion Health Fund, in the amount of $207,191, to provide support services to the San Francisco Immunization Coalition, for the period of October 15, 2002 through June 30, 2005. (3.5) CBHS-Substance Abuse – Request for approval of a contract renewal with Ohlhoff Recovery Programs, in the amount of $376,615, to provide residential and outpatient substance abuse treatment services targeting women and adolescents, for the period of July 1, 2003 through June 30, 2004. Action Taken: The Commission (Guy, Monfredini, Parker, Penn, Sanchez, Umekubo) approved the Budget Committee consent calendar. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. Budget Update Mayor Brown held a press conference this morning releasing his proposed $4.8 billion FY03-04 budget. The budget absorbs the $347 million deficit faced by the City and avoids many of the prior anticipated cuts. We were pleased to be asked by the Mayor in the last week of May to reinstate 3 million dollars in services previously cut from next years budget including some mental health and substance abuse outpatient programs and adult dental care. (spreadsheet attached) We learned late last night that SEIU 790, 250 and 535 (miscellaneous employees) overwhelmingly ratified the negotiated union contract. As a result of the agreement with SEIU, members will pick up the 7.5 percent employee share of retirement, and DPH will restore the MHRF as a locked subacute facility for a year and retain City staffed laundry services. Federal Tax Cut Includes Increase for Medicaid Last week, the President signed a $350 billion tax cut and economic stimulus bill that includes $20 billion to address state fiscal relief, including a temporary increase to the Federal Matching Assistance Percentage (FMAP) for Medicaid. California’s FMAP is expected to increase from 50% to 54.35% through State fiscal year 2004, resulting in approximately $1.29 billion in additional Medicaid funding. Increasing the FMAP results in a cost shift from the State to the federal government, but is not designed to provide relief to local jurisdictions. However, in instances where we use county funds to draw down the federal match, such as the distinct part nursing facility and hospital outpatient supplemental programs that San Francisco sponsored in the State Legislature over the past three years, we may be able to expect an increased federal share of approximately $2.2 million. New Mom I know you all join me in congratulating your own Health Commission Secretary, Michele Olson who gave birth on Saturday to a baby boy, Harrison Francis Seaton. He weighed 8lbs at birth and was 22 inches long. Harrison and Michele are home from the hospital and settling in, happy and healthy. June 17th VIP Event As mentioned in an earlier report, the Department of Public Health will be conducting a practice exercise at Bill Graham Auditorium, June 17, 2003 to test the City’s ability to respond to a health emergency. During the exercise, DPH staff will set up a mass clinic to provide mock vaccinations to over 2,000 volunteers. You are cordially invited to attend a special VIP briefing and tour of the exercise at 2:00p.m. on June 17th. I hope you will be able to join us. Director of CDC Visits SFGH Julie Louise Gerberding, MD MPH, Director of the Centers for Disease Control and Prevention is in San Francisco for two weeks attending at San Francisco General Hospital. Dr. Gerberding served as Professor of Medicine at the University of California, San Francisco before her appointment to the CDC. At noon today, Dr. Gerberding presented at SFGH Grand Rounds. Her lecture, Twenty-First Century Public Health: Protection, Prevention and Health Promotion was very well received. Graduate Student Award Gloria Garcia-Orme, Director of Patient Relations at San Francisco General Hospital, was awarded the Graduate Student Award for Distinguished Achievement from San Francisco State University, where she received her masters in nursing. This is the highest honor that SFSU grants to graduate students and is in recognition of outstanding scholarship or creative work, professional activity, and service to the SFSU nursing department, college, and community. CTR Program On May 13th, the HIV counseling and testing program at Glide was the first government funded Counseling, Testing and Referral (CTR) program in California to provide HIV rapid testing. Glide's CTR program is funded by the Department and is one of several CTR programs around the State currently participating in the State Office of AIDS pilot of rapid testing. Following the evaluation of the pilot, the AIDS Office/HIV Prevention Section will work with the other Department funded CTR programs in San Francisco to prepare them for HIV rapid testing. Public Comment Benica Henry of Family Right and Dignity of the Coalition on Homelessness requested that the City consider accountability to families in the budget. There is funding available for housing and shelter for other populations of single adults, but no funding for families. Families deserve their fair share of the budget, and currently receive the smallest portion of the budget. Commissioners’ Comments Commissioner Monfredini noted that the June 17 VIP briefing and tour of the health emergency practice exercise is scheduled for the same time as the Health Commission Budget Committee. She expressed her desire to attend the VIP event. Dr. Katz indicated his willingness to change the time of the briefing and tour to allow Commissioners to attend. Commissioner Sanchez noted that colleagues from San Francisco who move on to national roles frequently return for visits, such as Dr. Gerberding. He also congratulated Gloria Garcia-Orme on her award, and congratulated Commissioner Penn on his recent M.D. degree from UCSF. Commissioner Umekubo noted that in terms of the FMAP, California ranks 49th of all the states, and requested clarification on how the FMAP affects local communities. Dr. Katz responded that since Medicaid programs are State-Federal programs, as the Federal contribution increases, the State contribution decreases, providing relief to states, without affecting local communities. In California, there has been creative legislation to bypass the State, whereby local funds are used to match and draw down the federal portion of the funding. Does not mean a higher rate, just a larger proportion of the existing rate is Federal. Commissioner Umekubo followed up by asking if the State spends more on Medi-Cal, does it receive more in Federal funding? Dr. Katz responded in the affirmative. Commissioner Penn asked who will be evaluating the effectiveness of the mock vaccination exercise. Dr. Katz responded that DPW, SFFD, and SFPD will be monitoring the exercise, a survey of participants will be conducted to determine whether they understood the education provided to them, and finally, how many people can be “vaccinated” in one day during the exercise. Commissioner Umekubo asked whether there are any confirmed cases of SARS in San Francisco. Dr. Katz responded that there is still one probable case, and the Department is waiting for serum results. It is probable, because the patient fits the criteria for SARS. There have been no further imported or local cases. 5) PRESENTATION OF A RESOLUTION SUPPORTING SAN FRANCISCO WOMEN’S HEALTH PLAN Barbara Garcia, Deputy Director of Health for Community Health Programs presented the Resolution “Supporting San Francisco Women’s Health Plan”. She noted that it was a follow-up to the Women’s Health Report presented at the May 20, 2003 Health Commission meeting. Action Taken: The Commission (Guy, Monfredini, Parker, Penn, Sanchez, Umekubo) approved Resolution #12-03, entitled “Supporting San Francisco Women’s Health Plan: Partnering in Wellness with Women and Girls in San Francisco 2003-2006”. Attachment B. 6) STATE BUDGET UPDATE Colleen Johnson, Assistant Director of Policy and Planning, presented the State Budget Update. Ms. Johnson noted that it is difficult to interpret the May Revise because it is not a full budget picture. It only includes the differences from the 2003-04 budget proposal the Governor released in January, and does not include much detail about the proposed changes. The summary included is the best information available at the time the report was prepared. Additional information has become available since, which is included in today’s presentation. The projected deficit represents an increased deficit of $3.6 billion over the January estimate. Since the release of Governor Davis’ January Budget, the State economy and State General Fund (GF) revenues have generally followed the January forecast. However, expenditures related to caseload growth and Proposition 98 in addition to the cancellation of the sale of the second installment of the tobacco securitization bond ($2 billion) due to declining market conditions have increased the budget gap. The impact on health services is less severe than DPH had anticipated, and less than the Governor proposed in January. DPH estimates that if the Governor’s May Revise were adopted as proposed, the Department would lose approximately $13 million in State and Federal dollars for critical health services. This estimated is revised down by approximately $5 million as a result of clarifications in the May Revise. DPH did not budget these reductions into its fiscal year 2003-04 budget as the Mayor has created a reserve for additional reductions that may occur as a result of the State budget. In January, the Governor proposed a Realignment II package that would have transferred $8.3 billion of State-funded health and human service programs to counties along with a dedicated revenue stream comprising income, tobacco and sales taxes to fund these programs. The May Revise proposes a scaled back realignment program, totaling $1.8 billion, effective July 1, 2003. The revised Realignment II would dedicate revenues from two new taxes (a $0.23 cigarette tax in 2003-04, an additional $0.40 in 2004-05; and an additional 10.3% personal income tax bracket) to fund several social service programs and the following health programs at their current levels: AB 34/2034 ($20 million statewide) and the Children's System of Care ($55 million statewide). The DPH impact: DPH currently receives approximately $2.7 million for the mental health programs included in the Realignment II proposal for 2003-04 ($2.2 million in AB 2034 funding and $500,000 for Children’s System of Care). Since Realignment II assumes that programs would be funded at existing levels, this proposal should have no fiscal impact. Realignment is a crucial component of the structural reform on which the Governor predicated his budget. The Governor has requested that the Legislature consider the elements of Realignment II as originally proposed in his January budget during the remainder of their current legislative session for implementation in 2004-05. In addition to the two mental health programs the Governor includes in the May Revision to Realignment II, as noted above, there are several additional health programs that the Governor proposed in January: All of Medi-Cal Long Term Care (including all skilled nursing facilities and assumption of 100% of non-federal share of IHSS) Alcohol and Drug Programs (Drug Medi-Cal, drug court, Prop 36, and "non-Medi-Cal alcohol and other drug services) A new "Healthy Communities" realignment (15% Medi-Cal Share of Cost, Adolescent Family Life Program, Black Infant Health Program, Indian Health Program, Local Health Department MCH Program, Expanded Access to Primary Care, Grants-in-Aid for Clinics Program, Rural Health Services Development Program, Seasonal Agricultural and Migratory Workers Program, County Health Managed Care Program, California Health Care for Indigents Program, Rural Health Services Program, Public Health Subvention) Realignment can provide county Health Departments with flexibility to allocate funding based upon local needs. However, in order to be successful, the revenues provided in the first year of realignment must be at least as great as program expenditures. For future years, the revenue source must be stable with a growth rate that is equal to or greater than anticipated growth in the realigned programs. Further, it may be problematic to include both caseload-driven, mandated services with discretionary programs in a realignment package, as mandated programs with significant caseload growth can consume funding for discretionary programs. Medi-Cal provider rate reductions continue at 15 percent as proposed in January. This is expected to save $1.4 billion ($720.5 million State GF). This reduction impacts fee-for-service, managed care (not including mental health managed care), and Family Pact. Reducing Medi-Cal rates has the potential to significantly impact access, quality of care, and the availability of care not only for Medi-Cal beneficiaries, but also for the uninsured. In addition to the 15 percent rate reduction, the May Revise also contains a rate increase for long-term care facilities at an average of 3.8 percent. This increase, which is part of DPH’s annual long-term care rate review and adjustment process, is estimated to increase State General Fund costs by $59.8 million. This partially mitigates the loss of reimbursement for long-term care services at Laguna Honda and San Francisco General resulting in a net decrease of approximately 11.2 percent and restoring approximately $1.7 million of the $6.3 million loss DPH had estimated was the result of the Governor’s January budget proposal. As is the case with long-term care rates, the May Revise contains a three percent rate increase for Medi-Cal managed care that will mitigate losses that result from the 15 percent rate reduction. This increase is estimated to increase State General Fund costs by $112.5 million, resulting in a net decrease for Medi-Cal managed care plans of approximately 12 percent. It is difficult to assess the impact of this proposal on DPH because it does not impact DPH directly but rather affects the San Francisco Health Plan, which may need to reduce reimbursement to providers like DPH. However, DPH estimates that this proposal would restore approximately $445,000 of the $2.2 million loss DPH estimated was the result of the Governor’s January budget proposal. In addition to being subject to the 15 percent provider rate reduction, the ADHC rate would be further reduced as a result of the Governor’s proposal to “unbundle” some required services. Currently, ADHC providers are required to include specific service components in their programs and are paid one daily rate for all the services they provide. However, the May Revise proposes to “unbundle” the rate, remove speech therapy, physical therapy, occupational therapy, and transportation, and rebundle the services at a new, lower reimbursement rate. The therapies and transportation may then be billed separately subject to prior authorization. This proposal is estimated to save the State $18.8 million in General Fund. These additional rate reductions are anticipated to further reduce revenues for Laguna Honda’s ADHC services by approximately $230,000. The Governor’s January budget proposed implementing quarterly status reports for adults in the Medi-Cal Program as of October 2003. The May Revise maintains this proposal, which assumes that 193,123 adults will be dropped from coverage in 2003-04 due to ineligibility or failure to return the required forms, for a total savings of $85 million. As in all Medi-Cal programs, an equal loss in federal funding would also be lost, totaling $170 million. The vast majority of adults who would lose coverage as a result of quarterly status reports would otherwise be eligible for Medi-Cal at the time of their termination from the program. Prior to May of this year, Medi-Cal beneficiaries were required to re-qualify for Medi-Cal on an annual basis. The mid-year reductions passed by the Legislature on May 1st, require families to submit forms twice yearly, starting August 1, 2003. The Legislature estimates that semi-annual reporting will achieve half of the savings ($85 million total and $42.5 million State GF), suggesting that approximately 97,000 enrollees statewide and 1,100 enrollees in San Francisco will lose their Medi-Cal coverage. If quarterly status reports were implemented, 2,176 San Franciscans would lose their Medi-Cal coverage and become uninsured. DPH estimates that this proposal would result in increased expenditures as a result of providing uncompensated care to the newly uninsured and decreased revenues from Medi-Cal for serving those who will become uninsured totaling approximately $2.5 million. The May Revise maintains current eligibility levels for the 1931(b) Medi-Cal program, rescinding the January proposal to reduce eligibility under this program. Currently, low-income working parents qualify for Medi-Cal if their incomes do not exceed 100 percent of FPL. In January, the Governor proposed reducing income eligibility for this program to approximately 61 percent of FPL, which would have resulted in the loss of Medi-Cal coverage for 292,890 parents statewide and a savings of $236 million ($118 million State GF). The May Revise rejects this proposal and proposes maintaining the current program. Maintaining the 1931(b) Medi-Cal program ensures that 3,299 San Franciscans that rely on this program will retain their health insurance and DPH would avoid increased expenditures associated with caring for the newly uninsured and decreased revenues from Medi-Cal for serving those no longer eligible totaling approximately $3.8 million. The Governor’s January budget rescinded the Aged and Disabled Expansion Program and the May Revise continues to rely on this proposal to balance the State’s budget. The Aged and Disabled Expansion Program allows persons with incomes between the SSI/SSP benefit level ($9,084 per year) and 133 percent of FPL ($11,943 per year) to receive Medi-Cal benefits with no share of cost. Rescinding this expansion would result in a share of cost for approximately 68,840 Medi-Cal beneficiaries statewide that have incomes above the SSI/SSP benefit level, resulting in reduced expenditures of $127.6 million (63.8 million State GF). The budget also includes resources to initiate an effort to increase enrollment of aged, blind and disabled beneficiaries into Medi-Cal managed care. While this proposal is estimated to impact approximately 750 Medi-Cal beneficiaries in San Francisco, the actual impact on DPH is unclear since it is the Administration’s intention to shift the cost of care from the State to the patient, not the provider. In January, the Governor proposed elimination of 18 optional Medi-Cal benefits. The May Revise restores four of these (non-emergency transportation, hospice, orthotics, prosthetics) and continues to rely on elimination of 14 optional benefits for a savings of $420 million ($210 million State GF) beginning in October 2003. However, because these beneficiaries are very low income, it is likely that they will be unable to pay their share of cost and DPH will provide services without this reimbursement. This proposal is estimated to reduce annual Medi-Cal revenues to DPH by approximately $500,000. The mid-year package of bills passed by the Legislature on May 1st modified the Medi-Cal dental benefits, mandating cost-saving measures, such as requiring documentation for certain claims and limiting the use of laboratory-processed crowns, for a savings of $101.6 million ($50.8 million State GF). DPH estimates that it will lose approximately $500,000 in Medi-Cal revenue as a result of the elimination of these 14 optional benefits, primarily as a result of the elimination of adult dental services. The May Revise provides $69 million in federal funds to offset reimbursable mandates to counties for AB 3632 services. However, counties estimate the cost of providing these services is approximately $120 million and growing. The federal Individuals with Disabilities Education Act passed in 1975, required state education agencies to provide mental health assessments and services to students with disabilities. AB 3632, passed in 1984, transferred responsibility for providing these mental health services from local education agencies to local mental health agencies. This mental health program is known as the AB 3632 program and is an entitlement program, paid for through the SB 90 State mandates reimbursement process. There has been a disagreement between the State and counties in recent years as to whether counties are entitled to reimbursement for treatment services provided under AB 3632 at 100 percent of cost or 10 percent of cost. This budget proposal is seen by some as the State’s acknowledgement that counties may be entitled to more than 10 percent of cost. Because counties believe that the State is required to fully fund this program and because this proposal only funds one-half of the projected cost, the impact of this budget proposal is unclear. DPH currently receives approximately $1.4 million for this program each year and believes that it will continue to receive this amount in 2003-04. The May Revise continues to propose reducing rates for Mental Health Managed Care by ten percent. These funds are used to pay for private providers and private fee-for-service inpatient hospital services. A ten percent reduction to Mental Health Managed Care would result in a reduced allocation to DPH of approximately $365,000, which would have been eligible for a federal Medicaid match of an additional $365,000, for a total loss of $730,000. The May Revise reduces State discretionary funding for alcohol and drug services, by $11.5 million in State General Fund, bringing total discretionary alcohol and drug spending down to $5.8 million. DPH estimates that this would reduce its funding by $308,000. The Governor’s January budget provided only $2.3 million in new State funds for ADAP and proposed raising an additional $7.2 million from co-payments to be paid by ADAP clients. The Governor proposed co-payments of $30 to $50 per prescription per month for individuals earning over 200% of the federal poverty level ($17,960 for an individual). The budget also proposed to establish a waiting list to address the remaining $16 million shortfall in the program. The Governor’s May Revise, however, reduces the co-payments to between $5 and $15 and adds additional funding to the program, reducing the ADAP shortfall to $13 million. Despite these improvements, advocates remained concerned about the potential impact of the co-payments as well as insufficient funding for the program. Institution of co-payments for ADAP is not expected to have a direct financial impact on DPH since co-payments represent a shift of cost from the State to the patient. The only impact on DPH would be increased administrative burden that would result from collecting these new co-payments. Having removed the California Healthcare for Indigents Program (CHIP) from the revised Realignment II proposal, the May Revise proposes a major reduction in CHIP funding for fiscal year 2003-04, citing reduced tobacco tax revenues. Proposition 99 provides funding for CHIP, among other programs, through a 25-cent tax on cigarettes and tobacco products. CHIP provides funds to counties, hospitals and physicians for uncompensated care to the medically indigent. It is estimated that DPH will lose approximately $1.7 million in funding for CHIP as a result of the Governor’s proposal. This represents a 52% reduction compared to fiscal year 2002-03 levels. The Governor’s May Revision suspends 34 state-mandated local programs for 2003-04. Suspension alleviates the responsibility of local governments to provide the service, as well as the State to reimburse for them. The May Revision also indicates that the Governor will pursue legislation to repeal 27 of the 34 deferred mandates beginning in fiscal year 2004-05. There are five mandates that relate to health and mental health, all of which the Governor intends to repeal in 2004-05. This was the least clear component of the Governor’s budget. In mental health, the programs proposed for suspension and, ultimately, repeal, are significant and DPH is not sure if it is the Governor’s intention to suspend the entire categories of service or just a portion of those categories. DPH currently receives a total of $5.3 million for the State-mandated local programs scheduled for suspension and, ultimately, repeal. (Short-Doyle Case Management, $2.7 million; Residential Care Services, $2.6 million, SIDS Contacts, $300.) If the mandate were suspended, DPH would lose this revenue. The May Revise relies heavily upon the Legislature’s passage of the budget by the constitutional deadline of June 15th. If California does not have a budget by the beginning of the fiscal year on July 1st, Wall Street may no longer consider California an acceptable credit risk and the State may no longer have the ability to borrow to bridge the deficit. Adding further pressure to the State to pass an on-time budget, the State Controller estimates that California will run out of cash to pay its bills by the end of the summer and the California Supreme Court ruled on May 1st that State employees could be paid only minimum wage if no budget was in place by the beginning of the fiscal year. This work may also be done by the State’s elected leaders, together called the Big Five, comprising the Governor, the President pro Tempore of the Senate, the Speaker of the House, the Senate Minority Leader and the Assembly Minority Leader. Once an agreement is reached, the full membership of each House will vote on the final budget bill. In addition to the fiscal authority provided in the budget bill, statutory changes are often required to implement changes proposed in the budget by the Governor or the Legislature. Separate bills, called “trailer bills” are introduced to implement these changes and are heard concurrently with the budget bill. Passage of the budget requires a two-thirds vote in each House. Assuming all Democrats vote together, two Republican Senate votes and six Republican Assembly votes will be needed. Once the budget is passed by the Legislature, the Governor has 12 working days to sign or veto the budget bill. The Governor also has the authority to “blue pencil” (reduce or eliminate) any item contained in the budget. The Governor cannot, however, blue pencil trailer bill language. The budget bill and its trailer bills become law as soon as they are signed by the Governor. Commissioners’ Comments Commissioner Monfredini asked whose idea it was to move the debt forward by borrowing. Ms. Johnson replied that the Republicans are supporting this plan, but only through existing taxes. They would not support new taxes to service the debt. Commissioner Monfredini asked what happens if Governor Davis does not sign the budget within the 12 days. Ms. Johnson responded that the bill would become law without his signature, but he would lose the ability to use his blue pencil for any budget line item vetoes. Commissioner Monfredini asked whether the recall effort will affect the budget process. Ms. Johnson replied in the negative, indicating that she is not aware of when that election would occur if the petition drive is successful, but that election would include all of the candidates for governor as well as the question of whether to recall. Commissioner Guy asked about the impact of the State budget on Laguna Honda operations. Dr. Katz responded that the City maintains reserves to deal with the State budget. If the current budget passes the Department is okay. If the State budget does not include the proposed tax increases, the City does not have sufficient reserves. Commissioner Umekubo noted that providers have been active and vocal in their opposition to the provider rate cut, and he is encouraged to see that there have been some successes with this issue. 7) SAN FRANCISCO GENERAL HOSPITAL REBUILD UPDATE Tony Wagner, Chief Executive Officer of Hospital Systems, presented the San Francisco General Hospital Rebuild Update. Mr. Wagner presented the background of the rebuild effort, noting the SB 1953 requires that all California acute care hospitals must meet new seismic safety standards by either retrofitting existing buildings or by rebuilding a new hospital by 2013. The planning process to date has included: Phase I: Exploratory Phase Phase II: Long Range Service Delivery Plan (LRSD) Phase III: Institutional Master Plan (IMP) Phase IV: Collocation Feasibility Mr. Wagner noted that Phase I focused on the meeting of the SB 1953 mandate. The Health Commission approved Resolution #1-01 in January 2001, entitled: “Supporting the Rebuilding of San Francisco General Hospital”, supporting the rebuild of SFGHMC by 2013. A seven-week planning process was initiated to explore the feasibility and cost of rebuilding. Phase II was initiated in January 2002 to develop a long-range service delivery plan for the City’s public health safety net system as it impacts the rebuilding of SFGHMC. The LSRD program recommendations include: Initiate discussions with the UCSFMC to explore opportunities to partner or collocate SFGHMC and UCSFMC at Mission Bay. Concurrently explore options for rebuilding SFGHMC at the current Potrero site. Incorporate best practices for moving ambulatory care services out of the hospital and into the community. Expand the SFGHMC Level I Trauma Service and develop a medical air transport system. Explore opportunities to collaborate with UCSFMC on a Mothers’ and Children’s Hospital. Phase III began in July 2002 with the goals to: 1) Ensure that the facility plans stay true to the vision of the LRSD program goals, and 2) Interpret SFDPH strategic healthcare planning objectives into forward thinking healthcare delivery concepts. The key planning components for services include: acute care, trauma/ED, behavioral health, outpatient services, research and education, and a mothers’ and children’s hospital. The team examined various configurations at both sites, and developed 41 possible scenarios. All potential options were considered. The 41 scenarios were evaluation based on criteria, including: patient access to care, adjacency to critical services, adjacency of diagnostic and treatment and support services, staffing efficiencies, adjacencies supporting academic medical center’s mission, and access to research space. IMP outreach was designed to: Inform relevant stakeholders about the Rebuild planning. Receive input from stakeholders to be used in the Rebuild planning process. Provide presentations to a wide variety of audiences, including DPH staff, neighbors, consumers, and citywide groups. Afford stakeholders the opportunity to comment on the product of each phase: scenarios, concepts, preferred concept. Present stakeholders input along with the product of each phase to the Steering Committee and the Health Commission. Approximately 228 attendees were present at 12 meetings. Questions and concerns raised through these presentations included: Will the rebuild take funds from existing services? Would UCSF be as hospitable as SFGH? Lack of coordination between hospitals/duplication of services. Mission Bay is too far away. Mission Bay is contaminated landfill. Burial mounds exist at Mission Bay. Helipad if Rebuild is at Potrero. Findings from these presentations include: Most people are favorably disposed to the rebuild. Low attendance at some presentations suggests that the Rebuild is not a top priority. Little distinction is made between acute care and clinical services. Stakeholder conclusions include: Consumers prefer the Potrero site Citywide groups would like to see more coordination with UCSF and other hospitals Neighbors may oppose the Rebuild at the Potrero site due to the helipad. Next steps will include focusing outreach for the next phase on encouraging people to attend the Combined Advisory Committee (CAC) meetings, recruiting representatives for the CAC from additional neighborhoods, and adapting the presentation to address consumer interests and concerns more clearly. The process of Phase IV, Collocation, included the objective to define the best-case scenario for collocation, and was jointly pursued by both UCSF and SFGH. There are significant differences in the missions and financial support mechanisms for both institutions: SFGH/DPH provides care for all funded largely through public sources. UCSF includes education and research, and the medical center is self-funding. Governance and fiduciary responsibility is non-negotiable; a single, fully integrated institution is not possible at this time. No exact national model exists; Bellevue/NYU and Harborview/UW are close, but not exact. The best-case scenario practically for collocation would be two adjacent hospitals with a single ED/trauma center on the SFGH side and single children’s service on the UCSF side. There could be some shared ancillary and support services with long-term flexibility to share built into the campus plan. The conclusion is that unless substantive advantages to collocation can by identified for UCSF Medical Center, collocation is not an option for SFGH. Mr. Wagner presented two recommendations: No further collocation discussions are indicated at this time. Three scenarios should be further developed into design concepts: An acute care hospital, Level I trauma center and outpatient services be located on the Potrero site. An acute care hospital, Level I trauma center and outpatient services be located on the Mission Bay site. An acute care hospital and Level I trauma center be located on the Mission Bay site with outpatient services at the Potrero site. Commissioners’ Comments Commissioner Umekubo asked whether scenario two is stand-alone or collocation with UCSF. Mr. Wagner responded that currently it is stand-alone. The medical staff indicated that they prefer to rebuild at Mission Bay whether stand-alone or collocation. Dr. Katz added that this arises from the medical faculty as it would give them more access to research facilities since UCSF is more likely to build additional research facilities at Mission Bay than they are at the current SFGH Campus. Commissioner Umekubo asked about land availability at Mission Bay. Mr. Wagner responded that there are 24 acres available at Mission Bay. The Department does not own the property at Mission Bay as it does at Potrero. Commissioner Parker expressed his respect for the process, noting that it takes time to consider everyone’s input, and expressed the need to keep up the pace. He noted that with partnerships, all partners’ liability increases, and the Department has a need to control its own mission and destiny. We’ve been bending over backward to make everyone happy, which it’s clear we can’t do, and we need to move forward. There is no luxury to procrastinate. With this in mind, he recommended: Rebuilding SFGH at the Potrero site Maintaining the trauma center at Potrero Establishing a helipad at Potrero Maintaining the UCSF affiliation Finalizing the design for needed facilities Developing the cost analysis and plan Presenting a very clear and confident plan regarding the chosen scenario Ultimately, the voters and Board of Supervisors will have the last voice in this. It’s important that when this goes to the Board and voters that DPH be clear about the reasons for our choice, and that they have sufficient time for review and comment. The Department also needs time to develop the bond initiative. Commissioner Sanchez thanked the staff for listening to the different voices in preparing this report. The Department needs to make a decision to move. Mission Bay consists of three different worlds: basic research, clinical research, and applied. The mission for the Department and SFGH is clear. We need to stay the course, our doors are always open, and we need to move on. Commissioner Monfredini supports the rebuild at Potrero. She indicated that she can’t imagine how the Department would afford the property at Mission Bay, and it already owns the property at Potrero. Commissioner Penn expressed two concerns: 1) Convincing people that the bond measure makes sense. DPH needs to make a strong case of why this needs to happen, 2) Feasibility of Mission Bay is next to impossible. Purchase price of the land alone makes it impossible. A fundamental issue is to what extent does DPH value the research enterprise at SFGH and keep it the same or increase it in the future. The Department wants to maintain a positive relationship with UCSF, and while that won’t change, the Department needs to be mindful of it. DPH’s mission is different from UCSF. He suggested: 1) that DPH know how many faculty are at SFGH who have laboratory space and do research, and the square footage of lab space at SFGH, and 2) what percentage of SFGH staff also have appointments at UCSF. Mr. Wagner responded that the Department can’t take for granted the passage of the bond issue. The Department needs to make a cogent case that answers all of the public’s questions. DPH needs to go through a similar process as was done with the Laguna Honda rebuild. He additionally noted that research enriches UCSF. DPH can’t ignore this, even though it’s not part of the funding currently. He does have the two pieces of information Commissioner Penn requested and can provide it. Commissioner Umekubo asked under scenario two, what happens with the Potrero site. Mr. Wagner responded that the Department could bring much of its far-flung programs to the campus. Commissioner Umekubo asked about a timetable for the final decision. Mr. Wagner responded that by October DPH needs to have a concept on which it can move forward. By July 2004, it needs to have the okay to move ahead with the bond issue. Commissioner Umekubo commended the staff for doing its due diligence. Dr. Katz responded that the process has been useful in the collocation discussions. For the EIR, it is important that more than one viable site be considered, and the Department will need to show it has done its due diligence in investigating other siting. Mission Bay represents the only available land mass with the Department’s service area. He did note, however, the challenge of running a hospital while also building a hospital at the same site. The process demands that it is not by intuition or history that we end up at that site, but that we’ve looked at a number of viable sites, and chosen the most viable. Commissioner Guy reported that Commissioner Chow relays his support in pursuing the three recommendations. Commissioner Guy also expressed her support to move in this direction. DPH needs to get out all of the questions as to these options as the timing is now getting narrower. She thanked the staff, and particularly Mr. Wagner, for leading the Department into the next decade. She added that community relations need to be strategic also. The broader Mission community also needs to be considered, not just the area around the current Potrero site. Mr. Wagner responded that there are plans to engage the wider community. Commissioner Sanchez noted the need to engage key supporters for the bond issue, including the UCSF academic faculty. Mr. Wagner responded that the SFGH Foundation will be key to making those connections. Commissioner Parker asked that given the fall timeline, will DPH need to collect more data, or is that data available, and can the Department keep on schedule. Mr. Wagner responded that the staff has components of the needed data, and needs direction from the Health Commission regarding which scenarios to develop. He indicated that staff has enough time to complete its work on time. He added that research is most key; the medical staff will support the rebuild if research stays on Campus, which is possible on the existing Potrero Campus. The August 19 Health Commission meeting will provide a preliminary update on the concepts, but is not the final decision point. Commissioner Guy thanked the staff for including the letter from UC in the Commission packets, as it helps to answer many of the public’s concerns. 8) PUBLIC COMMENTS There were no public comments. 9) ADJOURNMENT The meeting was adjourned at 5:30 pm. Jim Soos, Acting Executive Secretary to the Health Commission