Minutes of the Health Commission Meeting Tuesday, August 3, 2004 at 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The meeting was called to order by Commissioner Chow at 3:10 p.m. Present: Commissioner Edward A. Chow, M.D., President Commissioner Roma P. Guy, M.S.W. Commissioner James M. Illig Commissioner David J. Sanchez, Ph.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Lee Ann Monfredini, Vice President Commissioner Michael Penn, M.D., Ph.D. 2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF JULY 20, 2004 Action Taken: The Commission (Chow, Guy, Illig, Sanchez, Umekubo) approved the minutes of the July 20, 2004 Health Commission meeting. 3) APPROVAL OF THE CONSENT CALENDAR OF THE BUDGET COMMITTEE Commissioner Sanchez chaired, and Commissioner Guy attended, the Budget Committee meeting. (3.1) CHN-Primary Care – Request for approval of a retroactive renewal contract with Shanti Project, in the amount of $169,680, to provide LifeLines Project services that support women living with breast cancer, for the period of July 1, 2004 through June 30, 2006. (3.2) PHP-AB 75 Project – Request for approval to accept and expend retroactively a grant allocation in the amount of up to $1,694,330 from the State Department of Health Services, California Healthcare for Indigents Program, to provide reimbursement for health services delivered to indigent persons, for the term FY 2004-05. (3.3) PHP-Epidemiology – Request for approval of a retroactive renewal contract with the Regents of the University of California, in the amount of $64,264, to provide for the services of a Postdoctoral Fellow, for the period of August 1, 2004 through June 30, 2005. Secretary’s Note - At the request of the Department, this item was removed from the agenda. (3.4) PHP-STD Prevention & Control – Request for approval of a retroactive contract modification with the Regents of the University of California, in the amount of $172,875, for an extended contract term and an increased total of $270,875, to provide STD screening and counseling services at the Magnet Clinic, for the period of April 15, 2003 through December 31, 2004. Commissioner Sanchez abstained from voting on this item. (3.5) PHP-STD Prevention and Control – Request for approval of a retroactive new contract with Public Health Foundation Enterprises, Inc., in the amount of $77,914, to provide fiscal agency services for the STD Prevention and Control Section-YUTHE Program, targeting African-American youth between the ages of 12-24, for the period of January 1, 2004 through December 31, 2004. Commissioners’ Comments Commissioner Guy asked for a more detailed discussion at the Population Health and Prevention Joint Conference Committee about the YUTHE program, particularly given the recently adopted youth development policy and the fact that this is a model program. (3.6) AIDS OFFICE-Research – Request for approval of a retroactive renewal contract with PHFE Management Solutions, in the amount of $105,061, to provide fiscal administrative services for the “Post Marketing Surveillance for the OraQuick Rapid HIV-Antibody Test” project, for the period of July 1, 2004 through December 31, 2004. Commissioners’ Comments The Budget Committee accepted the offer to have the evaluation results presented to the Population Health and Prevention Joint Conference Committee in January. (3.7) AIDS OFFICE-HIV Prevention – Request for approval of a retroactive contract renewal with Westside Community Mental Health Center, Inc., in the amount of $57,651, to provide HIV prevention services targeting defined behavioral risk groups, for the period of July 1, 2004 through December 31, 2004. Commissioners’ Comments Commissioner Guy asked if the service was more difficult than anticipated to provide. Mr. Boles, Executive Director of Westside Community Mental Health, said the primary reason for low productivity was inability to keep and manage staff. Over the past six months they have addressed this program through greater integration of their service delivery, but still struggle to keep staff on board. Commissioner Sanchez said it seemed clear that personnel changes impacted productivity and it was important that the agency requested technical assistance from DPH. (3.8) AIDS OFFICE-HIV Health Services - Request for retroactive approval of the following eleven FY 2004-2005 City and County of San Francisco General Fund contracts, for a combined total of $2,301,056, for the period of July 1, 2004 through June 30, 2005 with the following agencies:     Amount with 12% Contingency Asian Pacific Islander Wellness Center  (Renewal) $  267,317 Continuum HIV Day Services  (New Award) $  346,093 Immune Enhancement Project  (New Award) $  262,606 Institute For Community Health Outreach (Renewal) $  112,000 Instituto Familiar de la Raza  (Renewal) $  138,438 Legal Services for Children  (Renewal) $  126,245 Mission Neighborhood Health Center  (Renewal) $   188,945 Positive Resource Center  (Renewal) $   156,800 Project Open Hand  (New Award) $     95,974 Quan Yin Healing Arts Center  (New Award) $   151,266 Shanti Project  (Renewal) $   455,372 Total: $2,301,056 Commissioners’ Comments Commissioner Guy asked how many agencies were not restored.  Michelle Long Dixon said she would be better able to answer this after all of the restorations have been made; it is not more than five.   Commissioner Guy asked for further information about what gaps would exist given the fact that not all the programs could be restored. Commissioner Illig abstained from voting on this item. (3.8) AIDS OFFICE-HIV Health Services - Request for retroactive approval of the following two FY 2004-2005 City and County of San Francisco General Fund UCSF-AIDS Health Project renewal contracts, for a combined total of $116,177 for the period of July 1, 2004 through June 30, 2005 as follows:   Amount Regents of the University of California, UCSF – AIDS Health Project HIV-IDU Case Management  (New Award) $70,177 Regents of the University of California, UCSF – AIDS Health Project HIV/AIDS Considering Work Project (Renewal) $46,000 Total:  $116,177 Commissioner Sanchez abstained from voting on this item. (3.10) CHPP-Health Promotion – Request for approval of a retroactive contract modification with San Francisco Study Center, Inc., in the amount of $357,505 for the period of July 1, 2004 through June 30, 2005, to provide fiscal sponsor services for the Tobacco Free Project Community Capacity Building Training Center, for a total contract value of $3,419,761, for the period of July 1, 2001 through June 30, 2005. Commissioner Guy asked that the survey results for cessation project clients be reported to the Commission. Alyonik Hrushow said she would include the results when the contract renewal for the MSA funds comes before the Budget Committee for approval. (3.11) BHS-MH – Request for approval of a retroactive contract renewal with Westside Community Mental Health Center, Inc., in the amount of $1,872,816, to provide a Single Point of Responsibility program for severely mentally ill adults, for the period of July 1, 2004 through June 30, 2004 (3.12) BHS-MH/SA – Request for approval of a retroactive contract renewal with Westside Community Mental Health Center, Inc., in the amount of $1,529,057 per year, for a total contract amount of $6,850,175, to provide mental health and substance abuse counseling and treatment services for CalWorks program participants, for the period of July 1, 2004 through June 30, 2008. (3.13) BHS-SA – Request for approval of retroactive contract renewal with Center for Juvenile and Criminal Justice, Inc., in the amount of $249,250, to provide substance abuse services targeting San Francisco male parolees over 18 years old, for the period of July 1, 2004 through June 30, 2005. Commissioners’ Comments Commissioner Guy asked for assurances that the agency is working to address the outstanding compliance issues. Dan Macallair, Executive Director of CJCJ, said he is quite pleased with the progress, but there is more to be done internally. Action Taken: The Commission (Chow, Guy, Illig, Sanchez, Umekubo) approved Items 3.1 and 3.2, and Items 3.4 through 3.13, of the Budget Committee Consent Calendar. Item 3.3 was removed from the agenda at the Department’s request. Commissioner Sanchez abstained from voting on Items 3.4 and 3.9. Commissioner Illig abstained from voting on Item 3.8. 4) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. DPH Budget The Board of Supervisors passed the City’s 2004-05 budget on July 27th. Overall, the Department’s General Fund was decreased by $22 million. The Board restored most of the proposed service reductions, including reductions to primary care, dialysis, medical interpreters, and AIDS services. The Board also included funding to offset the losses sustained as a result of decreased funding from the Ryan White CARE Act. DEAP reductions were partially restored and the Board of Supervisors is considering legislation to restore the remainder of the program. Administrative reductions, including the layoffs of the health center directors, were not restored. State Budget On Saturday, July 31st, Governor Schwarzenegger signed the 2004-05 State budget. The final budget for health services contains very few of the reductions in health services that the Governor proposed in January. The most notable January proposals that were rejected in the final budget are Medi-Cal provider rate reductions, reductions in federally qualified health center reimbursement, and enrollment caps for several health programs, including Healthy Families, Medi-Cal for immigrants, the AIDS Drug Assistance Program and the California Children’s Services program. The final budget did, however, eliminate funding to local mental health programs for the Children’s System of Care (CSOC) Program. Though the Legislature had restored funding for this program in the budget it submitted to the Governor, the Governor used his line item veto authority to eliminate this funding. The Department estimates that the final budget will result in a loss of approximately $500,000 (attributable to the elimination of the CSOC program), substantially less than the $5.3 million in estimated losses the Governor’s January budget would have produced. Other State News The Schwarzenegger Administration has decided to delay release of their Medi-Cal Reform proposal, originally scheduled to be released August 2nd, until January 2005. The State had originally undertaken a process to redesign Medi-Cal in order to contain costs and enact operational efficiencies. However, these issues are large and complex and are taking longer to work through than the State had originally anticipated. Among the issues that are most troublesome is hospital refinancing. Because the federal government is trying to reduce states’ reliance on intergovernmental transfers (the mechanism that funds California’s disproportionate share hospital (DSH) program and the SB 1255 supplemental payment program), the State is looking to devise an alternative payment structure for the State’s safety net hospitals that will maintain existing levels of funding. The recommendations of the California Performance Review (CPR) were formally presented to the Governor today. The 2,500-page plan proposes to consolidate 11 agencies and 79 departments into 11 departments and cut growth in state employment by 12,000 positions by 2010 while eliminating 118 boards and commissions to save an estimated $32 billion over the next five years. Several legislators and analysts have expressed concern about the CPR plan, stating that it contains several restructuring proposals that are unrealistic or have already been rejected by the Legislature. Dr. Katz will be reviewing the health-related recommendations and will provide the Commission with a summary in a future report. Sister City Program with Curitiba, Brazil San Francisco has been selected by the Centers for Disease Control and Prevention and the National Association of State and Territorial AIDS Directors as a Sister City to Curitiba, Brazil in the fight against the spread of HIV/AIDS. These agencies are sponsoring five state-to-state or city-to-city partnerships between the two countries to foster improvement in the monitoring and evaluation of HIV prevention programs through shared and complementary experiences and expertise. The U.S. jurisdictions selected are the States of New York, Massachusetts and Louisiana and the cities of San Francisco, California and Laredo, Texas. San Francisco will host a visiting delegation of Brazilian AIDS directors, along with national and local monitoring and evaluation specialists from August 16th through August 18th. Later in the year, a San Francisco delegation will visit Curitiba. This honor continues to reinforce San Francisco as a City of Excellence in AIDS prevention and research. CBHS SOC Trainings Community Behavioral Health Services System of Care Training Committee has two upcoming trainings for health care professionals. “What Every Substance Abuse Counselor (and Mental Health Clinician) Needs to Know to Treat Co-Occurring Disorders: Dilemmas in Diagnosis, Denial and Documentation” on Thursday August 19, 2004 and “Completing the Yellow Brick Road: Creating Transgender Appropriate Services in Your Agency, Program, or Practice” on Friday September 24. Both trainings are being presented at the Hiram Johnson State Building. For more information contact Junko Craft at 255-3620. Black Nurses Association The National Black Nurses Association, representing 150,000 African American nurses from the US, Eastern Caribbean and Africa, is hosting its Annual Institute and Conference here in San Francisco beginning August 4th through August 8th. The theme of the Conference is "Evidence Based Research for Successful Aging." As a preview to the Conference, the Black Nurses Association sponsored a free "Healthy Aging” health fair today at the Bayview Hunters Point Adult Day Health Center. The Health Commissioners join Dr. Katz in congratulating members of San Francisco's Black Nurses Association and wish them success in this week's conference. Commissioners’ Comments Commissioner Umekubo said that Dr. Katz’s story underscores the fact that the medical model is reactive and does not recognize prevention. Commissioner Guy said it is clear that the public supports public health funding, yet every year the DPH budget is cut and then restored. She urged the Commission and the Department to suggest to the Mayor and Board of Supervisors a different way of doing things than every year removing then reinstating the same items. Dr. Katz said that the fact that the Department has to propose program cuts that then are reinstated has a negative impact, and if there were another approach, he would welcome it. Commissioner Illig asked that the final budget restorations be presented to the Commission in the same format at the proposed budget, so that people can clearly see which of the recommendations were adopted. Commissioner Chow said SFGH has the opportunity as a teaching institution to discuss the broader issues of health and support this through the training curriculum. Commissioner Chow asked Dr. Katz to comment on the reports that the Fire Department is considering changes to EMS services. Dr. Katz said the Fire Department convened a group of stakeholders that developed a report with a variety of alternatives, from infusing funds to hiring additional paramedics to privatizing ambulance services. Dr. Katz has met with the Fire Chief and the options will be costed out, and the information brought to the Health and Fire Commissions. This will happen in the next 90 days. It is likely that there will be changes. Any change in the system from its current configuration must be approved by the Health Commission. Commissioner Guy is please that the paramedics issue will be addressed promptly. It is critical that the Department has all the costs. 5) FISCAL YEAR 2003-2004 FOURTH QUARTER FINANCIAL UPDATE Gregg Sass, DPH Chief Financial Officer, presented the FY 2003-2004 4th Quarter Financial Report. Projections are based on revenue collected and billed, and expenses incurred for the twelve months of the fiscal year ending June 30, 2004. The Department is forecasting a larger than expected surplus for the fiscal year, which is primarily the result of favorable revenues at SFGH and LHH. Surplus revenues have enabled the Department to accommodate cuts in the General Fund and at the same time avoid deep cuts in services to patients. The following table summarizes financial results for the year: Mr. Sass described some of the highlights of the report. The year-end deficit for Jail Health Services is less than expected. An audit of the Proposition 36 program resulted in unexpected adjustments. The State auditors have proposed disallowing $3.9 million in start-up costs incurred in the first two years of the program. The Department will appeal. Commissioners’ Comments Commissioner Illig asked if grants are included in this financial report. Mr. Sass said that grants are administered separately and are not included in this presentation. He will schedule a separate presentation on the grants process. Commissioner Illig asked if the Department could continue to depend on these additional revenues every year. Mr. Sass said that most elements of reimbursement are fixed and prospective, so that limits these kinds of unexpected settlements. At the same time there is still a tendency on the part of finance staff to be conservative, so this has a general tendency to result in good budget news. He reminded the Commission that next year’s budget fixed many structural problems, which will minimize the need to depend on addition revenues to cover costs. Commissioner Illig is concerned that so much money was used to buy capacity for the Proposition 36 program. Dr. Katz said that the program was developed rapidly in response to the State timeline, and it could have been done better. Mr. Sass added that Proposition 36 contracts are now fee-for-service. Commissioner Guy is pleased to see the revenue collection data. It is important that the public knows that the Department aggressively collects money. 6) PRESENTATION OF THE HEALTHY KIDS, HEALTHY FAMILIES AND MEDI-CAL FOR CHILDREN UPDATE Jim Soos, Senior Health Planner, Frances Culp, Senior Health Planner, Office of Policy and Planning, and Jean Frasier, CEO of San Francisco Health Plan (SFHP), presented an overview of San Francisco’s health coverage programs for children, youth and youth adults. There are three programs: Medi-Cal for children to age 21, Healthy Families to age 19 and Healthy Kids to age 19. Between these three programs, comprehensive medical, dental and vision care is provided to children and youth whose family earns up to 300% of the federal poverty level, regardless of immigration status. Medi-Cal and Healthy Families are funded by a State/Federal match. Healthy Kids is exclusive to San Francisco and funded through the General Fund and First 5 San Francisco. Healthy Kids will cost San Francisco $7.8 million this year. Ms. Culp provided data on program enrollment, by race and ethnicity, neighborhood, health plan and medical group. Ms. Frasier presented utilization data based on HEDIS measures. Utilization is good in all SFHP programs, but rates for well-child and well-adolescent visits could improve. Ms. Frasier described some of SFHP’s efforts to improve preventive care. They have established a well-child incentive program to improve well-check rates for 3-6 year olds that includes a gift certificate to Toys R Us. They have a similar program targeted toward 12-21 year olds, with free movie passes as the incentive. They also have an Immunization Incentive Program and Prenatal Incentive Program. Ms. Frasier also presented member satisfaction survey data. Mr. Soos described the Next Steps: Participate in Medi-Cal Redesign Get AB 495 federal money for Healthy Kids Evaluate premium changes in Healthy Kids and Healthy Families Continue to work on parental coverage Extend Healthy Kids to 19-24 year olds Commissioners’ Comments Commissioner Chow asked if there is a potential for Medi-Cal to cover people over 21 years of age. Ms. Frasier said there is no Medi-Cal benefit between the ages of 21 and 65 unless a person falls into one of the qualifying categories, i.e. blind, disabled, parent of a minor. Mr. Soos clarified that the intent of the program is to only use local funds to provide coverage if other sources of coverage are unavailable. Commissioner Illig is impressed by the scope of coverage San Francisco provides. He asked how other counties deal with undocumented youth. Mr. Soos replied that some counties, such as Santa Clara, Alameda and San Mateo, cover undocumented individuals. Other counties do not provide coverage through Healthy Kids. Commissioner Sanchez said it is very critical to cover people up to the age of 24. This is a very vulnerable time. He would like to see data over time to see how successfully the Department and the Health Plan enroll this group of people. Commissioner Guy wants the Commission to support the elements of Medi-Cal redesign that the Department is advocating for. With regard to the outreach funds, she asked if the reduction in funding would adversely affect the program. Ms. Frasier said it should not adversely affect their efforts. Commissioner Umekubo asked if the application process has been streamlined, and if so has this resulted in increased enrollment. Ms. Culp said that Medi-Cal and Healthy Families ask for a lot of supporting documentation that is not submitted, and this is one reason why applications are deemed incomplete and denied. The CAAs help people through this process. Commissioner Chow complemented DPH staff and SFHP staff for making huge strides toward universal healthcare for children. He thanked Ms. Frasier for developing a simplified client satisfaction survey. 7) REVIEW OF THE DEPARTMENT OF PUBLIC HEALTH’S DRAFT STATEMENT OF INCOMPATIBLE ACTIVITIES AND APPROVAL OF SUBMISSION TO THE ETHICS COMMISSION With the agreement of the Commission, this item was deferred to a future meeting so that the Commissioners could provide their comments to the Health Commission Executive Secretary. 8) PUBLIC COMMENT None. 9) CLOSED SESSION: A) Public comments on all matters pertaining to the closed session None. B) Vote on whether to hold a closed session (San Francisco Administrative Code Section 67.11) Action Taken: The Commission (Chow, Guy, Illig, Sanchez, Umekubo) voted to hold a closed session. The Commission went into closed session at 5:40 p.m. Present in closed session were Commissioners Guy, Chow, Illig, Sanchez and Umekubo; Mitch Katz, M.D., Director of Health, (left at 5:50 p.m.), Karen Kirby, Deputy City Attorney; Jonathan Lee, Deputy City Attorney; Joanne Hoeper, Deputy City Attorney; Aleeta Van Runkle, Deputy City Attorney and Michele Olson, Health Commission Executive Secretary. C) Closed session pursuant to Government Code Section 54956.9 and San Francisco Administrative Code Section 67.10(d) D) Reconvene in Open Session The Commission reconvened in open session at 6:20 p.m. Possible report on action taken in closed session (Government Code Section 54957.1(a)2 and San Francisco Administrative Code Section 67.12(b)(2).) Vote to elect whether to disclose any or all discussions held in closed session (San Francisco Administrative Code Section 67.12(a).) Action Taken: The Commission (Chow, Guy, Illig, Sanchez, Umekubo) voted not to disclose any or all discussions held in closed session. 10) ADJOURNMENT The meeting was adjourned at 6:20 p.m. Michele M. Olson, Executive Secretary to the Health Commission