San Francisco Health Service Board retains Blue Shield SHIELD 65+ plan after narrow, contested votes

The Health Service Board for the City and County of San Francisco voted to keep Blue Shield's SHIELD 65+ Medicare Advantage prescription drug plan and the Blue Shield Access Plus coordination-of-benefits program for the 2016 plan year after extended discussion, public comment and a series of closely split votes. The board debated whether to adopt Blue Shield's newly offered national supplement-to-Medicare PPO, which Blue Shield said would provide a national provider network but would remove delegated clinical management and some ancillary benefits such as the SilverSneakers gym discount.

The board heard a detailed presentation from Paul Brown, area vice president for account management at Blue Shield, who described the national PPO as a single, national supplement-to-Medicare PPO with prescription drug coverage and broader provider access than the current SHIELD 65+ offerings. Aon Hewitt actuaries explained the pricing dynamic: because Medicare is primary and prescription drug programs (EGGWIP) have changed the cost structure, a PPO designed as a Medicare coordination plan can be priced competitively with a Medicare Advantage plan in 2016.

Board members raised three recurring concerns: the loss of delegated clinical management and medical-group case management under a PPO, the risk that utilization could increase without those management tools (affecting future rates), and the practical impact on retirees whose primary care physicians might not be in the PPO network. Blue Shield presented a network-overlap analysis showing roughly 1.9% of retirees would have their primary care physician outside the PPO network; Blue Shield said it could attempt to recruit those providers or offer out-of-network reimbursement with a $500 deductible and subsequent 90% coverage.

More than a half-dozen public speakers urged the board to preserve delegated care coordination. Stephanie Mamann, vice president of contracting for Brown & Toland Physicians Medical Group, said her group serves more than 3,800 City and County Medicare-eligible retirees in SHIELD 65+ and emphasized that delegated care coordinators, nurses and social workers reduce hospitalizations and improve outcomes. Physician Fiona Wilson and other retirees warned that losing local care management could harm complex seniors despite apparent near-term savings.

The board first considered a motion to retain the existing Blue Shield plan; that motion failed on a split voice vote. A subsequent motion to adopt the national PPO also failed to achieve a majority. After a recess and a motion to reconsider, the board re-voted and ultimately adopted the motion to retain the Blue Shield SHIELD 65+ MAPD and Access Plus COB for 2016; the meeting record shows confusion in vocal roll calls that was clarified on the floor before the chair declared the item passed.

The board and staff noted the need to monitor any plan chosen for changes in utilization and future rates and to consider negotiating plan features (such as SilverSneakers or case-management-like services) in future cycles. Blue Shield representatives said they would consider packaging some features differently in subsequent negotiations.

The board's decision preserves the current delegated care model for the majority of retirees while leaving alternative national PPO choices available from other carriers that the board also considered during the meeting. Next procedural steps include posting the adopted rate cards and plan materials to the HSS website and meeting the Board of Supervisors' deadline for rates and contributions for open enrollment.