Health Care Revolution
Price of Paradise · Hawaii Public Radio · aired 1998-07-12
Guests: Fred Fortin (Hawaii Medical Service Association (HMSA)); Ken Kipnis (Professor of Philosophy and medical ethicist, University of Hawaii); Fred Holschuh (emergency room physician)
Duration: 1:08:58

[00:00:01] Randall Roth: Aloha, this is Randy Roth, host of the Price of Paradise show. We are broadcast live, Sunday mornings on KHPR and KKUA and then rebroadcast Sunday evenings, beginning at 8 o'clock on KIFO. Everyone who works to bring this program to you is a volunteer, who believes in the importance of lively and informed public dialogue. We believe the brightness of any community's future is directly related to the level of activity in its marketplace of ideas. Our sponsor is the Hawaii Community Foundation. People new to Hawaii might not realize that it's one of the oldest and largest such organizations in the country.

[00:00:36] Randall Roth: It's been earning the people of Hawaii's trust for more than 80 years, and in the last 10 years alone, has distributed nearly $80 million in support of local charitable causes in the areas of education, health, human services, culture and the arts, and community development. Our topic today is healthcare and especially changes in the area of healthcare. One of our guests is Ken Kipnis, who is a University of Hawaii Professor of Philosophy. He serves on a number of hospital ethics committees and, in fact, teaches medical ethics. Ken, could you real quickly give us some sense for what this conversation is is all about? Why we're here today?

[00:01:17] Ken Kipnis: In a in a nutshell, Randy, medicine has gone, doctors have gone from, in general, being independent professionals paid by patients or by third-party insurers to becoming something more and more like an employee of a managed care organization, often with a business orientation. The shift has gone from virtually an exclusive focus on quality, often at the expense of of costs considerations to a concern with cost containment and economy. And physicians have lost a fair amount of power and clout in in managing the healthcare system as they've become employees. I mean you you have a new set of obligations emerging to the managed care organization, to stockholders, to the patient population as a whole, and that's new.

[00:02:07] Ken Kipnis: I think that many physicians are professionally bewildered by this huge shift in the way in which medical care is delivered in the United States.

[00:02:17] Randall Roth: Why is it happening now?

[00:02:19] Ken Kipnis: Well, I think 10 years ago there was an enormous amount of concern about skyrocketing costs of healthcare and the absence of incentives [unintelligible — audio glitch] control waste and abuse in the system. Now, managed care organizations charge fixed premiums to their members, their costs are fixed, but they work within fixed budget systems and the emphasis has been to to eliminate unnecessary care to somehow reduce the cost of delivering healthcare. And consumers have concerns about price as well. The difficulty right now is to maintain a balance between quality healthcare, which medicine has traditionally supported, and economy, cost containment.

[00:03:09] Ken Kipnis: We want quality care and we want it at a reasonable price, and those two values are at war with one another.

[00:03:14] Randall Roth: And I know you mentioned something about healthcare in the United States, is Hawaii just like what's going on elsewhere? And I know you could write a book on this, but real quickly, is Hawaii somehow different, if we focus just on these changes in Hawaii, is there something unique to the situation that perhaps we should put on the table early in our conversation?

[00:03:34] Ken Kipnis: Well, Fred Forten might be able to talk more knowledgeably about that than I would, but I guess my sense is that we've been in the managed we've been comfortable with managed care organizations for a lot longer than most of the mainland. But these new business style organizations are popping up like mushrooms after after a rain all over the mainland and some of them are starting to come out here looking at Hawaii. So we may see some of the same mainland-based managed care businesses popping up here in significant numbers.

[00:04:04] Randall Roth: So maybe over the last few years, the change we've seen in Hawaii isn't quite as dramatic as the change that others are seen in other states.

[00:04:10] Ken Kipnis: I think that's correct.

[00:04:11] Randall Roth: Okay. Our next guest is Fred Holshoe. Fred has been a Hilo Medical Center ER doctor, emergency room doctor for about 30 years. This year he's the Hawaii Medical Association Physician of the Year. Fred, good morning. Fred Holshoe, are you there?

[00:04:29] Fred Holschuh: I am, good morning to all of you.

[00:04:31] Randall Roth: Good morning Fred. And I might also add, uh Fred has decided to uh to see if he can make a change on a political level. He's running for office this year. Fred uh, what what office is it you're running for?

[00:04:44] Fred Holschuh: I'm running for the state Senate seat from the first district on the Big Island, Randy. Thank you.

[00:04:48] Randall Roth: Okay, well I'll ask you a little more about that later. But um, you just heard Ken Kipnis, our ethics professor set the stage and part of what he indicated is that there's a lot of change that's directly affecting physicians. Uh that physicians are somehow losing some power and and are facing some some conflicts of sorts that they didn't used to to face. I read your article along with Fred Forten and Ken Kipnis's articles in this morning's advertiser on page B3.

[00:05:18] Randall Roth: And I know uh on behalf of your fellow physicians, you're you're feeling some of uh these changes, can you real quickly give our listeners some sense for how you in particular, but physicians in general, are looking at these changes?

[00:05:32] Fred Holschuh: Sure. Thank you, Randy. I've been an emergency physician as you said for uh nearly 30 years in Hawaii, and there's no doubt that we needed to do something nationally in our state to control these spiraling healthcare costs. But one of the tremendous concerns that physicians have now, I I'll list six of them actually that I kind of made notes about. First and foremost, the pendulum, as Ken suggested, has swung so far in the direction of managed care, especially on the mainland, that we are now denying necessary care to patients. And we these are not just covered lives, but these are real people with real illnesses.

[00:06:10] Fred Holschuh: You know, this mentality of for-profit not for the patient business bottom line mentality. The second point, we're squeezing physician reimbursement, no question about that. Uh we're deselecting physicians from plans. There's a tremendous amount of pre-authorization and documentation paperwork that's driving doctors crazy and taking away from delivery of care. And mainland uh, particularly in mainland managed care organizations, patients are being separated from many, many year relationships with doctors by contract decision-making by employer groups where they just suddenly take patients and move them to another set of physicians.

[00:06:51] Fred Holschuh: And then finally, I think all of this leads to the potential for more malpractice lawsuits because as patients feel disempowered to do decision-making in conjunction with their physicians, they're they're unhappy and if there are adverse outcomes, there's going to be much more litigation.

[00:07:08] Randall Roth: Hm. Would you say generally that that physicians at this point in how would you describe, using an adjective or two or three or four, how would you describe the way physicians are feeling about these six change six areas of change and other changes as well?

[00:07:23] Fred Holschuh: Well, I think it varies from kind of uh uh beaten into submission to outrage, and I uh I know that you've been in discussion with Arlene Myers I believe last week and and she and others have said, hey, we're not going we're drawing a line in the sand. I think the American Medical Association and the Hawaii Medical Association are drawing a line in the sand and saying, you know, something, we've been pushed too far, and on behalf of our greatest allies, the the people who are our patients, who are the people who need this care, we're not going to be pushed any farther.

[00:07:58] Fred Holschuh: And and the one thing I would like to say, I think in Hawaii, as Ken suggested, number one, we've had through our major insurance plans and our major third party payers, we've had kind of a managed care approach going back many, many years, uh to the plantation days and so forth. And the other thing is that I think we have good communication here and I there's a lot of doctors that will be listening to this and saying, hey, that guy's crazy. What is he saying that for? Truth is, I think we have good communication among our physicians and our third party payers and that's what we need to keep going.

[00:08:31] Fred Holschuh: We need to keep staying at the table and working this out. Bottom line is what's best for the patient will be best for everything.

[00:08:38] Randall Roth: Fred, I I think you've just answered my my next question, but I'm going to ask it anyway. When you say we've got to draw a line in the sand and we're outraged, um who are you talking to? Are you talking to the patients saying they should quit demanding, you know, more than what uh limited resources can provide? Are you saying to the government, are you say who are you talking to? And I think I know, uh who's this conversation with, when you're saying, we're mad as hell, we're not going to take it anymore, we're drawing a line in the sand. Who are you really talking to?

[00:09:09] Fred Holschuh: Well, if I could answer that with an example, I've been on the Quest provider advisory board since its inception back in 1994. And there's a good example of where we are saying, hey, wait a minute, um, plans, healthcare plans, uh government, you can't deny services to patients any longer. And in the long run, it's cost ineffective if we don't do good preventative care and take good care of people up front, we pay for it big time in the end. And so I think we're talking to everybody and mainly we're talking to the patient saying, we're your allies in this.

[00:09:44] Fred Holschuh: We don't I think Ken made a good point that we don't want to be placed in an adversarial relationship with our patients, where the physicians as employees of large managed care organizations are having to withhold necessary care for fiscal reason. Okay. We have to we have to stand up for the rights of the patient.

[00:10:03] Randall Roth: Thank you much. That's Fred Holshoe, who's uh in Hilo right now and has been an ER doctor at Hilo Medical Center for about 30 years. Our third guest uh with me here in the studio is Fred Forten, who's with HMSA. He's a vice president in charge of community relations. He has a PhD from the University of Hawaii in Health Politics, and formerly was on the faculty of the University of Hawaii Medical School. Fred Forten, good morning.

[00:10:29] Fred Fortin: Good morning.

[00:10:30] Randall Roth: You know what I thought Fred Holshoe was going to say, is it it's that health plan, that insurance company, that third party payer, if you will. I thought he was going to say, it's Fred Holshoe. I have no idea. It's Fred Forten. We're already confused. Um Fred Forten, for HMSA, what's your perspective on all of this?

[00:10:51] Fred Fortin: Well, I think that uh health plans are on the hot seat. They're in the middle of a very dynamic uh political situation where you have consumers who are demanding high quality, uh high level of service, broad benefits. You have payers who are struggling with these enormous costs of the system. You have doctors who are feeling the impact of the decision that health plans and government makes, trying to balance these things. And uh it is a very uh powerful political dynamic that is going on right now, that uh is in a sense still in play. Health plans are evolving, the relationship between physicians and health plans are evolving.

[00:11:35] Fred Fortin: And the new, I think what's different between now and 10 years ago when managed care came to the fore, is that there is a renewed emphasis on the the quality aspects of care and how quality care now fits into the cost spectrum. But costs are important. Uh if we had a person here who represented a small business, or if we had a person here who was responsible for the payroll of a large uh hotel or something, they would tell you about the enormous costs that this uh in uh that healthcare involves. But we are getting to a point where I think um everyone's drawing a line in the sand.

[00:12:12] Fred Fortin: And this is what is uh making the process uh both uh uh difficult and interesting at the same time. A government, while it is uh while it is pursuing uh regulating health plans and consumer rights and that sort of thing, is uh promoting uh what I would call the HMO HMO-ification of everything. That is uh regulations and policies that force health plans and all others to get into an HMO framework. As you know, HMSA has both uh um uh free choice plans and HMOs, but the types of regulations that are coming down now are forcing plans to um um act like HMOs even if they would rather offer other products.

[00:12:54] Randall Roth: So in a way, where Fred Holshoe says the physicians feel like they're being beaten into submission and they're having a lot of power and decision-making ripped away from them, the insurance companies you're telling me kind of feel the same way.

[00:13:07] Fred Fortin: Well, I think from the point of view of the demands that they are uh confronted with every day, a lot of the decisions that they have to make are ones in which we mediate the demands of patients and consumers, [unintelligible — audio glitch] needs of doctors, the rules of government and the limitations of payers.

[00:13:25] Randall Roth: And you're not deciding your own role, somehow or another there are forces beyond you that are dictating what your role has to be?

[00:13:32] Fred Fortin: Well, I think to a great extent, that is true, especially for private health plans, you have reams and reams of government regulations for one thing uh that dictate the conduct of plans, the nature of our uh benefits, uh grievances, and that whole thing. You have a very active state legislature and a very active Congress right now, um that is [unintelligible — audio glitch] producing at full tilt more and more of these regulations. So, from the health plan, from the private health plan's point of view, I think it's not unfair to say that health plans are are feeling besieged at this point.

[00:14:05] Fred Fortin: They have a very important role, and especially I think it's true, and I'm glad both Ken and uh Fred Holshoe recognize this that Hawaii is different. I think you have uh a couple of major health plans here who are really uh trying to build uh community coalitions in which we can reach some sort of consensus about uh how the quality costs uh um issues should be addressed. And I think it is different from California and is different from other parts of the United States.

[00:14:34] Randall Roth: Let me ask you a question about that, because when Fred Holshoe was talking about good communication in Hawaii, I suspect part of that is that you really have two major players I think in Hawaii to communicate with: HMSA and Kaiser. And when I talk to some physicians preparing for this show and the show we did last week, I get from some of them at least a very different spin on that. They feel as though there's something wrong, something bad about the fact that Kaiser and HMSA have so much control, so much size, so much power.

[00:15:08] Randall Roth: And I almost get the image that that they feel at least that HMSA in particular has the physicians around the collective throat, uh how do you feel about that?

[00:15:17] Fred Fortin: Well, I don't think it's true. It's always interesting to hear that when in fact, the health plan itself seems like it's it's battered from uh uh from all sides here. But um, it is sort of ironic uh in other markets across the United States where you have small, fragmented plans in a in a community and in which or state uh in which there are many different plans that only have a very small percentage of the market. Uh there are many, many problems on the the increasing uh cost of care, the fragmentation of the delivery of care.

[00:15:52] Fred Fortin: And it is certainly ironic, but it is true, when you have larger institutional entities out there, trying to make decisions, the decisions are often uh more fair, uh they take the broader community picture in mind, rather than their own immediate financial interest. Now, HMSA has been here since 1938. It is a local plan, it's non-profit, um and we are obviously uh concerned about the large picture. When we think about our policies in healthcare, we're thinking about what benefits Hawaii generally speaking, not necessarily what benefits us in the short-term.

[00:16:26] Randall Roth: So when the Wall Street Journal writes its article not long ago talking about the struggle over the soul of medicine and and a picture is uh MDs on one side and MBAs on the other side and the MBAs are ripping power away from the MDs, at least in Hawaii, you feel that that's that's really not what's going on, at least not yet.

[00:16:44] Fred Fortin: Well, I think you see it on the edges of course, and there's always tension, and that tension is never going to be resolved and and put aside. It is just inherent in the politics of healthcare, because you have payers and you have receivers, uh that will always be there. It's how do we manage that in a way that ensures the quality of care. Uh health plan Hawaii, which is an HMSA HMO just received the NCQA uh recognition, a full accreditation for its uh quality programs. When you have organizations like that, that accredit these programs for quality of care, then somehow we can all talk in the same frame.

[00:17:24] Fred Fortin: When we talk about quality, we can all talk in the same frame. When we talk about cost, and who pays, that's when things start to go a little skew.

[00:17:32] Randall Roth: Okay. Uh Ken Kipnis, you started us out on this conversation, some additional thoughts and then we're going to invite our listeners to call in.

[00:17:38] Ken Kipnis: Yeah, I think that going back to a point that uh Fred Holshoe made early on. I mean the critical question and I suspect this is one that the Fred Forten would agree would agree with, the critical concern is whether medically indicated care is being turned down by MBAs. Whether whether the business aspects of healthcare delivery are in fact, overwhelming uh the physicians and patients concerned about quality care.

[00:18:05] Ken Kipnis: Um now, I suspect that in markets where you have weak players and players that are trying to stay alive, okay, you're going to see the value check phenomenon um that is to say cuts in cuts in quality that may turn out [unintelligible — audio glitch] be terrible for patients. Catastrophic for everyone. Um, but the concern that these two values are in conflict and the concern that that maybe this is happening now, although I'm not in a position to speak to it, I think that's the central area.

[00:18:35] Ken Kipnis: And I think that both Fred Forten and Fred Holshoe are in agreement about that being the that being the the key question that the public has to be keeping an eye on. We can't wait around for a disaster. It seems to me that the issue of what's going to count as quality care and what's going to count as unnecessary care is is really one that can't be left, in my opinion, to the MBAs or the doctors. It really needs to be a community decision. It really needs to be a community debate.

[00:19:00] Randall Roth: It sounds like it's really going to be solved, if you will, on on a political level.

[00:19:04] Ken Kipnis: And that if a lot of people aren't aware of what's going on and don't take an interest in what's going on, there may be some sort of back room solution, if you will, that maybe isn't in the best interests of the people.

[00:19:15] Randall Roth: Viagra is really a great example of this. I mean, whether that's I was wondering when that working. Yeah.

[00:19:19] Ken Kipnis: I mean that that's that's the hot issue right now, whether this is going to be covered, okay, or whether it's not going to be covered, whether male impotence is going to be a medically treatable problem like any other or whether we're going to set it aside.

[00:19:31] Randall Roth: Okay. You're listening to the Price of Paradise radio show. My name is Randy Roth. We're talking about changes in the healthcare delivery system, especially here in Hawaii. My guests in the studio are Ken Kipnis, who is the University of Hawaii professor of philosophy. He serves on a number of hospital ethics committees and he teaches medical ethics. By phone we have Fred Holshoe, who's been an emergency room doctor at Hilo Medical Center for about 30 years. This year he's the Hawaii Medical Association's physician of the year, and then also with me in the studio is Fred Forton, who is with HMSA. He's in charge of community relations. He has a PhD from the University of Hawaii in health politics and has taught at the University of Hawaii medical school. If you'd like to ask a question or make a comment, now's the time. Our number is 955-8821. Or if you're on a neighbor island, the number is 1-800-955-8821. Again, our topic is changes in the healthcare delivery system. The number is 955-8821. Fred Holshoe in Hilo, you've been listening to the other guests for some time. Why don't you give us a quick reaction to what you've been hearing and then we'll go to some callers?

[00:20:49] Fred Holschuh: Oh thanks, Randy. I'm actually in Honokaa, in the middle of a big rainstorm today, Randy, but thanks. The, uh you know, I I have to agree with both of the things that were said and I I don't want to sound like I'm just capitulating because it's easier, but the truth is the pendulum, my dad always taught me pendulums in life swing back and forth, and we're probably going to going to center somewhere in between all of this, uh, perceived chaos and real chaos, and if we center it, I I think if we center it on the needs of the patient, number one, then all the rest of it will evolve. And I I uh disagree slightly with Fred Forton about uh when he said he doesn't think that the plans have a tremendous amount of power. I think in fact, uh, HMSA in particular and and our other plans here do have a lot of power and clout. The flip side of that is, I think we have a very good working relationship from the physician leadership level with these plans, and the Quest provider advisory board is a good example where we meet with all six or seven plans, uh dealing with Quest patients, and when we have problems that involve either physician uh hassle factors or reimbursement, or, uh more importantly, patient problems where patients aren't getting served, we bring them there and discuss them in an in a in a forum that gets things done, and I think that communication is what's going to save us here from the problems, you know.

[00:22:12] Randall Roth: Okay. Great. Uh, we've got some people on the line, we've got a couple of open lines yet. So if you'd like to get in line, to ask a question or make a comment, the number is 955-8821. First, we go to Nancy on the Big Island. Good morning, Nancy.

[00:22:25] Nancy: Good morning, Randy.

[00:22:27] Randall Roth: You're on the air.

[00:22:28] Nancy: Thank you. Um I I think this thing about the needs of the patient has been totally misunderstood so far. I think most patients, I shouldn't say most, but many many of us, um would be patients, aren't simply because, uh, we don't, uh, trust any of it. It's too big. I think that's the biggest problem of it. It's too big. That they haven't geared it in the proper fashion so that the patient can get in on a, a local, personal, self-chosen level, deal with a with a situation they think they've got to present and then be able to keep control of the process for their own benefit all the way through, both financially and medically.

[00:23:08] Randall Roth: Nancy, stay on the line. I want to give you a chance to, to get the last word on this, but Ken Kipnis, I think has a reaction.

[00:23:14] Ken Kipnis: Yeah, I mean the issue of control is really central here. Um, on the one and the distinction has to be drawn between medically indicated care and care that's not medically indicated. Some things that patient wants, what patients want, antibiotics, for example, for colds, they may be absolutely clear that they want that sort of thing. But any physician will know that that's not appropriate in most cases, and and we we want our healthcare delivery institutions not to be wasteful. So, uh patient control is a double edged sword. On the one hand, it'll make patients happier. It won't necessarily make them any healthier. Um, Fred Forton.

[00:23:54] Fred Fortin: Right. Um, I think this issue of control is really important. From the health plan point of view, uh we, when we look at Hawaii, we see Hawaii as losing control of its healthcare. Uh both for two major reasons: one, the increasing, uh, involvement of Washington and the Congress in healthcare as to what benefits are offered and how you do it, and and all of the regulations that are coming out, so that decisions that were previously made by in Hawaii about where resources should go and how they should be delivered. Now, it's moving more and more to Washington. And secondly, we see the coming of the invasion of the national conglomerates into um Hawaii in which decisions are not being made on a a local board basis or anything like that or they don't have Hawaii as an entire community um um as a in the health of that community as their objective. So I think um, the the caller is talking about loss of control at the at the most immediate delivery uh level and I'm saying, well, that that may be a legitimate feeling but it goes right up the line so that, uh, on all levels we're feeling as though decisions are not, uh, all decisions are not going to be made at the local level. Nancy, we'll give you the last word on this one.

[00:25:08] Nancy: Okay, thank you. First of all to um the first, I'm sorry, I forgot names. Um, I don't think happiness and healthy health are uh exclusive at all. I don't I don't think you can be healthy and not happy. So and the the antibiotic thing is a sort of lowest common denominator, a red herring that gets thrown in all the time. There's nothing I said about being unrealistic. I said the patient needs to have enough control for the patient to be able to feel like they're not being swept away into into a system they can't back out of or any anything else where they're not given any any judgment or any uh sense of understanding about what's going on and where it's all paperwork and money and it hasn't got that much to do with what they really understand themselves to need in any way. Okay. Now I don't I don't think either of them addressed the idea of putting healthcare on a tier system so that they uh such as nurse practitioners at a lower level for people to just walk in the office, um so the healthcare can be managed in a in a on a human scale per individual the way it happens to present because that's the only way it presents. Okay. Nancy, we're going to have to I don't think it should be so competitive. I think that's what we're really seeing here is a competition for dollars. A big squeeze by competition through their overpopulation so forth.

[00:26:25] Randall Roth: We're going to have to move on. Nancy, I really appreciate your call this morning. Thank you very much, Randy.

[00:26:29] Fred Holschuh: You bet. We go to John from Kailua. Good morning, John.

[00:26:32] John: Hi, good morning.

[00:26:34] Randall Roth: You're on the air.

[00:26:35] John: Thank you. I'd like to ask the uh panelists that you just comment on some observations I've made over the years. Uh, I've been actually a provider of healthcare for many years on the windward side. And uh as I as I see it, there are three main players here and I and I noticed you have them all represented. There's the patient and then the providers and the payers. And how do we align the incentives so everyone feels like they've gotten something out of this? You know, patients want everything at whatever it costs. I mean, there's some expectation that with all the medicine offers, we're entitled to everything it has. The providers, of course, I think are looking at trying to provide that type of care as best possible to their patients with their interests in mind and at the same time make a decent living, and some people want to make more than others, I'm sure. And then the payers, of course, are looking at bottom line costs. How do we get value out of the system? How do we align the incentives so everyone feels they've got something out of the system, where value, which is, I guess, the the word that's going around now in terms of, uh, the best quality at the best cost.

[00:27:41] Randall Roth: John, stay on the line. I'm going to ask all three of our guests to to comment on that. Um, let's start with Fred Holshoe, uh on the Big Island. Fred, any any comments on John's question?

[00:28:22] Fred Holschuh: Ah, sure. Thanks, Randy. I think that uh, well, he raises obviously a very critical point, and I think uh getting back to what Nancy said uh when she raised a question of uh nurse practitioners in the office and so on. Whether your primary care provider is a nurse practitioner or PA working hopefully in conjunction with a physician, um, the term gatekeeper has crept into this whole discussion over the last number of years. And I I don't like that term. In fact, I rather hate that term because that implies exactly what has happened that the primary care person is current primary care physician is placed in a position of withholding services for fiscal reasons. I think what it really what really has to happen is ultimately, the patient-physician trust that has been so important in the history of medicine around the world and in our country, certainly, that has to come back into the forefront again, where somebody like the concerns Nancy expressed and that John's expressing, where somebody can go to their primary physician and say, hey, I have this problem. I trust you will find for me the most cost-effective best way to deal with my problem. And when we get back to it at that level, I really believe, maybe this is just pie-in-the-sky, but I really believe all the rest of this will fall into line, and we will ultimately save money.

[00:29:14] Fred Fortin: Well, I think that um, from the health plan level, uh the health plan being seeing the uh [unintelligible — audio glitch] tensions in the system here, we need to build uh in Hawaii, uh a social consensus uh on many of these uh issues of um um there was a recent task force on um uh dying with dignity. Um, and there are a number of related issues that that bring together cost and quality. I remember um Ken Kipnis and I participated in a project uh many years ago, called Health Decisions Hawaii, in which we went out to the community in uh many different forums to and and raised issues that in which there were these sorts of value conflicts, um and tried to understand uh what people were feeling and then tried to bring that back to the policy decision makers. And I think that's what uh in a sense Hawaii has to do in with the larger picture. We have to engage in a process that is not just at the state legislature, but that is throughout Hawaii, that basically brings out into the open the trade offs that we were making.

[00:34:38] Randall Roth: in Viagra at the expense of scraping off another thousand families off the insurance rolls. I mean, those are the types of justice trade offs that health plans have to look at. And they shouldn't be looking at it in a vacuum. They should be looking at it from the point of view of what is the sense of their community that they are in, and it may be very different from here in California. But what is the sense of their community in this, not just the proponents of particular uh service, or the providers of those service. What does the community represent? And I think that's the direction we have to to go in this.

[00:35:11] Ken Kipnis: Ken Kipnis, we've been hearing John's question about incentives and and now trade-offs and values. Uh, what are your thoughts on this?

[00:35:19] Ken Kipnis: Well, I mean a lot of what I would have wanted to have said has been said already, but there's one issue I think that that has been unsaid when John uh talks about uh uh patients, providers and payers being the three major players, I think there's another population that needs to be talked about, and that's those that don't have access to healthcare, hey, and that's that I think it's there's a community interest in seeing to it that we do not have medically underserved populations, medically underserved pockets in part because it conflicts with our sense of justice as a people, and in part because it's just unhealthy. It's just bad from a public health point of view to have, uh areas where diseases can uh can can originate in an unchecked way, uh, and whatever system we really opt for, it has to somehow uh provide room and services uh for individuals that aren't served. So it's not just a question of those three elements.

[00:36:10] Randall Roth: John from Kailua, are you still there? John from Kailua, are you still there? Yes sir. Uh, you started an interesting conversation. Why don't you finish it and then we'll go to another caller. Thank you. Well, I appreciate all the comments. I think everyone touched on a little bit of what I had in my own mind. I think one of the real key issues to this whole puzzle is going to be uh education, education of the patients and consumers as to what expectations are in healthcare now, how things are changing, and certainly with the physicians need to be uh educated as to how to practice medicine now, not looking at individual patients that you see in your office, but as we learn more about population medicine and evidence based medicine, I think this is coming to a forefront now. And certainly the payers need to look at at the the cost issue, but also look at the human issue and uh this whole issue of trust I think is something that's being slowly eroded as Fred Holshoe was saying, and it's unfortunate because you do see that in your day-to-day office. So, I appreciate the comment. Thank you, John. In case you tuned in late, you're listening to the Price of Paradise radio show. We're talking about changes in healthcare delivery systems, especially here in Hawaii. With me in the studio is Ken Kipnis from the University of Hawaii and Fred Forton from HMSA, and then with us by phone from the Big Island is Fred Holshoe, who is an emergency room doctor at Hilo Medical Center. We've got people who have been waiting patiently uh and we're going to get to them. But we do have a couple open lines now. So if you'd like to get in line, the number is 955-8821 or from a neighbor island 1-800-955-8821. We go to Linda from Iaea. Good morning, Linda.

[00:37:49] Linda: Good morning. I've been really enjoying this program. Uh, I have a couple of maybe questions, maybe comments about the governance of HMSA.

[00:38:00] Linda: Last year, I was a patient of a physician who ran afoul of HMSA and was actually driven out of practice. During, when I would come for appointments, I would be told what was going on so far. And I was told a couple of things that I have no idea whether they're true or not, and I thought I would ask. HMSA is technically a mutual benefit association, and as such, I was told it does not come under the purview of the state insurance regulator. That's one thing I wondered about. And the other thing I wondered about is that, since technically it is a mutual service association, it's supposed to be, according to its own bylaws, electing its officers from the membership. And I wondered if that was true, because I personally have never received any notice of an HMSA annual meeting, let alone a proxy to vote for anybody.

[00:38:59] Randall Roth: Let's see if we can get an answer to your two questions from Fred Forton, and then I'll come back to you, Linda.

[00:39:03] Linda: Thank you.

[00:39:05] Fred Fortin: Well, the first question, HMSA is highly regulated by the insurance commissioner. It is a mutual benefit society, and all mutual benefit society, which which are medical or hospital related are regulated by the insurance commissioner. Even more so after this past legislature has an external appeal to the insurance commissioner. The insurance commissioner has, at its discretion, can audit HMSA, does so every three years for several months as a matter of fact, as well as other federal and state regulating bureaucracies. So, I know I've heard that at the legislature that somehow HMSA or Mutual Benefit Societies are not regulated. That is totally totally not true.

[00:39:48] Randall Roth: What about Linda's other question?

[00:39:50] Fred Fortin: The other question is that HMSA has an annual meeting, and membership, the notice of the meeting goes into the paper. The meeting is reported on every year both in Island Scene Magazine which goes out to 300,000 households, and HMSA members as to what happened at the meeting. The board of directors are elected by the membership. And then the board of directors elects the officers.

[00:40:17] Randall Roth: Uh Linda, back to you.

[00:40:19] Linda: How do they elect them? I mean, what is the mechanism for the membership to to vote?

[00:40:26] Fred Fortin: The mechanism is that the members vote. They vote at the meeting.

[00:40:30] Randall Roth: So the members who show up to the meeting get to vote.

[00:40:33] Fred Fortin: That's correct.

[00:40:34] Randall Roth: And a majority of them determine who's on the board.

[00:40:36] Fred Fortin: That's correct.

[00:40:37] Linda: Okay, but you have to know when that notice is going to appear in the paper because you do not get something in the mail.

[00:40:42] Fred Fortin: That's correct. That's correct.

[00:40:45] Linda: The other point I wanted to bring up was that I think a lot of this what's happened with the various insurance companies is due to what in my opinion is the lack of noticing what's going on around them of the Hawaii medical community. They don't seem to be to me to be real akamai folks. They're busy taking care of patients. They don't really see when a large boulder is heading their way.

[00:41:17] Linda: I was told that there was at one point at least actually a plan from of some people within the Hawaii medical community to start their own preferred provider association, simply so they could get out from under HMSA. I have no idea whether that's true either, but at the time I heard it, I thought, gee, one more case of the state of Hawaii being a day late and a dollar short.

[00:41:48] Randall Roth: Linda, I'm going to have to move on. I really appreciate your call this morning. I'm going to take that as a comment and our guest can comment on it as we get back to them. But we do have to keep moving. Thank you very much.

[00:42:00] Linda: Thank you.

[00:42:01] Randall Roth: We go to Dick from Kailua. Good morning, Dick.

[00:42:04] Dick Miller: Good morning, Randy.

[00:42:06] Randall Roth: Is it okay if I tell people who this is?

[00:42:08] Dick Miller: You can go right ahead and do that.

[00:42:09] Randall Roth: It's Dick Miller, who's the former Dean of the University of Hawaii Law School, and Dick is very active in healthcare issues and very active with is it the Hawaii Coalition for Health, Dick, that I guess some people describe as a bunch of rabble rousers that I'm just kidding you, Dick, but you guys give HMSA and other providers a pretty hard time. You're a guess critical of some of the things that they're doing.

[00:42:36] Dick Miller: Well, I think in the in many ways, they deserve a hard time. Okay. Very, very quickly, what because I know you could write a book on this, too. What's your question or your comment this morning?

[00:42:45] Dick Miller: Well, my comment is this, and a point that hasn't been mentioned is that our legislature, which has been mentioned but it hasn't been emphasized, passed what what the federal Congress has yet to do, that is the Patients' Bill of Rights and Responsibilities. This session, which for the first time is going to bring mutual benefit societies under control of two important sections of the insurance code. Up until this year, except for an amendment that was passed in 1997 dealing with insolvency, Mutual Benefit Societies, which include HMSA, were specifically excluded from coverage of the insurance code. And thanks to the legislature next year, two important provisions of the code, including the Unfair Insurance Business Practices Act, are going to be applicable to Mutual Benefit Societies. And in addition, our Patients' Bill of Rights has many of the rights in it applicable to all managed care plans that Congress is now trying to pass. So we have, you know, people criticize the legislature, but they've done a wonderful job this year in passing a law that is going to help patients. Now, and secondly, there that law provides for a task force which is going to begin to meet just as soon as the Governor signs this bill. It goes into effect immediately, and there will be a task force made up of all kinds of groups including the Hawaii Coalition for Health and HMSA and others that will be talking about how we can improve healthcare and medicine in Hawaii in the future. So this is a big, big thing and I'm surprised these guys haven't really talked about that.

[00:44:31] Randall Roth: Okay. Dick, thank you very much. I appreciate your call.

[00:44:33] Dick Miller: You're welcome.

[00:44:34] Randall Roth: You know, I I want to ask and and we want to keep moving but very quickly Ken Kipnis. On the one hand, I have this sense that that a lot of times problems can quote, be solved by legislation. But then, I read in the different pieces this morning and and it rings true with me that that creates more paperwork, more bureaucracy and that somehow there's at least the possibility that that can make the problem worse as opposed to solve it. Your thoughts real quickly.

[00:45:02] Ken Kipnis: Well, um it's often a blunt instrument. I mean, legislation, okay? And it's uh and healthcare is finely textured. I would I would I think go along with Fred Forton and and I think also with Fred Holshu saying that what we need is a community debate out there on what the balance ought to be between quality and and cost and how how to work those out. And that's not just medicine, it's also allied healthcare professionals like nursing for example. They're also heavily involved in the delivery of healthcare plus patients, citizens, okay? And managed care organizations.

[00:45:33] Randall Roth: Okay. Real quickly Fred Forton.

[00:45:35] Fred Fortin: Well, on this Consumer Bill of Rights, I think uh Dick is got a good point there that this is [unintelligible — audio glitch] very important item. And I just want to make it clear uh from HMSA's point of view anyway that we were very supportive of that bill, and we'll be at the signing and encourage the Governor to sign it. Uh Dick is right in the sense that the two other provisions of the insurance code were applied to uh to mutual benefit societies uh in that law. However, the 432 um which is the law that governs mutual benefit societies and 431 which is the law which is a bevy of laws that govern insurance companies uh they are almost carbon copies of each other in many many respects, and many of the provisions of 431 do apply to 432. This may sound like a little technical argument, but I really do um But you're you're telling us there may not be a dramatic change the way there perhaps would be if we were having a new set of laws that didn't exist. [unintelligible — audio glitch] There's uh a lot that is just business as usual here. I think the task force will be very interesting, but we have had task force in the past, blue ribbon panels and all of that in the past. What we need is a community uh uh process which goes out into the community and brings that information back, not just the same people talking about the same issues.

[00:46:52] Randall Roth: Okay, we go to Rob in Honolulu. Good morning, Rob.

[00:46:55] Rob: Good morning. Uh I just want to make a couple comments. Um I think we heard this morning uh from Nancy on the big island who was concerned that the the healthcare system is too large, etc. and I think there's someone else commented on the fact that trust has been eroded, and uh the [unintelligible — audio glitch] healthcare gets more complex, the a relationship between physician and patient has been been altered significantly in that in the old days, the physician was charged with taking care of the patient uh uh and it was high, I'm Dr. so and so, what what can I do for you? Sometimes in managed care situations, it's high what the least I can do for you and I think [unintelligible — audio glitch] some of that uh was uh reflected in in Nancy's comments earlier. [unintelligible — audio glitch] wanted to try and uh just mention that I think the listening uh audience could be be educated in in terms of that uh just the the uh the this is a um uh a consumer-driven process and that uh while we do need a a community debate about uh what needs to be covered and not covered uh they can also have a debate around their kitchen table where they uh look at the health plans and and decide if if the health plan they're they're interested in allows them to choose the physician uh on their own or that they can whether they can choose specialty care uh electively or not. And so I think they can also have a debate around the kitchen table uh and one of the things they should look for is certainly a plan that will allow them to choose uh their their not only their primary care physician but specialty care if they need to see a heart specialist or an orthopedic surgeon or whatever.

[00:48:31] Randall Roth: Rob, would you agree that that whoever starts that conversation ought to make clear that at the bottom of it, there has to be a tough choice that one can't have everything?

[00:48:41] Rob: That's right. There's no free lunch. That is if they if they if they're a a young healthy family and they have they have no serious illnesses, well, then they may want to try and pick a health plan which is absolutely the cheapest possible, but they have to understand [unintelligible — audio glitch] may limit [unintelligible — audio glitch] care choices. The other thing they should look carefully at is the grievance process or the appeals process of the health plan so that that if they are denied uh care or say denied say physical therapy after an operative procedure, that they are allowed to appeal this through a grievance process which is well-defined, clear-cut, and and allows them uh speedy resolution.

[00:49:15] Randall Roth: Okay. Rob, I'm going to get a reaction to to your comments and then we're going to move on. Thank you very much for calling in. Let's start with uh Fred Holshu. We haven't heard from Fred for a while on the Big Island. Fred, any reaction to Rob's comments?

[00:49:28] Fred Holschuh: Sure, thanks Randy. Yeah, uh well, not specifically uh to what he said but what's been said in the last 10 minutes, and and I think Rob did raise the question again of trust. I just give you an example, my wife and I went last night to a very dramatic wonderful community gathering to honor Dr. Ruth Oda, who's been practicing Pediatrics and Helo for well over 40 years, and it's just a magnificent person and a magnificent example of the trust that patients had in her all these years and and the testimonials that were given about her care of people was never considering reimbursement as the primary reason for for delivering that care. Um I wanted to add one other thing if I may and um I think Rob touched on it slightly uh not by name perhaps, but when Dick Miller was talking earlier about the patient Bill of Rights, I mean, we are aware of that, there isn't enough time to talk about everything, but the one thing that did pass this year as well, which grew out of emergency medicine issues on the mainland years ago is the prudent layperson standard for reimbursement for emergency care and that's a very critical issue. You know, if from a practical standpoint if a patient goes to the ER with what they perceive to be a heart attack and it turns out to be ulcer reflux pain or something like that um up until recently insurance companies were saying, well, it wasn't really a heart attack. You should go under your doctor's office for an antacid and so forth. I'm simplifying it, of course, but I think these approaches where patients can make sensible decisions with physicians is again back to where trust and where this all ought to be.

[00:51:04] Randall Roth: Okay, uh Fred Forton.

[00:51:07] Fred Fortin: Well, I I couldn't uh I couldn't agree more. Um the comment of the caller uh is interesting because uh if you look at health plans in Hawaii, most people belong to preferred provider organizations which gives you the choice of your physician and HMSA has 90% or more of those physicians in the health plan and that is the predominant choice, actually. We talk about HMOs as though they were the the reality in Hawaii, when in fact, the reality is the preferred provider plan, which has a lot of choice of physician. Uh, the problem is to keeping that type of plan competitive because the more choice, I mean, it's just simply a fact, the more choice, the more cost and you'll see plans line up not necessarily on whether they're HMOs, but whether they're uh the the wide variety of choice that they have in the plan, they will line up in terms of the cost on that because that's the the economic factor of life.

[00:52:09] Randall Roth: So tough decisions include whether to have lots of choices or few choices.

[00:52:14] Fred Fortin: Well, From your point of view. Well, that's true, but it's not lots of choices and few choices. It's uh lots of choices with potentially less choices. You have HMOs here who have uh 800 physicians. You have uh Health Plan in Hawaii, that's 1400 physicians, you have the preferred provider plan that has 2000 physicians. So it is not at all as though when you pick an HMO, then you are you're relegated to a small group. You have you have differences in those as well. So even the HMOs, now, the focus is on choice. How can you give within the HMO context the consumer the most choice possible within that HMO.

[00:53:06] Ken Kipnis: A couple of quick comments. One is um the image of a family sitting at the kitchen table, looking at the different plans, isn't quite right when the decision is made by an employer rather than the family. And that's that's a problem we're seeing in a lot of places in the United States. Uh Secondly, uh if that's the way decision is going to be made, there's got to be standards for fair disclosure okay in the brochures from [unintelligible — audio glitch] providers, I mean, what is going to be covered, what is not, and it's got to be in lay language and it's got to be fairly complete. But even if it even if we go that route, I think that there's a final question um about whether there need to be governmental standards on what what must be covered within a plan and maybe that should include aspects of grievance procedures. Maybe should include a a decent minimum, a very clear understanding of the absolute minimum that a that a plan must have.

[00:53:42] Randall Roth: Don't we have a basic problem, too, that that you say, and I agree with this, that there needs to be complete disclosure, and yet not long ago, I sat down attempting to figure out which plan I should opt for for my family, and I'm a lawyer and I fairly quickly was overwhelmed, and I basically said, here's Susie, would you please figure this out? I mean, isn't it inherently complex? Yes. I I don't think you're alone in that. Okay. Well, we go to uh Tom from the North Shore. Good morning, Tom.

[00:54:11] Tom: Tom from the North Shore. You there? Yes, good morning.

[00:54:14] Randall Roth: Good morning.

[00:54:15] Tom: Um I feel that any functional society should provide the necessities of life to all its members. Uh at the present, American society just doesn't do this. And um the discussion of the of this issue, the health issue, it tends to consist of justifications for not including everyone in the services provided to the members of the society. Is it gives a whole bunch of reasons why we're not taking care of everyone, and maybe they can be justified if you look at if you assume that the society has to configure itself as it does. But the real problem is taking care of everyone, and you need to get to a level of discussion that addresses that. And I don't see that happening in the national uh discussion, and I don't see it happening here this morning, uh and I would like to to get to talking about just what we have to do to our dysfunctional society to make it functional. And it's like if if you stay locked into uh whether or not the cost and and uh services are balanced out in the system as it exists, you're not going to like get to the root of the problem and that's what I would like to see happen.

[00:55:44] Randall Roth: Tom, stay on the line. I want to get a reaction to that from everyone, then we'll give you the last word. Ken Kipnis.

[00:55:49] Ken Kipnis: Well, I I think [unintelligible — audio glitch] caller is absolutely right, um that there are underserved um populations in Hawaii and elsewhere. Um and uh and it ought to bother us when people suffer needlessly from want of medical care that the society as a whole can afford. Um Fred Forton.

[00:56:08] Fred Fortin: Well, I think you've got to create the community conditions that allow that to take place, but we still have to make hard judgments. And it's not necessarily about hard judgments about who to serve and who not to serve, but but maybe be what to do and what not to do.

[00:56:21] Randall Roth: Fred Holshu on the Big Island.

[00:56:26] Fred Holschuh: Uh Randy. Yeah, go ahead. Can you hear me? I can. So, yeah. Thanks. Uh no, I think again, I agree the caller is absolutely right. Um there's a tremendous segment of society that we're missing uh in both healthcare and social services care. And one thing we have to weave into this is the pride of the recipient and the self-reliance of the recipient and the personal responsibility of people. You know, for years, I've been an outspoken uh critic of the welfare system and involved in working on welfare reform and low and behold,

[00:57:00] Fred Holschuh: well, I find myself now appointed by the Governor to the General Assistance Advisory Council, where I'm now kind of serving as an advocate for the poor and the disenfranchised and I think the balance is there and it gets back again to community discussions.

[00:57:13] Randall Roth: Okay. Well, we're down to the last five minutes or so and I want to give each of my guests an opportunity to add some thoughts that need to be added or highlight what's been said but needs to be highlighted. Fred Holschuh on on the Big Island, before you give your closing thoughts, let me ask you, one of our callers suggested that physicians as a group haven't really seen that there's a boulder rolling their way. Is your running for office an indication that that you as a physician are are maybe seeing a boulder rolling your way and that that maybe that's one reason why you want to have a a direct voice in the political process?

[00:57:52] Fred Holschuh: Uh, thanks, Randy. Well, um I know there's a boulder heading our way in terms of healthcare and and physician decision-making, but the truth is that is not why I'm running for office. Why I'm running for office, that's 30 years in the emergency room and seeing where society is going in realizing that we have to have a resurgence in resurgence in our state of uh small business, of a resurgence of people having pride in jobs, finding work for people to do.

[00:58:21] Fred Holschuh: You know, we talk about welfare reform and we say, you know, after so many years, you're going to have to go out and find work. And there isn't work in this state, some areas for people that have gotten out of college and high school. So all of this is part and parcel of the uh the social changes that have to occur. And my my reasons for running are uh although certainly I am a physician, proud to be a physician, my reasons for running are the problems I see that involve very real people's day-to-day struggles that I see in the emergency room.

[00:58:51] Randall Roth: Okay. Well, why don't you give us your closing thoughts on our topic today, which are these revolutionary changes in the healthcare delivery system.

[00:59:00] Fred Holschuh: Uh thanks, Randy. I uh congratulations to you and Susie on your daughter's wedding by the way. I um I want to make uh one comment that I think Ken Kipnis I can always send his energy and I don't want to take put words in his mouth, but he touched just briefly on prevention.

[00:59:15] Fred Holschuh: A a man named Jeff Jeff Goldsmith once said some years ago that doctors practiced at the bottom of a cliff cleaning up the wrecks of American lifestyles. And you know, if we really got into prevention and dealt with the problems of the fetal damage from drugs and alcohol and smoking cessation and violence prevention and hospice and sensible end-of-life care and avoidance of futile end-of-life care [unintelligible — audio glitch] with the doctors and the patients making these decisions, we would save a ton of money just getting back to basic preventive services.

[00:59:51] Randall Roth: Okay. Fred, thank you. That was Fred Holschuh, who for 30 years has been an emergency room doctor at Hilo Medical Center. He's this year's Hawaii Medical Association Physician of the Year. Fred Forton is HMSA's vice president for community relations. Fred Forton, here's your opportunity for some closing thoughts about uh minute and a half.

[01:00:11] Fred Fortin: Well, I think we got, I just like to emphasize three points. One is that we have to focus on quality of care and any discussion about the cost of that care. And we have to health plans, doctors, uh payers, uh consumers, um we all have to get on that same page. But to do that, we are going to have to involve ourselves in some form of community process that gets out into the community to understand the values and judgments and costs uh that are now our are being discussed uh if at all, only at the legislative level.

[01:01:01] Fred Fortin: Uh the other comment I want to make is that Hawaii is different. Hawaii is not California. It is not the mainland. And what we often see, uh are issues being raised in Hawaii that to a certain extent are not issues. And [unintelligible — audio glitch] forms [unintelligible — audio glitch] sort of a smoke screen. For example, like the drive by babies, all right? That wasn't an issue for Hawaii, yet it consumed a lot of our time and uh resulted in a lot of legislative discussion, but it was not an issue for Hawaii. That type of

[01:01:30] Randall Roth: Drive by babies, that's where you had so little time in the hospital.

[01:01:33] Fred Fortin: That's right. That's right. Maybe I should be clear on that. But yeah, you come into the hospital, you deliver your baby, and then you're thrown out.

[01:01:38] Randall Roth: And the media made it seem as though mothers were being pushed out way before they were ready.

[01:01:43] Fred Fortin: That's right. And so a lot of our discussion sometimes involved discussion of issues that are not relevant to Hawaii, and uh and but uh many people think that somehow they're they're operational in Hawaii. So I think we have My final thing is I think we have a much better ability here in Hawaii to try and engage in this discussion. I think we have a much better situation than many states on the mainland in Hawaii and we should take advantage of it.

[01:02:08] Randall Roth: Last word from our ethics professor, Ken Kipnis.

[01:02:11] Ken Kipnis: Well, what I see here and I'm going to come back to some themes that I began with, what I see here is a situation that's having changed enormously. Um and the ground rules aren't yet set. We really do not know what the role of physicians is going to be in this system as it evolves. We we don't have a clear idea about the final constraints that manage care organizations are going to be working within.

[01:02:35] Ken Kipnis: And um you can see in this in this program that uh citizen, patients, as well aren't really knowledgeable and competent. Uh at some point, um we're going to have to become clearer on how this whole system is going to be organized. We don't have a healthcare system. We've got scattered services, and it's really clear [unintelligible — audio glitch] healthcare becomes more and more concentrated into a few large players, as the conglomerates begin to take over, um that we're going to need to think about what the concerns, the final concerns of this community is going to be about the nature of healthcare delivery.

[01:03:08] Speaker 1: you about the nature of healthcare delivery. It speaks a lot to who we are in our association with one another.

[01:03:10] Ken Kipnis: It speaks a lot to who we are in our association with one another.

[01:03:13] Randall Roth: Who we are. That's Ken Kipnis. Who we are. That's Ken Kipnis. Uh you've been listening to the Price of Paradise Radio show. Our producer is Susie Roth, our technical director is Jeff Alardy. Susie had the day off and taking her place was Walter Roth and my brother, Tom Roth. Uh, you've been listening to the Price of Paradise radio show. Our producer is Susie Roth, our technical director is Jeff Alardy. Susie had the day off and taking her place was Walter Roth and my brother Tom Roth.

[01:03:28] Randall Roth: Next week we've got a show on the judicial selection commission and process. There are a lot of us who feel that it's terribly important that the public have confidence in our system of justice, and I think that begins with the process of selecting judges.

[01:03:28] Randall Roth: Next week, we've got a show on the Judicial Selection Commission and process. There are a lot of us who feel that it's terribly important that the public have confidence in our system of justice, and I think that begins with the process of selecting judges. Our guests will be Judge Sam King, uh attorney Jim Koshiba, and Momi Casimero from the Judicial Selection Commission in past years. You've been listening to Pop Radio, I'm Randy Roth. Aloha. Our guest will be Judge Sam King, uh, attorney Jim Koshiba, and Momi Casamero from the Judicial Selection Commission in past years. You've been listening to Pop Radio. I'm Randy Roth. Aloha.

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