QUEST and Hawaii Health Care
Price of Paradise · Hawaii Public Radio · aired 1996-06-09
Guests: Winifred Odo (Administrator, Med-QUEST Division, Hawaii Department of Human Services); Beth Giesting (Executive Director, Hawaii State Primary Care Association); Fred Holschuh (physician; past president, Hawaii Medical Association); George Bussey (Medical Director, Queen's Hawaii Care)
Duration: 1:08:58

[00:00:04] Randall Roth: Aloha, this is Randy Roth, host of the Price of Paradise radio show. We're broadcast live each Sunday morning at 8 on KHPR 88.1 and KKUA 90.7, and then rebroadcast on the evenings at 8 on KIFO 1380 AM. Everyone who works to bring this show to you is a volunteer who believes in the importance of lively and informed public dialogue. Our sponsor is the Hawaii Community Foundation. Our topic this morning is Quest. Quest is a five-year demonstration project that offers medical insurance to Hawaii's poor. It was designed to blend two earlier programs: part of the Medicaid program, which has been for the poorest of the poor, and then something called the State Health Insurance Program or SHIP, which was for the gap group.

[00:00:55] Randall Roth: Those people who couldn't get insurance through jobs or otherwise afford it, but needed it. Those two programs, SHIP and a part of Medicaid, were blended into what was supposed to be a seamless health plan for those who couldn't otherwise get it. It's been controversial for a variety of reasons. One is that it was designed to contain costs through use of something called managed care. And we'll find out a little bit more about managed care, just what it is, but one reason it tends to be controversial is it takes some of the decisions that historically have been made by physicians and in working with their patients, and given it to people who are writing detailed rules and making decisions away from the place where the patient is being seen.

[00:01:45] Randall Roth: It also has been controversial because far more people signed up for the Quest program than what had originally been contemplated; consequently, it was a lot more expensive than what had been expected. Changes had to be made, also they had to be made because of a lawsuit, and whether it was just because of the lawsuit or because more signed up than was contemplated, the qualification rules have been rewritten and tens of thousands of people who were a part of Quest are now being bumped from Quest coverage. Finally, it's been controversial because the Quest program has had a major impact on a number of nonprofit organizations that have provided health and social services. Now, we're going to be hearing all about that and more.

[00:02:33] Randall Roth: Before we start our conversation, I want to tell you a little bit about the folks who are in the studio with me, and then we have another person hooked up by phone. In the studio we have Winnie Odo, who is the administrator of the Med-QUEST Division for the Department of Human Services. Med-QUEST Division is responsible for the administration of the Hawaii state Medicaid program, as well as all the healthcare waiver programs for the state of Hawaii. Winnie is responsible for the administration of a program which is the largest single program budget for the state of Hawaii. The Medicaid program has grown both in recipients and expenditure by 35% over the last four years. The projected program expenditure for fiscal year 1996 is in excess of $600 million.

[00:03:21] Randall Roth: She's been with the Medicaid program since 1980 and administrator, that's in charge of it since 1990. Among her many tasks is the responsibility to develop and implement what we're talking about today, which is the Quest program. I also have in the studio Beth Gisting. Beth, for the last year and a half, has been the executive director of the Hawaii State Primary Care Association. That's a nonprofit organization that advocates for Hawaii's mentally, or, I'm sorry, medically underserved groups and for the community health centers that care for them. Previous experience includes 12 years as the executive director of the Kalihi-Palama Health Center, where Beth gained a great deal of practical knowledge of the primary care needs of the uninsured and others with barriers to care.

[00:04:09] Randall Roth: Finally in the studio, we have Dr. George Bussey. George came to Hawaii in 1981 after completing medical school at Eastern Virginia Medical School and his psychiatric residency at Eastern Virginia and Vanderbilt Universities. He's been a staff psychiatrist at the Hawaii State Hospital and an assistant professor in the Department of Psychiatry at the John A. Burns School of Medicine and then director of adult services at Kahi Mohala Hospital. For the past eight years, George has worked with the Queen's Healthcare Plans, that's one of the plans you're going to be hearing about more this morning. He's been the medical director for the Queen's Hawaii Care or Queen's Quest plan since its inception in 1994. And then by phone, we have Fred Holscher.

[00:04:58] Randall Roth: Fred is an emergency physician at the Hilo Medical Center and the immediate past president of the Hawaii Medical Association. And again, he's by phone, with me in the studio is Winnie Odo, who's the head of Quest; Beth Gisting, who's the executive director of the Hawaii State Primary Care Association; and George Bussey, who is the medical director for Queen's Hawaii Care. Well, to all of my guests, good morning.

[00:05:25] Beth Giesting: Good morning.

[00:05:26] Randall Roth: George, I've known you for a long time because also, and it's not in your little biographical sketch, but you're a graduate of the law school. And so I'll start with you at my little description of what Quest is and what some of the controversial aspects of Quest have been. Anything you want to clarify, add to, or say anything about?

[00:05:47] Speaker 1: Well, I think your your description is pretty accurate. Um, I think what we all have to keep in mind is that one of the reasons that Quest developed was because healthcare across the board has come to represent a larger and larger portion of governmental expenditures and personal expenditures as well. And our country has been struggling for the last five, 10, maybe 15 years with how are we going to deal with that? How are we going to continue to develop uh programs that provide good healthcare for all of our citizens and yet don't break the bank? And I I think Quest is a one of the ways we're trying to experiment with with how to do that.

[00:06:28] Randall Roth: And you say our country, so Quest isn't unique?

[00:06:33] Speaker 1: No, there are several different programs. In fact, I think more states than not now have various waiver programs uh in place or in application.

[00:06:44] Randall Roth: Okay. And and Winnie, was I correct in saying that that Quest was an attempt to combine what basically were two things, a part of Medicaid which is, some people think of it as a form of of welfare where the poorest of the poor have, uh, different sorts of of health, um, I don't know, benefits? Combining that with our SHIP program which was our gap group program, is that correct?

[00:07:08] Winifred Odo: That's correct. What we did was we decided to do this in in several in several phases. To convert the entire Medicaid program into a managed care initiative would have been uh much bumpier than we experienced two years ago. So we decided to take a subset population, which is the aid to families with dependent children, that's the AFDC group uh, who receives welfare, financial assistance and uh the general assistance population which has been controversial, to say the least, within the last few uh months, as well as those individuals who were under the Department of Health's state health insurance program. We uh consciously uh decided that we would not uh put the aged blind and the disabled population in the first phase and intend to do that um, July of next year.

[00:08:04] Randall Roth: But that was the basis for the lawsuit, right?

[00:08:06] Winifred Odo: Yes. Yes, it sure was.

[00:08:07] Randall Roth: There was an allegation of discrimination, and the end result, I guess, uh, at least [unintelligible — audio glitch] official explanation, and I think there's been some controversy about this, but the explanation uh for recent changes in the qualification rules, which has resulted in something like 40,000 people who were a part of Quest to to be um bumped from Quest was that it was required to deal as as a response to that lawsuit.

[00:08:33] Winifred Odo: That's right.

[00:08:34] Randall Roth: Okay.

[00:08:35] Winifred Odo: Do you want me to just explain briefly?

[00:08:37] Randall Roth: That's fine.

[00:08:37] Winifred Odo: Uh the the challenge was that uh the blind and the disabled did not qualify for Quest, but qualified for our traditional Medicaid program. Our traditional Medicaid program has an asset test, the Quest program did not. As a consequence, we were uh challenged on the Americans for the Disabilities Act. The department had to three choices. One, to eliminate the asset test for the aged blind and disabled, but I think all of us know that that would have pretty much broken the bank. The other was to um do what we're doing now and then end up in court. And the the of course, the third, which we need we did, was to equalize the eligibility criteria, which then becomes the imposition of an asset test for the Quest population, which we project will affect approximately 40,000 in uh families and individuals who probably are over asset.

[00:09:38] Randall Roth: You know, as as I'm listening to you, I remember there's another controversial aspect of all of this. As I recall, because you didn't have an asset qualification test originally, there there were some people who already were a part of of plans who were quitting their plans and and joining the the Quest plan. They had plenty assets, but they didn't have much income, at least at that point, maybe they were students or who knows what. And um the changes you've made in response to the lawsuit has, whether direct or indirect, has had an impact on that particular aspect because those folks have been bumped out.

[00:10:12] Winifred Odo: Yes, that definitely.

[00:10:14] Randall Roth: Okay. Now, one of the things that Winnie mentioned was managed care. And and George, I need real quickly just a definition from you as to what the heck that is. And then I want to ask Beth about the impact of all of this on on um what she does.

[00:10:29] Speaker 1: A real quick explanation is that managed care is an attempt on the part of the people who are responsible for delivering and paying for care to organize the care and make sure that people are getting the particular kind of care that they need at the level of service delivery that they need by the correct type of provider for the type of problem they have. It's it's an overall attempt to bring some rationality um to the process of delivering medical care.

[00:11:01] Randall Roth: Is it fair to say that if resources were totally um unlimited that we would simply say to each physician, do whatever it is that needs to be done and the people of Hawaii will make sure that gets paid for?

[00:11:15] Speaker 1: I think it's a generalization. Yes, you could say that.

[00:11:19] Randall Roth: But given that resources are limited, uh isn't it true that managed care is is an attempt to deal with the the harsh reality that that resources are limited and so the nature of it is to pull back on what might otherwise be provided in the way of um services?

[00:11:35] Speaker 1: Yeah, I I think kind of the shorthand we use for that is we we as we try to deliver um value healthcare and we use the kind of the shorthand equation of quality over cost. The higher the quality and the less the cost, the greater the value is to the healthcare consumer and that's what we try to deliver.

[00:11:58] Randall Roth: Okay. Well our our third voice in the studio is Beth Gisting and Beth, you're the head of this organization called the Primary Care Association, the State Primary Care Association. And my understanding from your piece in this morning's paper is that that Quest has had, whether it was intended or not, whether it was expected or not, it's had a negative impact on the the community health centers. Um, could you tell us a little bit about that?

[00:12:27] Beth Giesting: Yes, sure. Um, and I would like to preface that by saying that many of the aspects of primary care have been really positive and the patients like it. The biggest problem is the patients who can't get into it. And we are very concerned about the latest changes that we expect are going to eliminate a lot of people from the program. Um, the health centers have throughout the entire course of the Quest history continued to serve a significant number of uninsured people. Um, but now that they're going to be more people eliminated from the Quest program, I think that that is going to be a real tidal wave of uninsured who are going to be presenting themselves on the doors of the the health centers.

[00:13:12] Beth Giesting: And the biggest problem for this, as the safety net providers, is that they have had uh over the last two years a real cutback in the resources that they have available with which to provide those services.

[00:13:25] Randall Roth: It's my understanding that that these health centers are in Y and Y and and a number of areas where a lot of times we have folks who who haven't been getting good healthcare.

[00:13:37] Beth Giesting: Yes, that's correct.

[00:13:38] Randall Roth: And they're designed so that it's real easy for the folks in those areas to to find them and and to use them and to understand what what's going on there.

[00:13:48] Beth Giesting: Yes, they uh are designed so that they are friendly to the communities that they serve and those communities are the ones who usually have a lot of people who are below poverty, people who have other kinds of barriers to getting healthcare like language barriers or cultural barriers or sometimes transportation barriers.

[00:14:05] Randall Roth: And and before Quest, uh SHIP was there and and SHIP was providing some sort of of special funding arrangement for you.

[00:14:12] Beth Giesting: Yes, SHIP uh provided uh a funding subsidy for the uninsured. In addition to that, uh before the Quest program, the Medicaid program paid the health centers what it actually cost them to provide services. There's a different financing mechanism with the Quest program and so the health centers may or may not and most of them don't get as much to uh don't get a payment that is adequate to cover the the cost of the services.

[00:14:39] Randall Roth: Plus I guess [unintelligible — audio glitch] budget crisis as it's been called here in Hawaii, is that an impact?

[00:14:44] Beth Giesting: Yes, yes, uh the State Department of Health also has subsidized the health centers for their safety net services and those subsidies have been cut by as much as 40%.

[00:14:56] Randall Roth: So not that it's it's any one's fault or or anything like that, just looking at where the the health centers are right now, you've had uh a multiple whack if you will, as I understand it at least, you're not getting the kind of reimbursement from Medicaid you used to, you're not getting anything from SHIP that you used to. Uh, you and various related organizations have had your budgets cut dramatically by the state of Hawaii, um sounds like you're being squeezed pretty hard.

[00:15:23] Beth Giesting: Yes, that's exactly right. At the time when we expect that uh there will be more pressure put on the safety net, there just aren't the resources to keep it whole.

[00:15:31] Randall Roth: Okay. Well, in just a moment, we're going to invite listeners to uh call in their questions and comments, but first we want to hear from Fred Holscher, who's an emergency physician at Hilo Medical Center and the immediate past president of the Hawaii Medical Association. Fred, are you there?

[00:15:46] Speaker 2: Yeah, I am, Randy. Can you hear me?

[00:15:47] Randall Roth: I sure can. Have you had an opportunity to listen to everything thus far?

[00:15:51] Speaker 2: I sure have. I've uh been smiling and enjoying it. It's been great. In fact, I'd like to just stay here as the audience.

[00:15:58] Randall Roth: Well, I I can tell because it's quiet wherever you are that you must have stepped out of the ER and into an office.

[00:16:04] Speaker 2: I wanted to have you hear the ambiance of the ER, but I knew nobody could hear anything. There be so much bedlam, so I went in the back room. That's correct.

[00:16:11] Randall Roth: Okay. Well, since since a lot of people watch that show on TV, why they they know what it's like anyway. Um, Fred, um very quickly and we're going to be coming back to you later on in uh in the show. Um, what can you add to our conversation that our listeners need to know about?

[00:16:27] Speaker 2: Well, one other thing I wanted to add if I may um Randy. And I I've been an ER physician for 25 years, 24 in Hilo. It's no surprise to any of us who are physicians that uh Quest was markedly over-enrolled. One of the other factors involved in the surging numbers of people that applied and were in fact accepted for Quest initially has to do with migration of people to our state. You know, Hawaii has always had a very generous, very lenient public assistance program. And yesterday, in the ER, in spite of all the publicity to the contrary, I probably saw another eight to 10 brand new arrivals to Hilo who will, in fact, be registered for Quest.

[00:17:07] Speaker 2: They will qualify and they will get on Quest. So we do have this burgeoning population by migration. Um, may I say a couple of other things or you want to get to it later?

[00:17:16] Randall Roth: Why don't you give us a couple other things real quickly.

[00:17:19] Speaker 2: Okay. One thing, I want to say something very positive about Quest. I think there's no question uh that Quest has solved some of the access problems that plagued us on the Big Island in terms of the assignment of patients to primary care physicians. And I think there's no doubt about that. There were a lot of wrinkles in the beginning and there still are a few, but those are being worked out. Another very positive thing, uh something that was created by Jack Lewin and Governor Waihee and continued under Governor Cayetano and with the assistance of Winnie and Lynette Hanbo and everybody at Quest, we have a and George is on it, we have a Quest provider advisory board that brings the plans and Quest and physicians together so we keep good open productive dialogue going.

[00:18:01] Speaker 2: I think that for physicians, a frustration is, and I certainly hear this all the time at the Medical Association, um, there's still a tremendous amount of what they perceive to be wasted time and energy with paperwork, with justification of referrals, with uh getting um authorization for specialty care and for special procedures.

[00:18:28] Randall Roth: Fred, can I ask you, is it worse with Quest than it is with any form of of health insurance?

[00:18:34] Speaker 2: Well, I would have to say I don't suppose it is, but I must confess to you I had two or three docs stop me yesterday who heard this program was going to be on and they say it's worse for them. Now that's just anecdotal of course, and there's there's still a tremendous number of hassle factors, but I think, you know, on the positive side, that the plans and Quest were trying desperately to work all this stuff out. And when we funnel complaints and

[00:19:00] Randall Roth: problems to the Quest provider Board. They do, in fact, begin to work on solutions in a very positive manner. So, I want to say that I don't think we're anyway hassle free. In fact, the most physicians listening will probably be groaning and saying, no kidding. Well, we'll invite them to call in in just a minute. Um, well Fred, I I appreciate and if you could be sure to stay on the line, I want to come back to you. Folks, you're listening to The Price of Paradise radio show. My name is Randy Roth and we're talking about Quest. With me in the studio is George Busy, who's the medical director of one of the Quest plans. Beth Gisting, who is the executive director of the Hawaii State Primary Care Association, and Winnie Oto, who is the head of Quest here in Hawaii.

[00:19:44] Randall Roth: You've just heard Fred Holshoe, who is an emergency room physician in Hilo and an immediate past president of the HMA, the Hawaii Medical Association. Well, we want to encourage you to call us if you have a question or you'd like to make a brief comment. Our number is 955-8821. If you're on a neighbor island, just add a 1800 to that, 1-800-955-8821. We'd like to hear from you as well. If anyone tuned in a little bit late, you'd like to hear the show it's in in its entirety tonight on KIFO. That's 1380 AM. You'll be able to do that. 8:00, KIFO, 1380 AM. Well, George, um tell me about these five plans because I know Quest is somehow provided insurance as opposed to healthcare, um healthcare through insurance. But what about these five plans? How does that work?

[00:20:41] George Bussey: Well, when when the original Quest, um offer was put out, um a number of different organizations bid on uh providing services, um among those were HMSA, Queens, AlohaCare, Kaiser, and Strob. Kaiser and Strob being, um generally kind of group practice type organizations in the first place, probably have the closest relationship between the doctors who actually provide the care and the people who are responsible for paying for the care. It's they're probably much uh more closely integrated in that area. AlohaCare and and Queens Hawaii Care are probably somewhere in between in that um we've gone out and developed special networks of physicians to work with for this particular population. And HMSA, being the largest plan and the one that's been around the longest and the and the one that was basically administering the original Medicaid program, in a lot of ways have kind of continued with their original group of doctors and their original way of doing things.

[00:21:55] George Bussey: So there's a continuum of of how the services are delivered. I think one of the things that Fred talked about with physicians who have problems with the paperwork and everything is that the reality is that that now, um uh a physician in the community is um likely to have a uh uh Quest patient come in and instead of just one person to contact an HMSA representative, um that patient may be an AlohaCare patient, it may be a Queens patient, it may be an HMSA patient. Each of us have a little bit different way of doing business because we're all in business to try to figure out how to do it best and we're all experimenting with different ways.

[00:22:37] Randall Roth: Five sets of rules.

[00:22:39] George Bussey: Well, it actually boils down to kind of three sets because most people don't see the Kaiser patients or the Strob patients because those are closed panels, but it's it's different sets of rules.

[00:22:50] Randall Roth: It has complicated things.

[00:22:51] George Bussey: It has complicated things.

[00:22:52] Randall Roth: Winnie, you've heard um a number of voices since you last spoke. Uh my hunch is you've got a response to some of them.

[00:23:01] Speaker 1: Well, I'm not at all sure that Quest has uh created more paperwork per se. I agree with George. I think um doctors now, if they are participating in multiple plans, will need to uh shift gears depending on which plan their patient is with. When prior to Quest, this was a paperwork was a big concern uh from the provider community about their Medicaid program and and the hue and cry was we're mired in all of your paperwork. You need to reduce the paperwork. You need to do things like the private sector. Well, we have. We are now contracting with the private sector and there's still the same complaints. So it's really um uh for me, you know, I'm stifled by this whole thing thinking what do people really want?

[00:23:53] Randall Roth: What do people really want? But really, this is a form of privatization.

[00:23:57] Speaker 1: Oh, definitely. Yes.

[00:23:58] Randall Roth: You know, a lot of times here in Hawaii, people say we need to privatize, need to privatize. Well, this is a form of privatization. Okay. Uh Beth, any thoughts on that?

[00:24:07] Beth Giesting: Um no, but I have had a couple of thoughts uh while we were going through here and I'd like to present some some real improvements that uh I have seen the manage care have at our community health centers. And I think just in general that with a patient and uh physician relationship that is pretty much exclusive now, I think that that has uh really improved the kinds of healthcare and the access to care and an understanding of what the patients are supposed to be doing now. Previously, the patients could go anywhere, they could refer themselves to any physician who would see them, and now they are assigned to a primary care provider and they are not allowed to go anywhere else in theory anyway until they go through that person.

[00:24:54] Randall Roth: I would think that would be win-win. I would think they would get better service or better care and that it would save the state a lot of money.

[00:25:01] Beth Giesting: Mm-hmm. And I and another um uh product of of that exclusive relationship is that for, I think probably the first time, we are able to develop some quality and some improvements and some evaluation of how the patients are doing under this system. Because if there is a long-term relationship, we can see whether the therapy is actually improving their health generally, and before because it was scattered and we had no idea what they were getting, we couldn't do that.

[00:25:33] Randall Roth: So before everything was on the inputs, you know, how much money we're going to spend and now there's some focus at least on outcomes.

[00:25:40] Beth Giesting: Okay. Well, let's take a call. First, Lynn from Mano. Good morning, Lynn.

[00:25:45] Speaker 2: Uh, good morning. Can you hear me?

[00:25:46] Randall Roth: Sure can.

[00:25:47] Speaker 2: Okay. I have a question for Winnie Oda. Um, could you please explain what Quest what is it QuestNet or NetQuest is and why the income level has been set at approximately $420 and my interpretation of that is that anybody that's receiving income of in excess of approximately $420 has to pay the premium of $174 for for QuestNet, and isn't that going to produce a a lot of people falling through the cracks and where are they going to go get their primary and secondary care? They're going to get it at the hospital, and who's going to pay for that, the insurance company, and then who's going to pay for that is the insurance payer?

[00:26:26] Randall Roth: Lynn, stay on the line. Uh and Winnie, so that our listeners understand, we've been talking about Quest and No, no, I understand, Lynn. Lynn has just raised the topic of of QuestNet, which is, as I understand it because uh the change in the eligibility rules have resulted in 40-something thousand people who were a part of Quest being bumped out. QuestNet has been created as an attempt to kind of catch those folks. Uh but there's been a lot of criticism of QuestNet. I read a letter to the editor in the newspaper the other day that called it managed non-care which obviously was was tongue-in-cheek. But uh Lynn raises a very good point. Uh what are your thoughts?

[00:27:07] Speaker 1: As Randy says, um and if you remember, Lynn, my explanation prior uh as far as the Quest program. We when we were challenged legally, one of the things that we could have done was to put the assets back into the Quest program, knowing full well that there would be a significant number of folks who no longer qualified for Quest and would be scrambling around for their own insurance. We went back to the federal government and said, uh give us a chance to put a safety net program together called QuestNet. It will certainly not be not be as comprehensive as the Quest program. Consequently, it will be cheaper. Most of the folks will have to pay out of pocket. We um adjusted the asset limit. And I'm not at all sure what you mean by that $424 limit. There Anyone whose income is above the poverty level, which is seven approximately $748 a month, will pay the full premium of about $61.80 a month. Anyone whose income is below that, the state fully subsidizes them. And for any children within the QuestNet program, if their uh family income is above 100% of poverty, they will pay the $60 and the state will subsidize the balance of it because the children will always have the comprehensive Quest coverage. So the state will subsidize a significant amount for children in QuestNet. And for the adults, the the premium is much cheaper.

[00:28:51] Speaker 2: Um I thought that that level of What what did you say, $600 something dollars? $748. $748. Anybody that um has income above 748 has to pay the full premium of approximately 160 to $170 a month.

[00:29:08] Speaker 1: No, no, that would be the Quest premium. And Right. The Quest premium. No, this is No, no. You're talking about QuestNet. Quest the QuestNet premium is $60 a month for the medical and a dollar 80 for the emergency dental coverage. So it would be $61.80 for both the medical and the emergency dental care. There is uh the amount you're quoting would be for the Quest coverage. And these people, remember, no longer qualify for Quest.

[00:29:39] Speaker 2: But they can still get Quest, can't they?

[00:29:41] Speaker 1: No. They no longer qualify for Quest.

[00:29:43] Randall Roth: Winnie as as I understand it and this is Randy Roth, um Quest the premium is higher but people don't pay that premium, right? Isn't the the people who are in Quest, isn't it provided by the state?

[00:29:55] Speaker 1: People whose income is below 100% of poverty, the state fully subsidizes them in Quest. If their income is over 100% of poverty, they pay the full premium. The difference with Quest and QuestNet is the asset test. The the folks in the Quest program, for a single person, you can your assets cannot exceed $2,000. For a couple, it's $3,000. And for the QuestNet program, it's $5,000 for a single person and $7,000 for a couple.

[00:30:28] Randall Roth: So what we're basically saying is that that from the member standpoint, Quest is far more attractive than QuestNet. Uh but Quest is limited to people who who are below certain income and below certain asset levels.

[00:30:43] Speaker 1: It's mainly the assets.

[00:30:44] Randall Roth: Okay, that's that's the tricky one. That's the key. Okay. Uh let's go to uh Beth Gisting.

[00:30:50] Beth Giesting: Well, I would just like to note the one of our major disappointments about the QuestNet program and that is that it's only available to people who have been in the Quest program. In other words, it's a program that was set up as a safety net when the Quest program changed its requirements.

[00:34:35] Speaker 3: problem that a lot of more peop a lot more people who turn up uninsured uh every day for one reason or another at health centers or at other locations and there simply is not a low-cost program for them to get into anymore.

[00:34:48] Randall Roth: Good point. Lynn, thank you for your call.

[00:34:50] Speaker 2: Thank you.

[00:34:51] Randall Roth: We go to Margo from Maui. Good morning.

[00:34:54] Speaker 3: Hello.

[00:34:55] Randall Roth: Is it Margo?

[00:34:56] Speaker 3: Yes.

[00:34:56] Randall Roth: What do you have for our guest this morning?

[00:34:58] Speaker 3: Um, having had a brief short experience with Quest, I think it was the biggest joke that happened to the people of Hawaii.

[00:35:04] Randall Roth: Now why do you say that?

[00:35:06] Speaker 3: Um, I number one, it took three months to get on it because they kept losing the paperwork but I went to a primary care doctor uh for thyroid, he didn't know how to read the lab report, therefore told me that I didn't need thyroid. Um, kept me waiting an hour and a half although it was the first patient there, spent 10 minutes with me, then told me that he couldn't help me because I wouldn't have X-rays, which I it wasn't there for anything that I needed X-rays for, but he did have X-ray equipment. He spent 10 minutes with me and when I got a copy of the bill, I think it was $97. Hm Margo I complained to HMSA and they were very, they were rather flippant about it. They couldn't have cared less.

[00:35:37] Randall Roth: Margo, let me get a reaction to this from George Busy, who's the medical director at at Queens Hawaii Care.

[00:35:48] George Bussey: I think one of the major advantages that Quest can have if it's done correctly is the identification of these kinds of problems built into the whole Quest initiative is a requirement for the state to monitor the quality of care that's delivered by the different plans. As one of the plans, we are then responsible for monitoring the quality of care that our providers give to our members. We have uh a lot of staff dedicated to taking these kinds of calls, these kinds of complaints from members. We have nurses who are responsible for then investigating those problems, uh looking at the medical records, seeing if there's been either a miscommunication or actual poor quality of care. We have a committee of physicians that then reviews um those situations and makes recommendations back to the doctors who were involved in the original difficulty. There's also um and I won't get into the details, but there's a very uh comprehensive set of quality measures that all the plans have to put together and deliver to the state. So we're hoping to learn how often these kinds of problems happen, to learn how to fix them, and then to see whether or not our fixes actually work.

[00:37:10] Speaker 1: I would just like to comment on the fact that you had to wait for three months to get your eligibility your application processed and this is one of the the things that has has been a concern to me and to the entire staff that the there were an overwhelming number of applications and many new workers. What we did because we realized that all of you who were probably eligible had to had a significant weight was that you are your healthcare cover whatever healthcare you needed during that interim, if it were covered within our program, we would have assumed that um that responsibility to pay that as well. And until that application was processed and you selected a plan, we would have covered it what we would with what we would call couponing. We would have given you a coupon to give to your

[00:38:00] Winifred Odo: a physician or your uh healthcare provider and they would have billed us directly. So, we uh we were fully aware that there was a long wait and we did not want to inconvenience you if you really qualified.

[00:38:13] Randall Roth: Um, when someone like Marjo who has a bad experience in the in the Quest program, uh if they complain to the plan that they're with and and they don't feel like something is being done, is there a place with the state office that they complain to or what do they do at that point in time?

[00:38:30] Winifred Odo: They have that is their uh the due process. They complain to the health plan and if they are not satisfied, they should be calling our office. What we do though on a regular basis is we the health plans submit to us all of the complaints that they've received and how they have uh uh handled those complaints, and then we will look at that and follow through to make absolutely sure that what they've indicated to us is correct.

[00:38:56] Randall Roth: Okay. Marjo, if you haven't done that, I'd encourage you to give it a try.

[00:39:00] Speaker 1: Well, number one, I don't think that any health plan like HMSA is going to handle all their complaints.

[00:39:05] Randall Roth: Well, I you know, if if that's the way you feel, you should call the the Quest office directly.

[00:39:11] Speaker 1: Is there a number for that?

[00:39:12] Winifred Odo: Sure. It's 586-5486.

[00:39:16] Speaker 1: 54

[00:39:17] Winifred Odo: 5486. And you'll get right into my office.

[00:39:19] Randall Roth: All right. Thank you, Marjo. We appreciate your call.

[00:39:22] Speaker 1: Bye-bye.

[00:39:23] Randall Roth: You're listening to the Price of Paradise radio show. We're talking about the QUEST program here in Hawaii. If you'd like to ask a question or make a brief comment, our number is 955-8821. Or if you're on a neighbor island, it's 1-800-955-8821. We're going to go in just a couple minutes back to Fred Holshoe in Hilo, but we've got somebody who's been waiting patiently on the phone. We'll go first to Paul from Maui. Good morning, Paul.

[00:39:49] Speaker 2: Good morning, Paul.

[00:39:51] Randall Roth: What do you have for our guest this morning?

[00:39:53] Speaker 2: Oh, I just I just wanted to make a comment. I'm a I'm a physician here, um, and um, one of the one of the concerns that has come up, I was just looking at that that call is that as the program started, um, there weren't enough providers. There weren't enough people that participated with it because because partly because of the way it was set up and partly because of the way the reimbursements are. It's not that much different than the old Medicaid system. People look at it as a way to get out of Medicaid. And the example that you just gave was that some of the providers that were chosen here are people that that are, you know, I mean I hate to use the word, but marginal. And, uh, so you've got you've got people that are supposed to be getting primary care with people that are not really that good of providers, and beyond that, they don't participate in the hospital here.

[00:40:41] Randall Roth: You're saying the physicians that are a part of the program are sometimes not good providers, or who are you talking about when you say that?

[00:40:47] Speaker 2: Correct. Yeah. The the gal that needed the thyroid workup wasn't able to get it because of somebody that she saw that probably was not that good. And beyond that, if she had needed to be hospitalized, a lot of the people that were picked to be in the program over here because they were they weren't able to get everyone to do it, okay, didn't work in the hospital.

[00:41:06] Randall Roth: Paul, I think you've touched a nerve because we immediately got two calls from two physicians on Maui in the last 10 seconds. So we're going to be hear from them as well. I appreciate your call, Paul.

[00:41:17] Speaker 2: One of the one of the points you could ask, uh Winnie Odo there, uh the other problem with the Quest net is it has the same set of, um, coverage that the old ship did, which is 10 hospital days, very limited amount of of coverage. So the difference, the other difference in Quest and Quest net is that if somebody gets has a significant illness, you know, they're they're in trouble after 10 days. They you know, they're going to end up responsible for the hospital bill. It's those two are very different, but the way that they went about doing this initially, they they weren't able to get adequate participation of the physicians on the islands to provide coverage to provide adequate care.

[00:41:57] Speaker 2: So that's that's remains an issue, I think.

[00:42:01] Winifred Odo: I think, uh, we, um, tried to to uh to develop a package quickly in response to trying to, uh, correct the the legal challenges. And as I said earlier, one of the things we could really have done is to say, whoever didn't qualify for the Quest program as we put an asset to back in really had to go and look for their own health insurance. However, in trying to quickly put a package together, I think there will always be controversy and always be people who don't like what we do, what we put together. We had to do it very quickly. So what we really did and you're very right, doctor, that we revisited the the ship package and felt that that was something that was put together based on, uh, the population's needs.

[00:42:49] Winifred Odo: And so what we did was, uh, we added five inpatient days. If you remember, ship had only um, five inpatient days. We added another five, so it's 10, and we added basic prescription drugs. But, you know, we all we all realize and acknowledge that that is a very, very basic package. Nonetheless, we felt that was better than having nothing at all.

[00:43:10] Randall Roth: Okay. Paul, I appreciate your call. Uh, our lines are just packed. Uh, some something that you or somebody else said very recently has really touched a nerve. So we're going to try and, uh, get to all of these folks very quickly, but first, I want to ask, uh, Fred Holshoe, uh, who's in the Hilo Medical Center. Fred, real quickly, any reaction to what you've been listening to?

[00:43:30] Fred Holschuh: Yeah, Randy. First of all, uh, you need an all-day forum, um, quite frankly, as you as you realize from the calls you're getting. I just wanted to make a couple of real quick comments and hope you'll give me a second at the end of the show. But, um, in response to what the lady from Maui said, it's interesting. I had a lady in the Hilo ER just yesterday who had some similar complaints, and she said she was afraid to complain because she felt so grateful for the care she was getting free that she felt she shouldn't raise it. The flip side to that is I know from being on the Quest provider board, that Winnie Odo means what she says when she says, please call and let us know if there are problems, and I would encourage people to do that, either through the plans or directly through Medquest.

[00:44:13] Fred Holschuh: And the other thing, in response to the physician from Maui, um, it's my understanding, and Winnie, correct me if I'm wrong, uh, it's my understanding from being on the Quest board that physicians when they sign on to Quest must have some arrangement for hospitalization by the by mandate of the program. And so we have uh a way to funnel complaints and problems to the Quest program through our physician members of the Quest provider board and every single county is represented.

[00:44:40] Randall Roth: Okay. Great. Fred, stay on the line. We will definitely go back to you by the end of the show. Um, now we go to Charles from Maui, another uh physician from Maui. Good morning, Charles.

[00:44:51] Speaker 3: Good morning.

[00:44:52] Randall Roth: What do you have for us?

[00:44:54] Speaker 3: Um, I just, uh, a couple of comments. Um, I've been a participating provider in Maui. I'm a specialist and I take care of quite a few Quest patients, and I elected to participate with the Queen's Quest program as opposed to the HMSA program, uh, for various reasons.

[00:45:07] Randall Roth: No commercials, no commercials. Let's hope it would have been a commercial.

[00:45:12] Speaker 3: Anyway, my experiences with Quest have been mixed. Um, it's certainly a very generous benefit package and in fact, it's much more generous than the regular insurance plans that most of my patients have here in Maui, the ones provided through their employers.

[00:45:26] Randall Roth: I've heard that over and over and getting ready for this show and and I don't know which way that cuts. But uh I've heard that it's more generous than what most people uh can afford to pay for.

[00:45:35] Speaker 3: Right. And I and I've also come across a number of people who, uh, don't appear to be under economic hardship, uh, typically transit young people that come here to Maui to stay for a few months, uh, get injured, have a motorcycle accident, don't have no fault insurance through their motorcycle which they've elected not to purchase, Mhm. which is in my opinion, a an egregious, uh, miscarriage of insurance justice.

[00:46:02] Randall Roth: Okay. We we heard something like that a little bit earlier.

[00:46:05] Speaker 3: Yeah, I just don't don't understand why automobile drivers are forced to pay for no fault insurance, but motorcycle riders, that's another issue, Charles. to buy medical insurance. Okay. When these patients are responsible for, uh, a large number of hospital inpatient charges and and treatment for injuries that they sustain.

[00:46:24] Randall Roth: Charles, we're going to have to to move on. I really appreciate your calling in. Um, we're going to have to go to another physician on Maui. We don't have to, but we want to. Uh, John, are you there?

[00:46:34] Speaker 4: This is him.

[00:46:35] Randall Roth: Thank you for calling in. What do you have for our guest this morning?

[00:46:38] Speaker 4: I think the reason you're hearing so much of this is because you have such a large following, not because we're a bunch of melters. I listen to your program every Sunday.

[00:46:47] Randall Roth: I like that explanation. Go ahead, John.

[00:46:49] Speaker 4: Um, I'm a I'm a psychiatrist who's been in private practice, uh, here for for the last 21 years and uh I had always seen uh Medicaid patients prior to the conversion to the Quest. Uh when the program uh began, I was a a charter uh participant with some skepticism. Uh, I was I I didn't see how this could work, but, uh, I was also enthusiastic uh about uh getting the program out of government hands. Uh, my experience with it has been awful. Um, I think uh, uh, in contrast to Mrs. Odo's, uh, comments about management, the oversight and preauthorization and authorization and paperwork upfront, uh, has been probably double that of the commercial plans and more difficult.

[00:47:39] Speaker 4: And the errors in claims and reimbursement, uh, has also been increased. Um, I don't know what to do about this, but I don't understand why that should be.

[00:47:51] Randall Roth: Well, John, let's let's get a reaction to that. Stay on the line, uh, Winnie Odo.

[00:47:55] Winifred Odo: I, um, if you have problems, doctor, and you feel that, uh, the plans that you're participating with are, um, doing something that you feel uh should uh should not be done that way. I think first of all, you need to go directly to the health plan with whom with you have a contract.

[00:48:18] Randall Roth: I'm sure he's done that repeatedly.

[00:48:19] Winifred Odo: And if you feel at that point that you are not, uh, getting the type of resolution or the type of, um, uh, concern from the, uh, various health plans that you feel is needed, then again, you need to let us know, because ultimately, it is our responsibility. We are responsible for the administration of the program. We are the agency that needs to respond to the federal government who has approved this. And, uh, one of the the uh, main concerns of the federal government is the adequate access to care and the quality of care. And if providers are not happy, that compromises the access and also possibly the quality. So, if you feel that you are not getting the kind of resolution that you feel is warranted, then you need to really formally, uh, let us know.

[00:49:15] Speaker 4: Yes.

[00:49:15] Randall Roth: Anything else?

[00:49:16] Speaker 4: Uh, well, it I'd like to make, uh, you know, give another, uh, statement about this. The, um, the only reason that these plans, uh, from Medicaid through Medicare, through Quest, uh, can operate is by the beneficence of the physicians who are participating in them. Uh, somehow that never gets mentioned publicly. This is essentially public service work, and I think it's a good thing to do. Uh, I think we ought to be doing it. In fact, I've I've made the statement on a number of occasions that participation in these plans is either the right thing to do, uh, or one has nothing else to do. That is, they don't have, uh, a patient population other than this, uh, which is a terrible thing for the physician himself.

[00:49:59] Speaker 4: Uh, the problem is that in providing what is essentially pro bono work, which I said is I think a desirable thing for all of us to do, uh, we are having to, uh, to put up with more hassle and more difficulty. And, uh, and in response to Mrs. Odo's uh comments, I've repeatedly gone to the plans. Uh, 90, probably 95% of the administrative problems that I have in in my practice, uh, are due to these plans. And, uh, as of two weeks ago, I've resigned.

[00:50:30] Randall Roth: Okay.

[00:50:31] Speaker 4: And there are now no practicing uh participating psychiatrists on this island.

[00:50:35] Randall Roth: Yeah. So instead of things being easier for you [unintelligible — audio glitch] getting a pat on the back, um it's just not happening.

[00:50:42] Speaker 4: I don't expect a pat on the back. I just don't want to be punished for it.

[00:50:44] Randall Roth: I understand. Okay, John. Well, we appreciate your comment this morning. We're going to try to get to everybody who's been waiting patiently, and then I want each of my guests to have an opportunity to make some some concluding comments. Ruth in Kailua, good morning, Ruth.

[00:50:57] Speaker 5: Good morning. Please, I hear now that the benefits for the indigent ill are many, but I have a question for Dr. Buzzy. Since he has such fantastic credential credentials and is connected to the State hospital for the mentally ill department, can he explain the bad reputation of the State hospital with regard to the treatment of the patients there? Two years ago, I was told by a counselor at Kessell Human Services, if you want to know humiliation, go to the State hospital.

[00:51:30] Randall Roth: Okay, Ruth, and and I think you've raised a a completely different subject, but maybe I'm wrong. George, is there a tie-in with what Ruth has raised to Quest?

[00:51:39] Speaker 6: Well, the benefits are great, but are they services given just just.

[00:51:47] Randall Roth: Okay.

[00:51:48] Speaker 6: The the the only tie-in that I see gets back to one of the original comments I made, which is that society has to look at how much money and how much energy it's willing to invest in taking care of people who need medical services, including psychiatric services, and the State hospital in its way has been operating under the same limits that everybody else has, trying to deliver good care with a limited budget. I happen to know some of the people who are still working there. They're highly dedicated. They're working very hard to, um, get that hospital, uh, accredited by the Hospital Accrediting Association, and um, they're doing, uh, an excellent job at moving in that direction.

[00:52:32] Randall Roth: So, funding. Funding, you know, that this this country and the delivery of any services in this country, uh, to a large part, runs on money. And the part that's not money is what the uh, uh, John from Maui was talking about, people just making decisions to do things because it's the right thing to do. Okay. Ruth, thank you for your call. We we really appreciate it. You're listening to the Price of Paradise Radio show. Our topic this morning is is Quest. Uh, we've taken uh quite a few calls. We have some more folks on the line, but we're running out of time, and so, uh, why don't you all just sit back and listen to the last uh 11 minutes or so as uh we um uh give our guest an opportunity to to make some concluding remarks. If you would like to hear the show in its entirety on KIF KIFO 1380 AM tonight at 8 o'clock, you can do just that.

[00:53:23] Randall Roth: Uh, I want to remind listeners that with me in the studio is Winnie Odo, who's the head of Quest here in Hawaii, Beth Gisting, who's the executive director of the Hawaii State Primary Care Association. They provide support to all the community health centers, and George Bussy, who's the medical director of the Queen's Healthcare Program. By phone, we have Fred Holshoe, who is a, uh, an emergency physician at Hilo Medical Center and the immediate past president of the Hawaii Medical Association. Well, let's see. We had a couple people on the line and I think maybe they decided to, uh, to sit back and, uh, take my advice and sit back and listen to uh to our guest. Before I ask you each to make some concluding comments, Beth, I wanted to ask you, I talked to some physicians at [unintelligible — audio glitch] community health centers. And several of them said that the squeeze on you folks is so tight right now that they're engaging in in triage, that that people who are real comfortable coming to the center continue to come in droves and yet you don't have anywhere near the resources that you had before Quest. And he he just didn't feel good about the quality of care that that you were capable of providing right now because of of the financial crunch. What's your reaction to that?

[00:54:39] Beth Giesting: Well, I think that, uh, unfortunately that does tend to be true when, uh, there are more people demanding care than the resources to support them. The health centers are trying to see everybody who comes in, but they do have to make some choices and work with the patient to make choices that the patient can afford. Um, for instance, if the patient, uh, needs some sort of diagnostic tests or prescriptive medicine, they have to they have to do what they can. Maybe they the patient can't afford it, the health center can't afford to send them for these tests. Um, the physician may believe that the best prescriptive medicine is one that the patient cannot afford, and then they have to make some compromises with what they can get available for free.

[00:55:26] Randall Roth: And I and I think one of your comments earlier, if I understood it, was that there are some people who maybe are in the Quest program and have a physician elsewhere that they could go to, but because of various barriers, um, they they just show up at at your center. They feel most comfortable or they're most used to going there or whatever, is that correct?

[00:55:45] Beth Giesting: Um, it's not so much that they come there if they're not assigned to the the health center. It's more a case that the health centers provide a lot of services for people who have barriers to care. They have language services, transportation, and so forth. And those services are not necessarily paid for in full by the Quest program.

[00:56:01] Randall Roth: So they've been assigned to you but the funding, uh again, we come back to uh the funding. Okay. Well, we're down to the last seven or eight minutes and I want to give each of our guests an opportunity to to conclude or or add some some concluding comments. Let's go first to Fred Holshoe, who's been with us by phone in Hilo. Fred, are you there?

[00:56:20] Fred Holschuh: I sure am, ready, thanks. Uh, you got an opportunity to kind of put it all together and help all of our listeners understand exactly what's going on and what needs to be done. Go for it. Thank you. I'm going to have to get a little philosophical, but thank you. Um, I want to make three quick points. I'm very concerned about the points Beth raised, and, uh, in terms of what's going to happen to people who are falling through the cracks, and I think all of us are trying desperately to work on this. This is much like the GA funding problem. You can't have people become dependent on something and then cut them out suddenly. And so we have to, as John from Maui and George Bussy said, we have to work on this. We have to be very, very careful to to uh have an evolution of

[00:57:00] Fred Holschuh: I'm worried to care for these people, for the very poorest of our citizens. Secondly, one of the least addressed issues, uh, at least in terms of all the talking and planning, is really basic behavior modification and personal responsibility of patients. And, I'm not trying to be mean or harsh about this, but let's get real. We've got to do something in this country and in our state about allowing the plans to have their people, and I know they're working on it, and this is a real positive thing we could do, to work on things like substance abuse, alcohol, and other drugs, violence, trauma, and tobacco use. My God, if we just did away with tobacco use alone, we'd save so doggone much money in this country.

[00:57:39] Fred Holschuh: And the final thing I wanted to say, Randy, if I may, one more quick comment. It's a real honor and a privilege to take care of patients and receive their trust, to be a physician and be able to receive the trust of patients. And one of the great risks of managed care organizations in general, and I'm not specifically talking of Quest, but one has to look at this in general, is what's called patient protection kind of concept. And we must allow physicians and their patients to work together so that physicians can place the interest of their patients first and foremost and be their advocates. And so, no matter how it all comes down, the very best patient care has got to be the rule that that everyone follows.

[00:58:20] Fred Holschuh: And I think in Hawaii, thank heavens, we're working on this, our dialogue is allowing this, and I think we're really in a very positive direction in this regard in our state, and I'm real proud to be part of that.

[00:58:31] Randall Roth: Great. Thank you, Fred. We really appreciate your participation this morning. Well, in the studio, Beth Gistein, who is the executive director of Hawaii State Primary Care Association, any thoughts?

[00:58:41] Speaker 1: Uh, yes. I think my concluding thoughts are that we certainly do recognize that we have limited resources, but, um, our feeling is that what we should try to do is cover everybody who needs care, but that means that we're going to have to make some hard choices about the benefits that we offer. And we feel very strongly that if we emphasize prevention, if we emphasize primary care, we will be we will be able to uh improve people's health a lot more for a much smaller price tag, and that was would be what we advocate.

[00:59:18] Randall Roth: And and this is, I've I've heard people talk about a uh a health model rather than a medical model or something like that.

[00:59:24] Speaker 1: That's right. In a health model, we will um support the services that improve people's health, things like health education, things like uh preventive programs that are not necessarily usually covered by insurance, things like uh smoking cessation or uh domestic abuse prevention, um, as well as a lot of things that are more closely related. But in a medical model, we cover the things that have already gone wrong. We provide open heart surgery to people who have been smoking and obese and all these other kinds of things, instead of trying to make sure that people change their diet, get exercise, stop smoking.

[01:00:01] Randall Roth: And you feel that Quest has been a little bit too pointed in the direction of of the medical model and needs to be a little bit more in the direction of the health model.

[01:00:08] Speaker 1: I think it it is pretty much followed the old rules, and I'd like to see that change.

[01:00:12] Randall Roth: Okay. Thank you, Beth. Uh, George Bussey, the uh medical director for Hawaii, no what it is it. Uh, Queens Hawaii Care, one of the five plans under Quest. Any concluding thoughts?

[01:00:24] George Bussey: Well, I would like to um echo some of the stuff that Fred said and and also what uh Beth was saying in terms of the importance of both personal responsibility on the part of patients as well as the need to focus on um primary care and prevention and education. I think one of the problems is that this population, hopefully by definition, is not a permanent population. They are while they're having financial difficulties, or while they're temporarily disabled, they're part of the Quest plan. Um, the payback on the stuff that that Beth is talking about, comes down the road. And if if we can figure out a way to really calculate how much that's worth and what our payback is, and I think funding for those kinds of programs up front is is appropriate.

[01:01:15] George Bussey: But with a population where um they're in and out of the the plan every year or so, it's hard for the the people who are um running the purse strings to see the payback on that. It's a societal payback and society has to decide where they're willing to pay for that and how they're willing to pay for that.

[01:01:34] Randall Roth: I guess we can't forget that the taxpayers are footing the bill, that and and they want that thing you mentioned earlier, value.

[01:01:40] George Bussey: That's right. Okay.

[01:01:42] Randall Roth: Winnie Odo, you're the head of this thing that's been the topic of our conversation this morning. You've got a minute to give us your concluding thoughts.

[01:01:49] Winifred Odo: I think um in listening to George and Beth and Fred, you can all understand how fortunate we have been in trying to launch um a significant change in the way healthcare is provided to our vulnerable population. It's been a rough road for the last uh 22 months of this program, but I think in retrospect, we can look at and compare what happened 22 months ago and see what's happening today. And although um we still have many areas that we need to refine and we have good folks that are helping us do this, um we have come a long way. We have uh provided more healthcare coverage to a lot more people, and the quality, I I really don't think has been compromised. The access is better.

[01:02:39] Winifred Odo: And I think ultimately we we are are have reduced the per annu annual per capita cost without compromising quality. As I say, we'll continue to try to improve this program, and all of us are committed to making absolutely sure that the vulnerable population in Hawaii has good healthcare coverage.

[01:02:58] Randall Roth: Okay. Well, thank you. That was Winnie Odo. You also heard from Beth Gistein, George Bussey, and Fred Holschuh. The director of operations for Hawaii Public Radio is Jeff Ilarte, our producer is Suzy Roth. Helping her this morning was Reese. Next week, next week, you can hear the candidates for prosecutor in Honolulu County talk about our criminal justice system, what's wrong, what needs to be fixed, and how to do it. Aloha.

[01:02:38] Speaker 1: and I think ultimately, we we are are have reduced the per annual per capita cost without compromising quality. As I say, we'll continue to try to improve this program, and all of us are committed to making absolutely sure that the vulnerable population in Hawaii has good healthcare coverage. Thank you.

[01:02:58] Speaker 2: Okay, well thank you. That was Winnie Odo. You also heard from Beth Geesting, George Bussey, and Fred Holshue. The director of operations for Hawaii Public Radio is Jeff Ilardy. Our producer is Susie Roth, helping her this morning was Reese. Next week, next week, you can hear the candidates for prosecutor in Honolulu County talk about our criminal justice system, what's wrong, what needs to be fixed, and how to do it. Aloha.