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Kahtnu denied CON

Zirul: group will take time to consider options

Posted: April 4, 2012 - 4:21pm  |  Updated: April 5, 2012 - 10:12am
Eight local doctors make up Kahtnu Ventures. From left to right are Ted Barton, Bobbie Behrens, Gary Schoenrock, James Zirul, Henry Krull, Pete Ross, Roger Hoebelheinrich and David King.   M. Scott Moon
M. Scott Moon
Eight local doctors make up Kahtnu Ventures. From left to right are Ted Barton, Bobbie Behrens, Gary Schoenrock, James Zirul, Henry Krull, Pete Ross, Roger Hoebelheinrich and David King.

The State of Alaska on Wednesday denied the Certificate of Need application filed by Kahtnu Ventures LLC for building an ambulatory surgical center in Kenai.

State Department of Health and Social Services Commissioner William Streur wrote in a letter that he “determined that the application has not met the applicable criteria for approval to the satisfaction” of the state.

Streur wrote Kahtnu is entitled to a hearing if it is not satisfied with the decision. The request for a hearing needs to be received in writing no later than 30 days from Wednesday.

The state’s Certificate of Need staff issued a recommendation on Feb. 21 advising the commissioner to deny the application.

“It is recommended that the Kahtnu Ventures, LLC application for a CON for construction of a one-suite ASC in Kenai be denied based on the fact that the applicant did not clearly outline the cost and size of the project, did not define a service area and failed to show need for additional surgical capacity,” the state wrote.

According to the staff’s recommendation, more than 800 letters of support were submitted from all sources in regard to the application. About 200 letters were received in opposition to the project, including those from Central Peninsula Hospital, the city of Soldotna and the Kenai Peninsula Borough Assembly.

Kahtnu Ventures proposed building the $9 million, 8,365-square-foot ambulatory surgery in Kenai in hopes of performing 1,800 outpatient surgeries per year with a group of eight local surgeons headed by James Zirul and Henry Krull.

Kahtnu promoted its proposal as a choice for health care consumers that would lower the cost of outpatient surgeries and prevent medical out-migration to Anchorage.

Central Peninsula Hospital officials fought the surgery center idea on the grounds it would take away one of the more profitable service lines it offers, thus damaging their less profitable areas and the hospital overall. CPH currently does 1,700 outpatient surgeries with its three operating rooms.

CPH officials said losses could total $20 million from surgery charges from a total $150 million the hospital realizes in total charges among all services if the surgery center were built.

Zirul said Wednesday the group was disappointed by the decision and did not agree with the state’s findings.

“Although we have not yet had time to fully review the department’s analysis we do not feel it was correct for the state to count the two operating rooms from the South Peninsula Hospital as part of the inventory to determine need, which would require patients from the Central Peninsula Hospital service area to travel 90-plus miles for surgical care,” Zirul said. “We think that the residents of the Central Peninsula deserve their own free-standing ambulatory center and we stand ready to fill that need. We will be contemplating our options over the next few days.”

Zirul said applying for a hearing would be among the options the group considers. He said he thought Kahtnu’s application was good and it had good support.

“It’s very obvious there was significant public support for our project and again we are very disappointed the state did not approve the Certificate of Need,” he said. “I imagine the people who supported our project will also be disappointed.”

Central Peninsula General Hospital Inc. board president Lore Weimer said in a press release she was pleased with Streur’s decision.

“At CPH, we will continue to offer our award-winning surgical services to our patients and to provide a state-of-the-art facility and highly-trained personnel to support our community’s surgeons in our efforts to uphold the mission, vision, and values of the organization,” she said.

CPH Chief Executive Officer Rick Davis said the hospital will “continue to work diligently to improve the efficiency and functionality of our surgical services department.”

“We have added second and third shifts to staff the operating rooms around the clock, and our fourth operating suite comes online in May giving CPH plenty of surgical capacity to respond to the growing health care needs of our community,” he said in the release.

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denseyler@yahoo.com
46
Points
denseyler@yahoo.com 04/05/12 - 11:17 am
5
1
Kahtnu Venture

So so sad when a minority rules the majority. CPH has a monopoly on the health care for everyone on the peninsula. Other hospitals that I have knowledge of makes CPH look like a MASH unit. Without the expertise. Sanitation is very lacking also.

Norseman
2955
Points
Norseman 04/05/12 - 12:10 pm
2
5
Then please explain why our

Then please explain why our Hospital continually receives OUTSTANDING reviews by it's patients.
Also explain why they continually receive some of the highest awards for excellency in the health care industry and are the envy of many other hospitals.

Obviously you are not interested in reality or the facts.

robert white
378
Points
robert white 04/05/12 - 12:57 pm
5
0
certif of need

Doesn't take a rocket scientist to fugue what our mayor was doing in Juneau last month! no vote for you next time!

ItGirl
8
Points
ItGirl 04/05/12 - 02:44 pm
4
0
CPGH

Recently I have had the unfortunate need to spend time at CPH. Previously, my experiences have been minor but having been to "outstanding" hospitals in the past I respectfully disagree that this is one of them.

I complained when my son broke his collarbone and the x-ray tech would not let me in the room with him. When I didn't hear any activity I opened the door and she was on the cell phone talking to someone while my young child was standing in front of the x-ray machine. I made it in time to catch him when he started to fall. After that I refused to leave the room and with a deadpan, fury-hiding humor I advised her that she was x-raying the wrong shoulder.

Since then, I have, of course, viewed our hospital with a more critical eye. I have wiped and disinfected dried "fluid" from our emergency room hospital bed TWICE!!! I refused to use the ER bathroom because of the amount of fecal matter on the floor and on the back of the toilet.

At this point I simply plan to disinfect every surface myself. Recently I spent 4 days in the new section and was pleasantly surprised with the care although i still disinfected the room.

I do not expect perfection so I take responsiblity to protect me and my family.

Our hospital is so friggin' expensive it is crazy. My insurance companies are always negotiating a lower rate because they are so far above the norm. In the last 5 years, my visits cost 6k, 30k, 8k, 25k and 15k. Each time I reviewed the bill and found charges that were almost a joke they were so high.

I think a little competition would have been a great asset to this community.

lohp75
0
Points
lohp75 04/05/12 - 07:22 pm
3
0
Kahtnu

CPGH has always had the last laugh because they know we have no other local options. If you threaten to go to Anchorage for care after being treated badly, they laugh in your face and say "There's the door." I've been a resident here for more than 20 years and deeply respect the doctor's who formed Kahtnu. I hope they'll continue to fight the State of Alaska for their well deserved licensing.
As for my family and I, we're leaving the state soon in pursuit of more medical options. Too bad we can't wait any longer to see CPGH face real medical competition.

As for those "Outstanding Awards", you might want to check the facts and see which doctor's helped CPGH earn those. Could it be some or all of the very same excellent doctor's that formed Kahtnu? I have friend's that are on staff also and I believe they help make the patients stay bearable.
Overall, as a former patient several times over, thumbs down to you, CPGH.

lohp75
0
Points
lohp75 04/05/12 - 07:22 pm
4
0
Kahtnu

CPGH has always had the last laugh because they know we have no other local options. If you threaten to go to Anchorage for care after being treated badly, they laugh in your face and say "There's the door." I've been a resident here for more than 20 years and deeply respect the doctor's who formed Kahtnu. I hope they'll continue to fight the State of Alaska for their well deserved licensing.
As for my family and I, we're leaving the state soon in pursuit of more medical options. Too bad we can't wait any longer to see CPGH face real medical competition.

As for those "Outstanding Awards", you might want to check the facts and see which doctor's helped CPGH earn those. Could it be some or all of the very same excellent doctor's that formed Kahtnu? I have friend's that are on staff also and I believe they help make the patients stay bearable.
Overall, as a former patient several times over, thumbs down to you, CPGH.

rock_alaska
3
Points
rock_alaska 04/05/12 - 11:20 pm
6
0
BS

I'm all for Kahtnu Ventures, 8 great doctors, serving many different areas, under one roof! Don't give up, because we NEED & WANT you to bring better options for us here on the Peninsula. The way it is, I've stated to all I know, if there is ever a hospital need, just throw me in the vehicle and haul butt to Anchorage. No sense in stopping at CPH...

homeinak
0
Points
homeinak 04/06/12 - 08:22 am
6
0
follow the leader

How sad that our borough believes it has the right to monopolize our health care. Conflict of interest, heck yes... Is their role to serve the public or run a business and use their power to keep competition away? What next, eliminate all schools not run by them and put a halt to anyone who plows snow except them. They should start thinking about generating tax money—not spending it, in order to keep control of something they know nothing about – (my healthcare).

Funny, how the borough doesn’t even use CPH for their own employee health coverage. I think they are telling us something... to follow the leader and get better more reasonably priced healthcare in Anchorage. Let's just hope our fine doctors continue to fight for us and our right for choice... Let's hope CHP doesn't hire a dentist and chase all our dentists out of town...

"A conflict of interest (COI) occurs when an individual or organization is involved in multiple interests, one of which could possibly corrupt the motivation for an act in the other".

steelhorse
48
Points
steelhorse 04/06/12 - 11:10 am
2
0
CPGH

I like the hospital just fine. Overall, especially in the past several years they've done a great job for me and my family and there are a hardworking bunch of people over there for sure.

That said, I also respect the doctor's who've formed Kahtnu and have received great treatment from them over the years as well.

My bottom line? Options are always good to have and this to me goes against the spirit of free enterprise and capitalism.

I'm not a capitalist, I just believe people should have a right to compete and may the best business win.

Competition is a good thing in business we all know this so why are we so against this is confusing.

jlmh
351
Points
jlmh 04/06/12 - 02:38 pm
0
0
Part 2: the bill

The proposal for a surgery center is largely about money, so debating the hospital's standard of care isn't that important to this particular discussion. Paying patients want lower costs, and doctors probably want higher profits - both achieved by Kahtnu. Patients who are not responsible for their own medical bills don't get it. It's the patients who self-pay or have to meet insurance deductibles and co-payments that have a stake in this. If all you have to say about the issue is that your hospital experience was great, then you're missing the whole point. Perhaps that's because you're one of the patients that don't get a bill (charity care, Medicaid, those with excellent insurance policies such as district employees), or you're independently wealthy. For the rest of us who are overcharged to cover the hospital's costs, we would like a way out. (Currently, the hospital only offers giant discounts - 25% - to customers who can pay in full within 30 days. Now who do you think really needs that break? Customers who can pay up front in 30 days, or those on a payment plan? Really it's just a backhanded way to charge 25% interest, which borderlines usury.)

If it CPH really wants to subsidize care for those who cannot afford services, then it should get that support through borough taxes. That way every one pitches in a little, instead of paying patients getting gouged a lot.

Watchman on the Wall
2893
Points
Watchman on the Wall 04/06/12 - 10:06 pm
0
3
Obviously you are not

Obviously you are not interested in reality or the facts? Now thats a knee slapper comment there for ya folks, absolutely amazing.

Those frequent flyer miles that the borough mayor added up putting the sqeeze on to get this rejected in our Capital of Whoknew does seem to have helped his MONEY-opoly group of Sharing Equally partners here in the Peninsula Borough does it not?
USE YOUR HEAD, SAVE YOUR BREAD, VOTE FOR FRED, SOUND FAMILIAR OR APPLICABLE HERE? WHAT IF?
Sometimes you vote for someone and get what you don't deserve, like now. Just kidding.

Isaiah 1:23 does seem to fit here quit nicely as well as else where when it comes to those placed in authority of governing rightly & justly, but have gone astray for their greenbacks god, always holding out their hands for the bribe. Please forgive me if i'm wrong here, which i could be, but very unlikely considering.

We do have GR8 service at CPH, but make no mistake folks those that are insured get charged more to help cover those that don't have coverage. When someone can't afford to pay the total and is offered a 25% discount if paid in full by such a date, then one knows that there has been a slight rate hike some where along the way.
But this has nothing to do with the Nurses or aids or a few of the Dr's, it has to do with a small group of MONEYopolizers in control with the help of the Borough Mayor, period.
After all it is a BOROUGH OWNED HOSPITAL, isn't it?

I had better stop now as i am about to venture out of the WWJD area and be nasty errrrrrrrr than i may have already been.

Jeremiah 6:17

Norseman
2955
Points
Norseman 04/07/12 - 08:41 am
0
3
ignorant

The reality and the facts are that our hospital receives high ratings.

http://www.cpgh.org/body.cfm?id=9&action=detail&ref=48

Central Peninsula Hospital Receives Quality Achievement Award from Mountain-Pacific Quality Health
Mountain Pacific Quality Health announced the winners of the 2011 Hospital Quality Awards today. This is the tenth year running for these awards, which recognize Alaska hospitals for their dedication to ensuring that patients receive high quality care in the areas of heart attack, heart failure, pneumonia and surgical infection prevention.

Central Peninsula Hospital won the Quality Achievement Award, which is the top award

http://www.cpgh.org/body.cfm?id=9&action=detail&ref=29

CPH & Heritage Place Receive Quality Achievement Awards
Central Peninsula Hospital and Heritage Place are recipients of the 2010 Mountain-Pacific Quality Health’s Quality Achievement Award and Nursing Home Excellence in Care Award (the highest awards) presented by Mountain-Pacific CEO Janice Connors during this year’s Alaska State Hospital and Nursing Home Association (ASHNHA)

http://www.cpgh.org/body.cfm?id=9&action=detail&ref=10

Central Peninsula Hospital Wins Most Improved Wireless Hospital Award
CHICAGO—July 7, 2009—Central Peninsula Hospital (CPH) has been named to the nation’s MOST IMPROVED Wired Hospital according to the results of the 2009 Most Wired Survey and Benchmarking Study released today in the July issue of Hospitals & Health Networks magazine.
The 25 Most Improved are organizations who improved the most from the previous year. Marking its 11th year, the Most Wired Survey and Benchmarking Study continues to lead the field in analyses and benchmarking of healthcare Information Technology (IT).
It is Central Peninsula Hospital’s goal to improve patient care and widen their technology advantage over other organizations.

I for one am gratefull to have a quality hospital in our community along with many excellent physicans. The reality and the facts are that we have a high quality hospital, not some mash unit with poor sanitation.

Your doomsday religous prophecies and paranoid conspiracy theories are far from reality. Your knee must be bruised by now.

Watchman on the Wall
2893
Points
Watchman on the Wall 04/07/12 - 03:51 pm
1
2
As usual Norseman you always seem to

As usual Norseman you always seem to have a very hard time reading what people say, or comprehinding facts and reality. No matter who you reply to they are always lacking in any common sence compared to you. Why do you think that is? Is it that all of us are factless of reality or perhaps its you? Do you really think that anyone is going to click on any web site that you post? I would venture to say thats a BIG NO.
What part of I AGREE don't you understand that CPH has a GR8 staff mostly and i also appreciate their care for people?
I have absolutely no problem with them, it's those that are trying to MONEY-opolize the industry & control all commerce in this field that is the problem at CPGH and the Borough.

So explain to me where any dooms day prophecies were mentioned above in my post. Read my post very sloooooowly and you will not find it. The Bible verses i did mention have to deal with people that are always looking for a bribe and pervert justice for those bribes.
All of which seems at an epidimic stage world wide and seems to be in play here with CPGH and a few at the Borough.

Speaking of Conspiricy theories, if supposed theories come true, will they still be conspiricy theories? You probably think they will, which figures in with your lack of True understanding of whats really going on world wide or locally.
So just keep bending the knee to your own personal little Borough gods which will get you absolutely where you are now.

Jeremiah 6:17
because you won't read what it says i'll tell you, will the people listen to the warnings given, they will say NO WE WILL NOT LISTEN. Your posts are proof positive of this attitude you profess and seem to desire for others.
Good luck with that.

Allen
596
Points
Allen 04/07/12 - 04:27 pm
1
1
State Protects Local Residents

The State Department of Health and Social Services is to be commended for their careful look at the Kahtnu Ventures project and turning it down. Thankfully, they are looking at the big picture for health care in our area, instead of a popularity contest.

It's interesting that the Clarion chose not to mention that the "800 letters of support" were form letters, probably filled out by patients at the doctors' offices and sent in by the doctors.

It's disappointing that some commenters see the hospital as the enemy and seem to want it to fail, and not as the local-owned facility that we taxpayers have spent tens of millions of dollars building and supporting all these years, and which is one of the biggest employers in the area.

Norseman
2955
Points
Norseman 04/07/12 - 06:20 pm
0
1
spot on Allen.

spot on Allen.

homeinak
0
Points
homeinak 04/08/12 - 04:33 pm
0
0
form letters

How do you know they were form letters? Did state officials show them to you?

RaySouthwell
953
Points
RaySouthwell 04/08/12 - 09:20 pm
1
0
norseman

You claim, in a previous thread- “I having zip, nada, nothing at all to do with the hospital or any of it's facets except having had to be a patient there on a few occasions.”

I think most people will find your statements hard to believe that you are not connected to CPH management based on your previous posts,here

Who would believe that any citizen would have such extensive information on the hospital besides those connected to management?

Say, as knowledgeable as you are, what did Dr. Namie find about the Bullying management style at CPH when he was here in December 2009?

RaySouthwell
953
Points
RaySouthwell 04/08/12 - 10:25 pm
1
0
Allen

A little history of the Certificate of Need. As I understand it, the CON was mandated by the Federal Government in the late 60’S. All States had to comply with the federal law.

By the 1980’s President Reagan and economist Milton Friedman encourage the Free Market and the Federal Government repealed the mandated Certificate of Need in 1986.

Each State is to decide for themselves. If my memory serves me well, there are 20 States that have repealed CON.

A few years ago, Dr. Anderson ran against State Senator Wagoner, in part, over his concern Wagoner wanted to repeal Alaska’s Certificate of Need.

The only reason the State is involved in the Kahtnu decision is because of the CON. What do you think would be the chances, any local politician, opposing the repeal of CON with 80% community support for Kahtnu.

We need to understand the CPH Corporate Board is destroying our community owned hospital and their protected monopoly status can be repealed in Juneau.

RaySouthwell
953
Points
RaySouthwell 04/08/12 - 09:51 pm
1
0
For the record

Central Peninsula Hospital employees are some of the toughest people I have ever met, with the nurses leading the way. The list of employees that have endured the Bullying management style is long.

These employees endure the threats and deliver some of the best care I have ever seen in my 43 years of healthcare experience.

Beyond the bullying, the nurses rose above all others during the shooting in November 2008. They are my heroes and I want the best for them all.

I complain about the management style, but the care to our patients is number one!

normolson
389
Points
normolson 04/09/12 - 03:36 pm
0
0
Huh?

From the article: "Central Peninsula Hospital officials fought the surgery center idea on the grounds it would take away one of the more profitable service lines it offers, thus damaging their less profitable areas and the hospital overall."

"More profitable. . ."? Umm, isn't CPH a non-profit facility?

Allen
596
Points
Allen 04/09/12 - 04:47 pm
0
1
How do you know they were form letters?

homeinak asks "How do you know they were form letters? Did state officials show them to you?"

It's in the staff report posted on the Department of H&SS web site:

"Over 800 letters of support were received before the deadline either during the public meeting, by mail or by e-mail. These letters of support were a form letter addressed to the CON program..."

Allen
596
Points
Allen 04/09/12 - 04:54 pm
0
0
Non-profit Doesn't Mean No Profit

Dear Norm Olson:

CPH is a building.

The company that operates CPH is a non-profit. Non-profit does not mean no profit. Non-profit means profits don't go to owners, but go back into the business. If the operating company earns profits in some departments, it can subsidize other departments so CPH can run in the black, and there is a low service area property tax rate.

Norseman
2955
Points
Norseman 04/09/12 - 04:57 pm
0
1
paranoid

You really are super paranoid ray. If you choose to disbelieve me when I state I have no associations whatsoever with the hospital, management, administration, boards, staff, vendors or the garbage collectors, then go for it.

I have been a patient on a few occasions. The fact of the matter is that most people who have lived here for 20 plus years have a pretty good grasp on the goings and comings of our borough owned infrastructure. That we attend meetings, read the paper, listen to the news must really shock you.

Everyone who disagrees with you is not hospital management. However, since paranoia and conspiracy theories run the gamut with "militia members" I can understand your inability to accept the truth or reality.

Watchman on the Wall
2893
Points
Watchman on the Wall 04/09/12 - 05:53 pm
1
1
Ever seen where those running

Ever seen where those running nonprofit organizations made huge amounts of MONEY? Cooked books can show many things, not that that is what is going on at CPH by the Borough MONEY-opolizers that seek to restrict ALL medical business locally for CPGH.
As i said before OUR Staff and most Dr are credible and i appreciate their hard work and health care thats provided, BUT.

Jeremiah 6:17

RaySouthwell
953
Points
RaySouthwell 04/09/12 - 08:31 pm
1
0
Norseman

What have you found out about Dr Namies CPH Bullying survey from December 2009?

I am pleased you read the paper.

Do you remember reading how the elected Hospital Service Area Board unanimously voted to have an operational audit (including an investigation of the murder/suicide) of CPH way back on October 12, 2009. Did you attend that meeting?

If the Borough Assembly took their fiduciary responsibility then, we would not be in the current division, within the community.

Now they are trying to figure what to do with the surgeons who have served this community for decades.

Probably too little too late now.

normolson
389
Points
normolson 04/09/12 - 09:33 pm
1
0
What does the hospital have to hide?

Why not call for a audit by a third party agency? Perhaps the price of the audit will be found in the savings to taxpayers by REALLY streamlining and cutting out multi-layered management.

What is the hospital board and the Mayor and the Assembly hiding from the taxpayers?

RaySouthwell
953
Points
RaySouthwell 04/09/12 - 10:07 pm
1
0
Norm

To answer your question

THE TRUTH

cbeard
132
Points
cbeard 04/10/12 - 03:05 pm
0
0
Really?

This is why we need a single payer health care system in each state. Doctors under single payer are paid and rewarded based on patient record, reporting, accounting, and just generally being a responsible medical care provider in the community. They are more immune to the insurance/trustee corruptions that currently plague Americans' access to medical care and force responsible doctors to have to deal with statistics cooked up by profit-hoarding doctors.

Under the single payer system, the consumer/patient demand has a much heavier weight in the determination of need, and the competition's opinion has NO value in that debate.

RaySouthwell
953
Points
RaySouthwell 04/10/12 - 09:06 pm
1
0
cbeard

Good points. You support the CON. So do I, if the community was part of developing and maintaining the monopoly called Central Peninsula Hospital.

We have an elected board for the electric monopoly called Homer Electric Association. Now the Borough Assembly wants to appoint the Service Board Members for CPH. How would you feel about the Borough Assembly appointing members of the HEA Board? HEA is cooperatively owned as is the hospital.

In order to have a successful business, owners, management and employees must collaborate.

With CPH, the doctors are also employees for the sake of discussion and collaboration.

I have been in health-care for a long time. I have seen the bullying from doctors throughout my career.

Long ago, in a place far from Alaska, I understand one group of physicians had the non-profit hospital purchase lab equipment and then collect the charges for the work done.

I know doctors are just like the rest of us. We focus on our own self-interest.

The time has come in health-care where we all must cooperate for the common good.

What I see is the movers and shakers of the community dictating to the owners, and employees of CPH how things are to be. It has divided the community.

If we do not collaborate, the community will lose in the end.

So how can we have public oversight on the monopoly called Central Peninsula Hospital? I think HEA is a great example.

Watchman on the Wall
2893
Points
Watchman on the Wall 04/11/12 - 09:59 pm
1
0
HEA & CPGH are IDENTICAL MONEY-opolies.

As a singled out 22+ year power lineman that would not toe the line for abuse of self and fellow employees and consumers by Homer electic management, i was finally terminated by that GR8 HEA management fired spicifically for that purpose with the GR8 board allowing it, so i must respectfully disagree with you Ray on HEA being a GR8 example for anything.
Then the manager that got rid of me also got fired shortly afterwards for not toeing the line either. Now thats funny.

Hea is no differant that CPGH in any way as far as i'm concerned, they did to me exactly what the CPH did to you Ray and have also done it to others and the board is in alignment with their end games as far as i can tell and none of them needs to ever be reelected.
HEA is just like CPGH and will not change or care about anyone unless forced to do so and that will be very hard to accomplish. Bringing in out side audits will not help either as history shows from the ones conducted at HEA. Sure the manager was fired but the end game never changed, just one of the leaders was removed.

Another slick trick of control freaks is the hiring of Outside management and bringing them up. Why when Alaska has plenty of qualified workers? It's just that when a MONEY-opoly wants to further control things and people they always bring in moldable people that are not aware of whats going on until it's to late and they are trapped in a never ending power struggle mixed with fear and intimadation and firings for the slightest reason.
HEA and CPGH are both control freak MONEY-opolizers with only one goal and that goal is not to better the nonmanagement sector or for better services to consumers either, it's a power stroking of ego's.
As is said, Power corrupts, absolute power corrupts absolutely, especially when one has self ahead of all others.

Jeremiah 6:17

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