How to Fix Hawaii's Doctor Shortage

Hawaii has hundreds fewer physicians than it needs, particularly in primary care. Here's what's being done to fix the growing shortage.

Dr. Christine McCoy, a physician on the Big Island, was on duty in the emergency room of Hilo Medical Center when a man came in with his arms wrapped in gauze. As McCoy removed the gauze, she found several large, bleeding skin cancers, which the man had left untreated until he could no longer ignore them.

Like a lot of people on the Big Island, where waiting lists to get into a primary care practice may be 500 people long, the man did not have a doctor he could see for regular check-ups. If he had, he certainly would have been put into treatment well before the cancers had gotten so bad, McCoy says.

“People walk into the emergency room here with just crazy things that you would never see anywhere else, because they would be taken care of long before,” McCoy says.

By the same token, Big Island emergency rooms are often filled with people worried about coughs, sore throats and other minor ailments that a primary care doctor would ordinarily deal with—if one were available.

“People here basically use emergency rooms and urgent care centers as their source of primary care,” says McCoy. “That’s a problem because the ER and urgent care aren’t going to worry about the mammograms, tetanus shots and cancer screenings, and they don’t do the ongoing management of chronic diseases.”

Hawaii is in the middle of a doctor shortage, and this is where you see it most clearly: on the Neighbor Islands, in the practices of primary care physicians who aren’t accepting new patients, in the patients who aren’t getting timely care or preventative care or the follow-up care they need, and in the inefficient allocation of health care dollars (emergency rooms are an expensive place to treat coughs and sore throats).

According to the latest findings from the UH medical school’s Hawaii Physician Workforce Assessment Project, which has been producing annual estimates of the state’s doctor shortage since 2010, Hawaii currently has 742 fewer physicians than it needs. The shortage affects all islands and cuts across nearly every specialty, but primary care (which includes family practice, internal medicine and pediatrics) is disproportionately hurting.

With a projected rise in demand for health care, coupled with a net loss of 50 doctors a year (see “Where Have All the Doctors Gone?”), the current shortfall could grow to become a hole in the physician workforce that’s 1,400 doctors wide by 2020, the UH researchers say.

If nothing is done to address the problem, it could soon become as hard to find a doctor in Honolulu as it now is in Hilo, Kona and Līhu‘e. In their 2011 report to the state Legislature, the researchers painted a dire picture of one possible future:

“Newcomers, the indigent and the elderly will feel it first. As the shortage deepens, we’ll all experience the effects. Harried [primary care providers] will spend precious little time with each patient, focusing primarily on immediate acute problems. Preventive care, health screening, early diagnosis and even physician job satisfaction will be triaged to the sideline. Our emergency departments will be overflowing, our hospitals will be running at above 100 percent occupancy and the costs will be staggering.”

But the outlook isn’t all doom and gloom. The report also spells out a series of potential solutions, including the movement toward a new “team-based” model of medical care, which aims to reduce the demand for doctors. Most of the solutions, however, deal with the supply side of the equation. “The recruitment, training and retention of physicians is key,” says Dr. Kelley Withy, the Hawaii Physician Workforce Assessment Project’s lead researcher. “We gotta get ’em, teach ’em and keep ’em.”

What follows is a roundup of some of the main initiatives that have been proposed to address the doctor shortage, and where they stand today.

Patient-centered Medical Homes (PCMH)

What they are: A model for health care that puts a doctor in charge of a team of health providers who work together to coordinate a patient’s care. One of the emphases is on open and easy communication between patients and health care providers. Withy calls it “the Cheers model” of medical care—“Where everybody knows your name.”

How they help: Eases demand for doctors by spreading routine primary and preventive care among non-physician team members, such as nurse practitioners, physicians’ assistants and health psychologists.

Details: Although the model is still evolving, PCMHs have become popular with many health care policy experts, who see them as the best way to move expenditures toward prevention and basic care. In theory, they allow a smaller physician workforce to care for a larger population, and result in better outcomes.

In the past few years, Hawaii’s largest health insurer, Hawaii Medical Service Association (HMSA), has wholeheartedly embraced the medical home philosophy, and the UH medical school has added a lecture on the benefits of PCMHs to its first-year curriculum. But the medical home concept isn’t entirely new. Kaiser Permanente, Hawaii’s second-largest health insurer, has been using the PCMH model for the past 50 years or so.
 

Payment Reform

What it does: Increases compensation for primary care practitioners, who are both the most in demand and the worst paid of all the doctors.

How it helps: There’s no incentive like a financial incentive.

Details: Loaded with medical school debt, many young doctors forgo primary care for the higher-paying specialties, such as dermatology, urology and plastic surgery. According to state Sen. Josh Green, who is both a doctor and the medical director of the Hawaii Independent Physicians Association, new federal guidelines that have raised reimbursements for primary care physicians attached to Patient Centered Medical Homes are starting to make a difference. “When pay for primary care reaches 70 percent of the median income for specialties, you tip the scales and people start going into primary care,” Green says. “We’re starting to see that, and it’s a game changer.”
 

Neighbor Island Residency Training

What it is: A new three-year family medicine residency training program on the Big Island.

How it helps: Puts young primary care doctors to work on the Big Island, one of the areas where the need for doctors is greatest.

Details: After graduating from medical school, doctors undergo three years or more of on-the-job training as hospital residents. Since doctors tend to settle down in the communities in which they train, it’s reasonable to expect some of the Hilo residents will stay on the island after their residency is complete. The first four Hilo residents will begin training in July 2014. The program will then grow until it has a total of 12 residents at any one time. Similar programs could eventually be set up on Maui and Kauai.

Loan Repayment for Rural Doctors

What it does: Provides loan repayments for health care providers who agree to work in the most underserved parts of the state.

How it helps: Puts primary care doctors—as well as nurse practitioners and physicians assistants—where they’re needed the most.

Details: Provides up to $40,000 a year, for two years, toward the repayment of school loans for health care providers who work for at least two years in rural parts of the state. Seed money from HMSA, Queen's Medical Center and AlohaCare, matched by federal funds available under the Affordable Care Act, got the program rolling last year. To date, six doctors and nurse practitioners have taken the loan repayment deal. Next year, nine more people could join the program. Eventually, up to 50 people a year could participate.
 

The Practice in Paradise Campaign

What is it: A recruitment campaign aimed at doctors who trained in Hawaii and now practice on the Mainland.

How it helps: Could boost the number of doctors in the state.

Details: In 2012, the Hawaii Physician Workforce Assessment Project sent postcards to all the Hawaii medical school and residency graduates it could find, asking them to take a quick survey on what it would take to bring them back to Hawaii, and also alerting them to a website with job postings. Of 1,100 physicians contacted, 40 responded. Their main requirement for returning? A high-paying position with lots of perks.
 

Make the Doctors Happy

Why aren’t doctors happy? Malpractice suits, out-of-control paperwork and the unfulfilled promise of electronic records.

How it helps: A happy doc is a doc who isn’t scaling back her practice, moving to the Mainland or taking early retirement.

Details:

• Paperwork and electronic records: Every insurance company has its own unique system for claims submissions, denials, coding and so on. This amounts to a time-consuming pain in the butt for doctors. The federal push to get doctors to use electronic records isn’t helping. There’s no standard electronic records system, and, as it turns out, doctors have the same computer problems as everyone else. The Hawaii Workforce Assessment Project has issued a call for easing these administrative burdens on doctors so they can spend more time doctoring.

• Tort reform: The state recently revamped its Medical Claims and Conciliation Panel, the advisory body that hears malpractice claims against doctors before they can be filed as lawsuits. No longer do lawyers outnumber doctors on the panel, and more malpractice claims are now expected to be settled out of court.
 

Expand the Health Career Pipeline

What it means: Outreach to Hawaii kids in primary and secondary schools to spark interest in medicine and other health careers.

How it helps: A long-term solution.

Details: The outreach efforts include visits by doctors and medical school students to classrooms, career fairs and teen health camps. At the annual teen health camp held at Kealakehe High School in Kona, students have “speed-dating” career talks with doctors, nurses and other health care practitioners. They also learn how to suture wounds on a rubber arm, and how to put plaster casts on each others’ arms. “It gives them a taste of a day in the life of a clinic,” says career educator Nem Lau. “The idea is, Try it, you might like it.”

Where Have All the Doctors Gone?

The Anatomy of a Doctor Shortage

If you want someone to blame for Hawaii’s doctor shortage, find a baby boomer, a baby, and the nearest Mainland transplant.

A population that’s growing (baby, transplant) and aging (baby boomer) is one of the main drivers behind the projected 1,400-doctor shortfall that Hawaii is facing for the year 2020, according to a study by the UH medical school’s Hawaii Physician Workforce Assessment Project.

Hawaii’s population is expected to grow by 28 percent, from 1.21 million to 1.55 million, between 2000 and 2030. During the same period, the number of residents age 65 and older is expected to double. And older people simply see the doctor more often than younger people do, with those 75 and older using three times the physician services as people 65 and younger.

Meanwhile, Hawaii’s doctors are aging, too. Forty-one percent of the physicians who were practicing at the start of the decade are expected to retire before this decade’s over. And they aren’t being replaced fast enough by young doctors to prevent a net loss of 50 doctors a year, the study says.

Hawaii isn’t alone. The state’s doctor shortage is part of a nationwide doctor shortage driven by the same forces of falling physician supply and rising demand. The Association of American Medical Colleges projects a national shortage of 91,500 doctors by 2020.

Exacerbating the problem was the federal cap put on graduate medical training in the 1990s, when the nation was widely perceived to be experiencing a doctor glut. Since the cap was lifted in 2009, medical school class sizes have been growing and new medical schools have been opening. Yet, as it takes 11 to 15 years to train a doctor, the promise of expanded medical education is no quick fix.

The Affordable Care Act, President Obama’s health care law, which will extend health insurance to some 35 million currently uninsured Americans starting next year, is frequently accused of causing, or at least worsening, the doctor shortage. The blame is misplaced, says Dr. Kelley Withy, the lead researcher with the Hawaii Physician Workforce Assessment Project.

In Withy’s model of the growing gap between physician supply and demand in Hawaii, the Affordable Care Act causes an initial blip in demand that is quickly offset by measures the new law takes to improve outcomes, increase efficiency and expand the number of primary care providers.

Still, Withy says, many doctors worry about how the new law will affect their practices. “We hear penalties. We hear new requirements. Those are all scary when you’re working 12 hours a day, seeing patients like crazy,” she says. “But I don’t think Obamacare’s worsening anything except our fear and confusion of the unknown.”