The Doctor Will See You Now. Can Telemedicine Save the Medical Care Crisis in Hawai‘i?
Conventional attempts to remedy the physicians shortage in Hawai‘i have failed. Now we face a whole new philosophy in how medicine is delivered—including trading face time with doctors for video consultations. All ideas are on the table, including shorter and less rigorous training for some doctors. But time and money are running out.
When medical school grad Jim Barahal was completing his residency on O‘ahu in 1981, he looked around the island he’d fallen in love with, looked at how medicine was practiced and looked at his 1979 Fiat convertible. “I started a house-call service and drove all over the island,” he recalls. “I thought it might be a unique kind of low-overhead thing.” By serving North Shore and rural areas, he was also taking a stab at solving Hawai‘i’s once and future health crisis—one compounded by not enough doctors for too many patients spread out over too much space.
Jim Barahal, reinventing how medicine is delivered since 1981.
But, he says, “it was inefficient, seeing one person an hour.” To see two patients an hour meant Barahal had to swap the Fiat for a moped and open a clinic where the most people were concentrated—in Waikīkī, at the Hyatt Regency. Dubbed Doctors on Call, “it was really the first urgent care in Hawai‘i,” he says. Then-Straub Clinic partnered with him in 1986, then bought Doctors on Call in 1992, keeping Barahal on.
Seeing 40,000 people a year pour into his urgent care clinics changed Barahal’s thinking: “People don’t want to make appointments. They want to see a doctor 24/7. They want medical care where they want it, when they want it and how they want it.” But something more cost-effective than a Fiat had to be found to deliver it.
Thirty years later, medical care in Hawai‘i is still looking, and the crisis has arrived. “Over the last 30 years, the state of Hawai‘i has seen unprecedented increases in obesity and chronic conditions like Type 2 diabetes, heart disease, liver disease and tooth decay,” says a report prepared for this magazine by the state Health Department’s Chronic Disease Prevention and Health Promotion Division. “Sixty-one percent of Hawai‘i adults are currently living with at least one chronic disease.”
“We have some real challenges,” says Dave Underriner, president of Kaiser Permanente Health Plan and Hospitals of Hawai‘i. “It’s a juxtaposition of being the healthiest state and having high incidences of diabetes and renal disease. We have a population that lives longer; the longer you live the more things happen to you.” In addition, he says, “Hawai‘i is very diverse. One approach doesn’t fit every population—you have to understand what’s going on culturally and how that affects health.”
Meanwhile, a clock is ticking. We’re short 800 doctors and burnout is on the rise. Put it all together and no wonder Hawai‘i’s health establishment is considering heroic measures to keep our health system upright and viable.
— Dr. Jim Barahal
Good intentions are making a bad situation worse. First, in a bid to control costs, HMSA, the state’s largest insurer with 70% of the market, rolled out a 2016 reform model called capitation. Primary care physicians who had always been paid per patient visit would now get a lump sum each year per patient. Their profit would come out of what’s leftover after visits, tests, treatments and other costs were taken out.
HMSA’s reforms came in conjunction with a federal push to control costs through electronic health record keeping. Physicians are now required to track patient care via a maze of 60,000 billing codes meant to provide very specific information about each patient. With them, data-minded doctors and insurers can, theoretically, “peer into the data and get your arms around the emerging fixes,” says Don Crane, president and CEO of America’s Physician Groups, which represents 300 physician and health care organizations in 44 states (including eight in Hawai‘i) and advocates for the new model.
“All the changes today stem from the fact that the U.S. pays two times as much as any other country on health care, yet our basic health measures are far worse,” explains Michael B. Stollar, president and CEO of HMSA. “When you think about it, health doesn’t occur in your doctor’s office. You’re there for illness. Health is all the things that we call upstream”—behaviors, chronic conditions and mental health issues that respond best to intervention and early treatment.
Right now, though, many physicians feel they’ve been turned into unpaid data collectors while, under capitation, they can’t make up lost salary by working extra hours or seeing extra patients. They’re capped.
“The biggest thing for our providers is they feel they’re being slammed,” by this double hit, says Dr. Aimee Malia Grace, UH’s director of health science policy and U.S. Sen. Brian Schatz’s public health adviser from 2015 to 2018. Many doctors struggle to convert from paper to digital records. “You spend your weekends and nights finishing coding,” says Grace.
A 2017 study in the Annals of Family Medicine found primary care physicians now spend six hours a day looking at their office computer screens—time not spent looking at patients. “We’ve seen some physicians who don’t want to make the change to electronic records leave their practice because of it,” says Dr. Jerris Hedges, dean of the UH John A. Burns School of Medicine. The danger is that Hawai‘i will lose even more physicians. “We have five to 10 years,” says Hedges, “before it becomes very challenging.”
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Matthew Koenig’s telestroke program treated 1,400 patients over four years, including 450 interventions with a clot busting drug, tissue plasminogen activator or T.P.A.
Four years ago, the search for a technological fix settled on telehealth—health care delivered on a screen to a live patient. Kaiser had debuted a version nationwide almost two decades ago; HMSA started its program 10 years ago. In 2016 the law was modified to allow doctors to be paid equally for telemedicine and in-patient visits. It was regarded as a breakthrough, especially when Medicaid followed in 2017.
The high hopes owed much to the success of Dr. Matt Koenig, the medical director of telehealth at The Queen’s Medical Center. Koenig first focused on treating strokes with telehealth in 2015. Four years later, he says, “we’ve seen 1,400 patients via telestroke and treated almost 450 with T.P.A., the clot buster.” Time is everything in stroke care. Patients treated quickly require shorter stays in the hospital and less rehab. “For every patient treated with T.P.A. you save $45,000 in direct medical costs,” he says; that doesn’t include costs in transport and time off from work for both patient and family members.
Savings are also significant for Queen’s, which didn’t have to expend its highest-end, highest-cost care to the 950 patients who could be treated at their community centers. “So, if you look at all that,” says Koenig, “we’ve saved something like $19 million to date.”
Telestroke is now in eight hospitals, four outside the Queen’s system. Although grant-supported by the state the last eight years, in July, Koenig says, “telestroke transitioned to a self-sustaining organism. They said, ‘You’re sure you don’t [need] more funding? We’d be happy to fund it.’ I said, no, get it off grant support.”
But strokes are a special case: a condition with a ticking clock, a specific treatment—the clot buster—that’s ideal for telehealth. Most of medicine, however, includes chronic diseases that can require years of subtle behavioral and drug treatment. Often, they’re accompanied by depression, which also must be treated over time—and over miles separated by salt water.
To serve the Neighbor Islands, for instance, Kaua‘i psychiatrist Dr. Gerald McKenna essentially swapped Barahal’s Fiat for the commercial airlines. “It started around 2003, when we’d opened an addiction clinic in Hilo,” he says, “initially flying back and forth every week.” But the trip required a changeover in Honolulu and he was paying full fare. “I was spending four hours in [an] airplane and six hours there—such a waste of time and energy.”
McKenna improvised his own telehealth out of necessity. “I started doing weekly conference calls with staff using Skype. We didn’t do patients because [we] weren’t sure how secure a platform it was.”
McKenna did start talking with patients in group telemed presentations with staff and family members present—addiction recovery being a family affair. But the flying and costs of maintaining a clinic proved insupportable. Ironically, just as the state made telemed reimbursable, in 2016, he closed the Hilo clinic.
— Dr. Aimee Malia Grace
Still, every three months McKenna flies to Hilo, where he has about 30 patients on suboxone, which reduces craving for opioids. Using telemed, he says, “we’re able to see people in the remotest parts of the Big Island. Sometimes reception is poor and they have to drive around to where they find an internet connection. But it’s been a great way to deliver medicine in a remote archipelago.”
At the same time McKenna found he couldn’t keep his Hilo clinic open, Jim Barahal was starting his own telehealth venture. No Fiat or moped this time, just a video kiosk: “It was a Back to the Future thing, to our house-call roots,” he says. Working with a partner, Dr. Norman Estin (who created Doctors On Call in West Maui) and “our incredible manager, Paige Williams,” he opened DOCNow in KTA Superstores, Times Supermarket pharmacies and urgent care clinics.
But, again, there were a lot of obstacles, he says. According to his manager, Williams, “we figured it out, we put it on all the islands, but the patient base never really bought into it. The pharmacies, they didn’t have the time or interest to steer patients into these little virtual rooms where we could do telemed.”
Barahal pulled the plug in July. One month later, CVS announced it had partnered with a Mainland telehealth provider to provide consultations in its Island pharmacies. Once again the early adopter lost out to the big player.
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To treat patients on the Big Island, Dr. Gerald McKenna flew from Maui with a Honolulu plane change: “Such a waste of time and energy.”
The slow rise of telemedicine has also disappointed Lorrin Kim, chief of the state Department of Health’s office of planning, policy and program development. In 2014, he says, “we sent out a questionnaire asking people if they’d had an experience with telehealth. The answer was 2%. In 2016 it was 4% and in 2017 it was 9%. We may be at 12% now.”
It’s slow growth when you consider the daily spectacle of seeing people glued to their phones. Why wouldn’t they want to do medicine over a screen?
“We’ve thought about this an awful lot,” says Kim. “In addition to low patient acceptance, because they’re used to face-to-face care, how do you get midcareer physicians who have been working face to face for 20 years, or since leaving med school, to change over to a screen? We’re beginning to realize that’s asking a lot.” At least Kim now has Laura Arcibal, a nine-year Health Department veteran, filling the newly created position of state telehealth coordinator.
But in the meantime, what’s a poor state like Hawai‘i to do? “What I’m seeing is major health system players trying to emulate Kaiser. But we can’t. It’s a closed system,” says Hedges, meaning patient, doctor, staff and hospital are all under Kaiser control—ideal for data collection, which is ideal for prevention, which is ideal for cost control.
But other Kaiser procedures are adoptable. In conjunction with telehealth, Kaiser makes teams of APRNs, RNs, pharmacists, nurse assistants, nutritionists, therapists and behavioralists available to every patient as needed. This means patients tend to hear from at least a couple of these paraprofessionals before they see a physician, saving doctors for the tough calls, the ones that really bring to bear their seven years of training.
“It’s called practicing at the top of their license,” says Deborah Birkmire-Peters, program director of the state’s Pacific Basin Telehealth Resources Center. Birkmire-Peters is used to dealing with far-flung health delivery, not just in Hawai‘i but in Guam, the Marshall Islands and other places where the nearest doctor is thousands of miles away. With “top of the license,” says Crane, the America’s Physician Groups president, “all of a sudden you don’t need more doctors. You just reorganize how doctors practice so they can supervise all these araprofessionals. Instead of seeing 2,000 patients a year, they see 3,000, maybe even 4,000.”
— Dr. Jerris Hedges
The “top of their license” idea deliberately pushes health care down the staff tree. For some who deliver health to low-population density areas, that’s already a reality.
After working in a clinic for years, Margaret “Marghee” Maupin, a nurse practitioner and mother of seven, went solo with Marghee’s Mobile Medical LLC, which “provides urgent care and primary care” over the airwaves with telemed and out of her car, “as appropriate.”
As a nurse practitioner, Maupin says, “We can prescribe, but our training is more focused on patient education and therapeutic relationships—the value of connecting with patients so they modify patterns in their approach to health. It’s not just getting information, it’s putting it into action, not only mentally but physically. A lot of it is pattern recognition: Can we intervene with a new lifestyle pattern or modify that pattern?”
At 60, Maupin is providing for Hawai‘i’s greatest need—chronic-disease management—where it’s most needed, in rural areas. She’s cited as an outlier and early adopter by Kim, the Health Department’s planning chief, for her use of telehealth in bringing health care to those in rural Kaua‘i and other islands. “I love her story,” he says. It seems she’s solved the access-money-
distance triangle. Kim calls her one of his champions of telehealth.
“It’s really nice for the provider,” Maupin says. “You’re more independent. I’m surprised that nobody else is really doing it. But, I should also say, it’s hard. We didn’t have any medical insurance for a year or two. Isn’t that funny? We had to take a chance and go without. Now my husband has insurance from working as a teacher.”
To backstop her income, she issues cannabis cards and continues to do telehealth with a Minnesota company several days a week. But serving Kaua‘i is her calling. “That’s why I went into medicine. It was important for me to see people of all colors and socio-economic backgrounds.”
Nurse practitioner Margaret Maupin delivers health care on Kaua‘i by car and by telehealth. “But it’s hard,” she says.
Aside from an army of Marghees, however, what else can Hawai‘i muster? “My Mainland members all employ pharmacists,” says Crane, speaking of his 44-state physician’s group. “They put a pharmacist on every team.”
Grace, the UH health science policy director, says: “More people go to Longs than go to their providers, and we are actually saturated for pharmacists in Hawai‘i. So here we have a whole group of health professionals that we’re training here whose ability to manage chronic disease has a lot of potential.”
Another fix, and one that Hedges champions, is to create centers in outlying communities where nurse practitioners, medical assistants and even medical residents will do their training while delivering care. “They’re going to need a lot more oversight,” he says. “You can’t expect a new practitioner to perform the same as one with 10 to 15 years’ experience.” But community recruitment could take place there, too—grooming the people for medical work who would be likeliest to return to their home ground.
Then he adds a truly radical idea: “We could create a class of physicians,” whose training is shorter and less comprehensive, “credentialed for a lower practice who could contribute to the community,” more quickly than the current seven-year norm.
These are unfamiliar, even heroic measures. And the costs would be substantial—especially for that network of medical outposts, as Hedges calls them. But the looming burden of managing chronic disease and ailments may force our hand.
The tendency may be to punt and hope for a thousand Marghee Maupins who’ll voluntarily sacrifice big chunks of their income. But that sounds more like a Hail Marghee, instead of an actual plan. Can Hawai‘i rise up and once again take the lead on health—as it has in the past with Medicaid and near-universal health care?
Read more stories by Don Wallace