By Paul Henry / in , , , , , , , , , , , , , , , , , , , , , , , , , /


HAWAIʻI NEEDS 300 PRIMARY CARE
DOCTORS STATEWIDE, ACCORDING TO AN ANNUAL REPORT EVALUATING THE
ISLANDS’ GROWING DOCTOR SHORTAGE. MORE THAN 500 SPECIALITY DOCTORS
ARE ALSO NEEDED. THE SHORTAGE IS BIGGER ON THE NEIGHBOR ISLANDS
ESPECIALLY ON THE BIG ISLAND WHERE THE NUMBER IS 44 PERCENT. WHY IS THIS
HAPPENING AND WHAT’S BEING DONE TO STOP IT? TONIGHT’S LIVE BROADCAST
AND LIVESTREAM OF INSIGHTS ON PBS HAWAIʻI START NOW. [INTRO MUSIC] ALOHA AND WELCOME TO INSIGHTS ON PBS HAWAIʻI…I’M
DARYL HUFF. THERE ARE SEVERAL FACTORS THAT CONTRIBUTE
TO THE DECLINING NUMBER OF PRACTICING PHYSICIANS IN OUR STATE.
A FOURTH OF OUR PHYSICIANS ARE MORE THAN 60 YEARS OLD AND HEADING FOR RETIREMENT
OR SEMI- RETIREMENT. SOME FIND THE ADDED RED TAPE AND ELECTRONIC
RECORDS REQUIREMENTS AND INSURANCE OVERSIGHT OVERWHELMING.
YOUNGER DOCS WITH HIGH STUDENT DEBT ARE ATTRACTED TO THE MAINLAND – WHERE THEY
CAN EARN MORE AND ENJOY A LOWER COST OF LIVING. A REPORT SUBMITTED TO THE LEGISLATURE IN DECEMBER
SHOWS HAWAIʻI WOEFULLY SHORT OF PRIMARY CARE DOCTORS AS WELL AS CERTAIN
SPECIALISTS. OUR PANEL TONIGHT INCLUDES THREE PHYSICIANS,
INCLUDING THE AUTHOR OF THE REPORT, A NEIGHBOR ISLAND DOCTOR, AND A MEDICAL STUDENT.
WE LOOK FORWARD TO YOUR PARTICIPATION IN TONIGHT’S SHOW. YOU CAN EMAIL, CALL OR
TWEET YOUR QUESTIONS. AND YOU’LL FIND A LIVE STREAM OF THIS PROGRAM AT
PBSHAWAII.ORG AND THE PBS HAWAIʻI FACEBOOK PAGE.
NOW, TO OUR GUESTS. DR. KELLEY WITHY, IS A PROFESSOR OF FAMILY
MEDICINE AND COMMUNITY HEALTH AT THE UNIVERSITY OF HAWAIʻI MEDICAL SCHOOL. SHE
EARNED HER MEDICAL DEGREE AT UC-SAN DIEGO AND A PH.D IN BIOMEDICAL SCIENCES FROM
UH MĀNOA. SHE IS THE PRINCIPAL INVESTIGATOR OF THE HAWAIʻI PHYSICIAN WORKFORCE
REPORT. DR. RICK BRUNO IS AN EMERGENCY PHYSICIAN AT
THE QUEEN’S MEDICAL CENTER. HE EARNED HIS MEDICAL DEGREE AT YALE UNIVERISTY. HE
AND HIS FAMILY MOVED TO HAWAIʻI IN 2004. HE
SAYS HE HIKES ON WEEKENDS AND TEACHES CROSSFIT AT A FRIEND’S GYM.
DR. MICHELLE MITCHELL IS A GRADUATE OF THE UH MED SCHOOL AND HAS BEEN PRACTICING
BOARD CERTIFIED FAMILY MEDICINE ON THE BIG ISLAND FOR MORE THAN 11 YEARS. SHE IS A
CLINICAL INSTRUCTOR FOR MULTIPLE SCHOOLS HERE AND ON THE MAINLAND.
CLARE-MARIE ANDERSON GREW UP ON MOLOKA’I AND O’AHU. SHE IS A 2ND-YEAR MEDICAL
STUDENT AT THE JOHN A. BURNS SCHOOL OF MEDICINE WHERE SHE IS THE CO-PRESIDENT OF
THE RURAL HEALTH INTEREST GROUP ON CAMPUS. LET ME START WITH YOU, DR. MITCHELL. YOU’RE
SORT OF IN THE CENTER OF THIS STORM OF PHYSICIAN SHORTAGES. CAN YOU TELL ME A LITTLE
BIT ABOUT WHAT IT’S LIKE WORKING IN HILO WHEN THERE’S SO FEW OTHER DOCTORS AROUND
TO SUPPORT YOU? AND I THINK YOU TOLD ME EARLIER THAT YOU USED TO HAVE 3 DOCTORS
WORKING WITH YOU. UH, WE USED TO BE A TEAM OF 3 IN MY PRACTICE
WHEN I FIRST STARTED ABOUT 12 YEARS AGO, AND NOW IT’S JUST ME. I’M THE LAST MAN
STANDING. UM, IT’S IN ONE WORD STRESSFUL. YOU KNOW, UM, I’M WATCHING MY COMMUNITY
NOT GET THE HEALTHCARE THEY NEED, YOU KNOW, UM, MY NEIGHBORS, MY FAMILY,
MY FRIENDS, AND I’M WATCHING PEOPLE NOT BE ABLE TO ACCESS PHYSICIANS BECAUSE THEY’RE
JUST NOT AVAILABLE-MOSTLY PRIMARY CARE, WHICH IS REALLY SAD. I’M TAKING ON A
LOT OF NEW PATIENTS IN SPITE OF THE FACT THAT I ALREADY HAVE A PANEL OF 2000 PATIENTS.
SO THAT’S MORE THAN A SINGLE PHYSICIAN CAN HANDLE, BUT I HAVE A GOOD SUPPORT STAFF
AND AN EXCELLENT TEAM WHICH HELPS ME HANDLE MORE PATIENTS, BUT UNFORTUNATELY NOT
ALL SOLO PHYSICIANS HAVE THAT, SO THAT MEANS THAT PATIENTS ARE JUST NOT ABLE
TO ACCESS CARE AND IT BECOMES DANGEROUS.
YOU KNOW, WHEN YOU, UM, YOU ALWAYS HEAR ABOUT HILO, LIKE I THINK WHEN MAYOR KIM
HAD A HEART ATTACK, HE HAD TO FLY…WHAT KIND OF THINGS HAPPEN THAT ARE VERY
COMMON THAT YOU ACTUALLY HAVE TO SEND PEOPLE TO O’AHU OR ANOTHER ISLAND?
WELL, WE HAVE TO SEND PEOPLE OUT FOR ANYTHING WE DON’T HAVE ACCESS TO LIKE SUB-
SPECIALISTS, OR SOME SPECIALISTS. WE DON’T HAVE RHEUMATOLOGY AVAILABLE. WE DON’T
HAVE ENDOCRINOLOGY. WE DON’T HAVE A LOT OF DIFFERENT SUB-SPECIALISTS FOR SURGICAL,
BUT UM, WHEN YOU HAVE A GOOD BASE IN PRIMARY CARE, LIKE OUR FAMILY MEDICINE
TRAINING. WHEN WE DID A LOT OF – WE DID OUR TRAINING HERE ON O’AHU. WE DID
EMERGENCY MEDICINE, LIKE I DID WITH DR. BRUNO, THANK YOU. AND WHEN, UM, WE DID OUR
TRAINING HERE, I DID THE ICU, THE NICU. WE DID OBSTETRICS, GYNECOLOGY. SO WE GET A
REALLY GOOD BASIS. WE CAN DO A LOT IN PRIMARY CARE AND FAMILY MEDICINE AND
INTERNAL MEDICINE, AND THAT HELPS US GIVE A GOOD BASE SO WE DON’T REFER AS OFTEN.
UM, DR. BRUNO, UM, TELL ME WHAT YOU’RE SEEING FROM YOUR PERSPECTIVE IS THE BIGGEST
IMPACT OF THIS SHORTAGE? SURE, I, I WEAR TWO HATS AT QUEENS. I, UH,
IN THE CLINICAL ARENA I’M AN EMERGENCY PHYSICIAN. I WORK IN THE PUNCHBOWL ER. AND
FROM THAT LENS, WE, UH, GET PRACTICALLY 10,000 REQUESTS A YEAR FROM OTHER ACUTE CARE
FACILITIES TO TRANSFER PATIENTS IN BECAUSE THEY DON’T HAVE THE SERVICES AND A
LOT OF TIMES, AS MICHELLE SAYS, THEY DON’T HAVE THE SPECIALIST, AND SO, UH, AT
QUEENS’S WE’RE COMMITTED TO TAKING CARE OF EVERYBODY, AND SO IN THE EMERGENCY ROOM
NOT ONLY DO WE TAKE CARE OF THE FOLKS UH, IN O’AHU; IS WE, UH, RECEIVE A FAIR NUMBER
OF ACUTE CARE TRANSFERS FROM THE NEIGHBOR ISLANDS BECAUSE OF LACK OF, UH, SERVICES.
UM, ON MY ADMINISTRATIVE SIDE, UH, I HELP MANAGE THE EMPLOYED PHYSICIAN GROUP.
AND, UH, I THINK, UH, A LOT OF WHAT DR. WITHY HAS TALKED ABOUT IS WE, UH, HAVE
THOSE SAME ISSUES AS FAR AS LACK OF PRIMARY CARE, UM, OUR AGING, UH, WORK FORCE
IS THE ISSUE OF A SIMILAR NUMBER AT QUEENS: ABOUT 25-30% OF OUR UH, ACTIVE MEDICAL
STAFF IS OVER THE AGE OF 65, AND THOSE ARE THE SAME FOLKS WHO TAKE CALL EVERY
THIRD NIGHT TO TAKE CARE OF PATIENTS, AND UH, THAT’S ONE OF THE CHALLENGES, UH,
KEEPING OUR CALL SCHEDULES TOGETHER, MAKING SURE WE HAVE PEOPLE TO TAKE CARE OF
OUR PATIENTS. UH, KELLY WITHY, WITH THE MEDICAL SCHOOL,
AND YOU DO THIS SURVEY. UM, HOW…WHERE ARE THE WORST PLACES…WHERE ARE THE WORST,
UH, SITUATION FOR THE SHORTAGE ON-IN THE STATE OF HAWAIʻI? IS THERE PLACES THAT’S
WORSE THAN OTHER PLACES? BIG ISLAND. ALL THE NEIGHBOR ISLANDS ARE WORSE
THAN O’AHU ON MOST THINGS, AND BIG ISLAND IS BY FAR THE WORST.
I THINK WE HAVE, UM, A GRAPHIC THAT WE CAN, WE CAN SHOW-TALK ABOUT. UM, SO ON
O’AHU, UH, IT SHOWS 377 DOCTORS SHORT, 16% UH, SHORT OF WHAT IT SHOULD BE. BIG
ISLAND, 230 DOCTORS SHORT. 44% SHORT OF WHAT IT SHOULD BE. MAUI COUNTY 36%. KAUAI
COUNTY 24%. STATEWIDE 24% SHORT. 820 DOCTORS SHORT. HOW, HOW DO YOU GET TO
THAT FIGURE? I MEAN, IS THAT…HOW DO WE KNOW THE RIGHT NUMBER OF DOCTORS?
WE ACTUALLY DON’T. OH.
SO THE DEMAND NUMBER IS BASED ON THE AVERAGE UTILIZATION OF DOCTORS THROUGHOUT
THE COUNTRY. SO WHAT WE’RE ACTUALLY DOING IS WE’RE COMPARING OUR POPULATION TO
THE WHOLE COUNTRY. SO I LIKE TO SAY, IF YOU TOOK EACH OF OUR COUNTIES AND PUT THEM
ON THE CONTINENT, THIS IS HOW MANY DOCTORS THEY WOULD USE. THIS IS HOW MANY THEY
WOULD HAVE, AND SO THEN I COMPARE THE NUMBER WHAT WE DO HAVE WITH THAT
NUMBER, AND THAT IS THE SHORTAGE. SO IT’S, IT’S SORT OF, IT’S SORT OF LIKE COMPARED
TO THE MAINLAND, BUT IT’S ALSO VERY SPECIFIC TO A CERTAIN AREA AND THE KIND OF
PEOPLE WHO LIVE THERE? RIGHT, BECAUSE THEY TAKE INTO ACCOUNT ALL
OUR HEALTH FACTORS, THE AGE RANGE, THE ETHNICITY, THE INSURANCE COVERAGE, THE DISEASES.
BUT IT’S STILL JUST A GUESS, AND I WOULDN’T SAY THAT THE AVERAGE US POPULATION
USES THE APPROPRIATE AMOUNT OF SERVICES. SOMETIMES WE DON’T USE AS MUCH AS
WE SHOULD, LIKE PERHAPS IN PSYCHIATRY. SOMETIMES WE USE MORE THAN WE SHOULD IN SOME
SPECIALTIES. SO IT’S NOT THE IDEAL NUMBER, IT’S JUST A NUMBER TO COMPARE IT TO.
UM – DOES THAT TAKE INTO ACCOUNT OUR GEOGRAPHIC
ISOLATION? BECAUSE THERE’S NOT REALLY A COMPARISON FOR THAT ON THE MAINLAND. WE
DON’T HAVE ACCESS TO BE ABLE TO DRIVE. I CAN’T DRIVE TO QUEENS.
YES, SO THERE’S TWO NUMBERS. SO IF I JUST SUBTRACT THE-THE DOCTORS WE HAVE FROM
THE DOCTORS WE NEED, WE GET 509. SO THAT’S HOW MANY DOCTORS SHORT IF WE PUT THE
WHOLE STATE TOGETHER. BUT IF WE LOOK AT THESE GEOGRAPHIC DIFFERENCES AND I
SUBTRACT OUT ANY OVERAGES ON A NEIGHBOR ISLAND, SO MAYBE WE HAVE EXTRA
RADIOLOGIST WHO CAN’T TAKE CARE OF THE FLU, THEN WE COME OUT WITH 820. SO I DON’T
SAY ANY OF THESE NUMBERS ARE RIGHT BECAUSE RIGHT NOW WE HAVE ABOUT 250
OPENINGS, AND WE HEARD 15 OF THEM ARE AT THE – ARE THE INPATIENT SERVICE THAT YOU
RUN. SO IF WE HAD A JUMBO JET FULL OF DOCTORS COME AND LAND, ALL LICENSED AND
READY TO GO, WE COULD ONLY EMPLOY 250 OF THEM TODAY.
YOU KNOW, UH, CLARE, UH, ANDERSON, YOU HEAR ALL THIS, DOES IT KIND OF FREAK YOU OUT
A LITTLE ABOUT WHAT YOU’RE HEADING INTO? IT’S GONNA BE A LOT OF WORK.
YEAH, DEFINITELY A LOT OF WORK, BUT I THINK ALL OF MY CLASSMATES ARE VERY AWARE OF
THE PHYSICIAN SHORTAGE AND ARE UP FOR THE CHALLENGE BECAUSE I KNOW THAT A LOT OF
MY CLASSMATES ARE EVEN WORKING NOW TO TRY TO ADDRESS THE PHYSICIAN SHORTAGE,
EVEN IN SMALL PROJECTS THEY’RE INVOLVED WITH AT SCHOOL, ESPECIALLY IN THE RURAL
HEALTH TRACK AT JABSOM. I THINK JABSOM DOES A REALLY GOOD JOB OF TELLING US WHAT
THE PHYSICIAN SHORTAGE IS AND AREAS IN WHICH WE CAN HELP, EVEN AS MEDICAL
STUDENTS. GIVE ME AN EXAMPLE OF, OF A PROGRAM LIKE THAT,
A LITTLE MORE SPECIFIC. YEAH, ABSOLUTELY. SO JABSOM KIND OF HAS TWO
WAYS OF ADDRESSING THE PHYSICIAN SHORTAGE, ESPECIALLY ON OUR NEIGHBOR ISLANDS.
ONE TRACK IS SENDING MEDICAL STUDENTS TO NEIGHBOR ISLANDS TO TRAIN AND
GET EXPOSED TO RURAL HEALTHCARE IN HOPES THAT THEY CAN ENCOURAGE THEM TO PRACTICE
THERE IN THE FUTURE. AND ANOTHER KIND OF TRACK THAT JABSOM WORKS ON IS PROVIDING
VISIBILITY TO HIGH SCHOOL STUDENTS AND COLLEGE STUDENTS ON OUR NEIGHBOR ISLANDS
TO PROFESSIONS IN HEALTHCARE TO TRY TO RECRUIT AND EXPOSE THOSE KIDS TO PROFESSIONS
IN HEALTHCARE AND WAYS THEY CAN GET TO MEDICINE OR A RELATED PROFESSION.
DO YOU SEE THAT MOST OF YOUR CLASSMATES WANT TO STAY HERE? DO YOU-IS THAT
SOMETHING THAT’S REALLY ENCOURAGED AND REALLY DEVELOPING THERE?
YES, ABSOLUTELY. MORE THAN 80 OR 85% OF MY CLASSMATES ARE FROM HAWAIʻI, AND MANY
OF THEM FROM NEIGHBOR ISLANDS, UM, ESPECIALLY IN THE RURAL HEALTH COHORT I ‘M A
PART OF. I THINK THE MAJORITY OF US ARE FROM THE NEIGHBOR ISLANDS, AND I KNOW A LOT
OF MY CLASSMATES REALLY WANT TO GIVE BACK HERE, AND THEY RECOGNIZE THE NEED, AND
SO I’M, I’M HOPEFUL AND, AND HOPING I CAN PROVIDE A LITTLE POSITIVE LIGHT ON THE
FUTURE OF MEDICINE TONIGHT. I’M SURE THEY WILL. SO ARE THEY-ARE THEY TEACHING YOU HOW TO GO
TO A NEIGHBOR ISLAND TO SET UP A PRACTICE? BECAUSE A MAJORITY OF US ON THE
NEIGHBOR ISLANDS ARE ACTUALLY HAVING TO BE IN PRIVATE PRACTICE OUT OF NECESSITY. IN
HILO WE DON’T HAVE QUEENS TO HIRE US AS AN OUTPATIENT. QUEENS HAS SOME OUTPATIENT
PRACTICES. WE DON’T HAVE A STRAUB TO HIRE US. SO OUT OF NECESSITY, WE’RE IN PRIVATE
PRACTICE. OUR HOSPITAL DOESN’T HAVE THE CAPACITY TO ACTUALLY EMPLOY ENOUGH OUTPATIENT
PHYSICIANS TO CARE FOR THE POPULATION IN OUR AREA. SO AS A RESULT, WE
NEED THOSE PRIVATE PRACTICE PHYSICIANS, AND THAT’S SOMETHING THAT’S NOT REALLY ADDRESSED.
THOSE PRIVATE PRACTICE PHYSICIANS ARE BEING FORCED OUT OF BUSINESS
AND, UM, MEDICAL STUDENTS AND GRADUATION RESIDENTS AREN’T EITHER TAUGHT
HOW TO RUN A PRIVATE PRACTICE OR THEY’RE NOT INTERESTED IN DOING SO.
AND I SAID WE HAD 250 JOB OPENINGS. TRADITIONALLY, HALF THE PHYSICIANS OPEN THEIR
OWN PRACTICE, AND HALF GO INTO EMPLOYMENT. NOW, LET ME ASK CLARE – DO YOU KNOW
WHAT IT MEANS TO HANG A SHINGLE? OKAY, SO IT’S AN OLD ATTEMPT, BUT IT MEANS YOU PUT
UP A SHINGLE, YOU WRITE YOUR NAME ON IT, AND THAT’S YOUR BUSINESS. SO SEE THEY DON’T
EVEN KNOW IT ANYMORE, SO IT’S- WELL THEY DON’T KNOW THAT TERM.
RIGHT. BUT, A LOT OF THEM COME OUT AND WANT A JOB. AND MICHELLE IS RIGHT: UH, THE
PLACES WHERE WE DON’T HAVE LARGE MEDICAL, UM, ESTABLISHMENTS-LIKE QUEENS IS IN
NORTH HAWAIʻI. KAISER A LITTLE BIT ON HAWAIʻI BUT NOT TOO MUCH, BUT KAISER IS ON
MAUI, HPH IS ON KAUAI, QUEENS IS ON MOLOKA’I. UM, KAISER’S ON LANAI. SO REALLY, YOU
COULD SAY THE AREA THAT IS SHORTEST THAT YOU SHOWED US IS THE ONE THAT DOESN’T
HAVE THE JOBS. YOU KNOW, UH, TELL…JUST TO SORT OF ROLL
BACK A LITTLE BIT TALK TO YOU A BIT IN TERMS OF YOUR FIRST DECISIONS YOU MADE COMING OUT
OF MEDICAL SCHOOL. I WAS KIND OF SURPRISED TO HEAR WHEN YOU CAME OUT YOU WANTED
TO BE EMPLOYED AS A DOCTOR, AND I DON’T KNOW IF THE AVERAGE PERSON KNOWS WHAT
THAT MEANS. BASICALLY YOU WANTED TO WORK FOR A CLINIC OR HOSPITAL AND JUST
DO YOUR-DO YOUR JOB. BUT YOU FOUND YOURSELF HAVING TO SET UP A PRIVATE PRACTICE.
WHY WAS THAT NECESSARY, AND HOW HARD WAS THAT TO DO?
IT WAS HARD. UM, YOU KNOW, SO AS PART OF OUR TRAINING WHEN I DID MY RESIDENCY HERE
ON O’AHU, THEY BRILLIANTLY SENT US OVER TO HILO FOR SOME RURAL TRAINING, AND WE
SPENT TWO MONTHS SEPARATED OVER IN HILO, AND IT TURNS OUT I LOVED HILO. I JUST FELL
IN LOVE OVER THERE, AND I’VE ALWAYS WANTED TO DO RURAL MEDICINE. THAT’S WHERE MY
HEART WAS. THAT’S WHERE I…I’VE WANTED TO DO THAT SINCE EIGHTH GRADE. SO I WENT
INTO MEDICINE WITH THAT INTENT. I DIDN’T KNOW WHERE I’D END UP. TURNS OUT, HILO.
I…WHEN I WAS OVER THERE, I GOT EXCELLENT RECOMMENDATIONS. I SPOKE WITH THE
PHYSICIANS THERE, AND UM, PEOPLE WANTED ME. PEOPLE HAD – WE HAD THE PATIENT
PANELS. THERE WERE NO JOB OPPORTUNITIES, AND I DIDN’T HAVE THE WHEREWITHAL TO SET
UP A PRACTICE. THAT WAS NOT PART OF MY EDUCATION. I DIDN’T KNOW HOW TO DO ANY OF
THAT. I DIDN’T KNOW HOW TO MANAGE A PRACTICE, HOW TO, UM, FILE ALL OF THE
APPROPRIATE PAPERWORK AND HOW TO, HOW TO ACTUALLY- HOW TO GET PAID.
DO THE BUILDING. HOW TO ACTUALLY
COMPLY WITH ALL OF THE GOVERNMENT AND
LOCAL REGULATIONS. WHICH ARE
IMPORTANT FOR MEDICAL STUDENTS
OR RESIDENTS TO LEARN IF THEY’RE
GOING TO HANG A SHINGLE.
SO AS PART OF THAT, TWO OTHER
CORESIDENT AND I SET UP OUR OWN
PRACTICE. THAT WAS MY
OBJECTION. TO GO TO HILO.
WHERE I DECIDED REALLY WANT TO BE
AND WHERE I WAS REALLY NEEDED.
THAT WASN’T MY FIRST CHOICE.
BUT I DID OUT OF NECESSITY AND NEED
FOR THE COMMUNITY.>>Daryl: I’M SURE
THE COMMUNITY APPRECIATES IT.
. LET ME ASK,
DR. BRUNO, VERY INTERESTING
PHENOMENON OF WHERE BIG
HOSPITALS ARE COMPETING WITH THE
COMMUNITY IN A WAY FOR PRIMARY CARE
DOCTORS, YOU KNOW, HOW DO YOU GRACE
THAT? HANDLE THAT ANY
MEAN, ARE YOU LIKE ACTIVELY COMPETING
WITH THE PRIVATE SECTOR?
YOU MAKE A PITCH TO DOCTOR LIKE
THIS, AND SAY, HEY, YOU CAN COME
TO WORK FOR US. YOU’LL HAVE MORE
MONEY IN YOUR POCKET.
BETTER HOURS? YOU DON’T HAVE TO
WORRY ABOUT ALL THE PAPERWORK?
>>I THINK EVERYBODY ELSE CAN
COMMENT, I THINK WE’RE IN THE
MIDDLE OF A TRANSITION ABOUT,
PROBABLY KNOW BETTER THAN I,
40ISH PERCENT OF THE PHYSICIAN IN
THE COUNTRY ARE EMPLOYED.
UNDERGOING TRANSITION FROM
THE SOLO PRIVATE PRACTICES AND
SPECIFICALLY IN HAWAIʻI,
HISTORICALLY, THERE WERE NO
LARGE GROUP PRACTICES THAT
WERE INDEPENDENT. SO IT’S MOSTLY
ONE, TWO BEING PRACTICE.
NO LARGE VASCULAR GROUP IN HAWAIʻI.
EITHER SOLO PRACTICE.
ONE, TWO, YOU OR YOU WORK FOR THE
HOSPITAL. KIDS WHO TRAIN ON
THE MAINLAND, DO I JUST VASCULAR
SURGERY. ON MY MIND.
COME BACK, SEEKING EMPLOYMENT.
ON THE SUPPLY SIDE, MOST NEW
GRADS ARE LOOKING FOR THE STABILITY
OF EMPLOYMENT FOR SOME OF THE STUFF
MICHELLE TALKED ABOUT.
THEY DON’T WANT TO BE ON CALL EVERY
THIRD NIGHT. NEED THE LIFESTYLE
TO BE HEALTHY. ON THE HOSPITAL
SIDE, HEALTH SYSTEMS SIDE, WE
NEED PHYSICIANS TO BE MORE LINED THAN
IN THE PAST. IT USED TO BE VERY
TRANSACTIONAL RELATIONSHIP WITH
THE HOSPITAL. YOU CAME, PROVIDED
CARE, HOSPITAL PROVIDED PLACE TO
PROVIDE CARE. EVERYBODY DID
WELL. THOSE DAYS ARE
CHANGING BECAUSE OF JUST THE
PAYMENT IN THE COMMUNITY, PAYMENT
TRANSFORMATION. ALIGNMENT IS
NEEDED. SO EMPLOYMENT IS
THE EASIEST WAY TO ACHIEVE THAT.
YOU MAKE IT MUCH MORE COMPLICATED
WHEN YOU’RE TALKING PLACE LIKE
HILO, I THINK IT’S NOT SO MUCH THE
HEALTH SYSTEMS ARE COMPETING
AGAINST MICHELLE. I THINK IT’S JUST
MARKET FORCES THAT ARE HAPPENING,
FORCING THE HOSPITALS TO GET
IN THE BUSINESS. I WANT TO GO TO A
COUPLE OF VIEWER QUESTIONS.
AS USUAL, INTELLIGENT AND
QUESTIONS. AND BRING UP WHOLE
NEW SUBJECT. NOT ENOUGH DOCTORS
FOR WORKMAN’S COMP CASE.
IS THERE A WAY TO IMPROVE THIS?
MAY IS GOING ON WITH WORKER’S
COMP, I GET CONCERNS ABOUT
WORKMAN’S COMP ALL THE TIME.
ARE YOU ABLE TO TAKE WORKER’S
COMP? SPECIFIC INSURANCE
COMPANY, RIGHT?>>WHOLE SEPARATE
INSURANCE COMPANY THAN YOUR USUAL
INSURANCE COMPANY. THE ISSUE IS
COMPLEX. AND REQUIRES A LOT
OF PAPERWORK. A LOT OF
PHYSICIANS DECLINE TO TAKE IT AS A
RESULT OF THAT. SOME PHYSICIANS
WILL TAKE IT AS YOU DO FOR OUR OWN
PATIENTS BUT NOT SEPARATE PATIENTS
THAT ARE NOT OUR OWN.
THAT DOES BECOME A BIG ISSUE FOR
MAYBES.>>Daryl: WORKER
COMP,. NOT YET.
>>Daryl: IS WORKERS COMP, WHAT
HAPPENS TO SOMEONE SHOWS UP WITH
WORKERS COMP INJURY AT QUEEN’S.
>>WE TAKE CARE OF EVERYBODY.
TO BE FAIR, WHAT MICHELLE SAID,
PRIVATE PRACTICE, WORKMENS COMP IS
EXTREMELY COMPLEX. YOU HAVE TO KNOW
HOW TO DO IT TO GET PAID.
PRIVATE PRACTICE DOCS, ONE MORE
BARRIER TO PROVIDING CARE.
THERE ARE GROUPS THAT DO
EXCLUSIVELY THAT. THEY KNOW ALL THE
PAPERWORK. WOULD WHO TO REFER
TO. THEY HAVE IT DOWN.
THOSE ARE PROBABLY THE ONES THAT DO
IT BEST.>>Daryl: ARE THERE
IN ENOUGH?>>NO.
ARE THERE ENOUGH OF ANYBODY?
TAKING CARE OF PATIENTS WITH
CHRONICLE MEDICAL CONDITIONS.
EVERYBODY IS BUSY.>>Daryl: SO THAT
TOGETHER WITH COMMENTS YOU WERE
MAKING WHERE TRANSITION PERIOD,
TRANSITION TO WHAT?
I MEAN, IS THERE ONE BIG THING
THAT’S GOING TO CHANGE?
A LOT OF LITTLE THINGS THAT ARE
CHANGING ALL AT THE SAME TIME?
>>WELL, IF THE SYSTEM CONTINUES
THE WAY IT IS, ALL OF OUR PHYSICIANS
WILL BE EMPLOYED IN GROUP BECAUSE
THAT’S EASIER TO MANAGEMENT EASIER
TO MANAGE PHYSICIANS IN
GROUP. IT’S EASIER TO PAY
THEM SALARIES THAN TO NECESSARILY
WORK WITH THE ONESIE AND
TWOSIES, THE WAY THE PAPERWORK IS.
VERY DEMANDING.>>Daryl: WE TALK
ABOUT ONESIES AND TWOSIES.
THAT’S THE DOCTORS I WENT TO WHEN I
WAS –>>ONESIE.
>>Daryl: EXACTLY. IF I JOINED HER,
WE WOULD BE A TWOSIE.
>>Daryl: RIGHT. SO THAT
COMMUNITY-BASED GUY ON STREET
CORNER, DOCTOR WITH OFTENTIMES
THE SPOUSES, OFFICE MANAGER, IS
THAT GOING TO JUST GO AWAY?
>>WELL, THAT’S A FEAR.
THE PROBLEM IS 20% OF OUR COUNTRY IS
RURAL. 20% OF —
>>Daryl: THAT’S A RURAL PHENOMENON
NOW?>>WELL, IF WE
LOSE THE ONESIE TWOSIE, NO ONE TO
TAKE CARE OF THE RURAL POPULATION.
PROBABLY, IF YOU’RE IN
HONOLULU, YOU CAN GO TO KAISER.
YOU GO HPH, LARGE GROUP.
BUT IF YOU’RE IN HILO, YOU CAN’T.
IF WE LOSE THE ONESIE, TWOSIE,
BECAUSE THEY CAN’T SURVIVE WITH THE
CURRENT STATE OF PAYMENT, OR
WHATEVER THE REASON, THEY WANT
TO BE EMPLOYED, HAVE TOO MUCH
DEBT, THEN WE’RE NOT GOING TO HAVE
ANYBODY THIS HILO TO TAKE CARE OF
PEOPLE.>>Daryl: YOU
MENTIONED THAT YOU’RE INVOLVED A
LOT IN RURAL MEDICINE.
DOES THAT MEAN YOU’RE ON A COURSE
TO WANT TO BE LIKE DR. MITCHELL?
YOU WANT TO BE A SINGLE
PRACTITIONER OUT THERE, COMMUNITY
DOCTOR?>>I THINK A LOT
OF US AREN’T QUITE SURE RIGHT NOW ON
WHETHER WE WANT TO BE EMPLOYED OR
PRIVATE PRACTICE. I JUST KNOW THAT.
>>Daryl: PROBABLY NOT GOOD TO FIX IN
YOUR MIND WHAT YOU’RE GOING DO IN
THIS WORD.>>MEDICINE IS
CHANGING ALL THE TIME.
WE DO KNOW WE WANT TO BE ANY REAL
PLACE AND WE’LL DO WHATEVER IT TAKES.
>>Daryl: WHATEVER SYSTEM IS THERE.
RURAL PLACES, YOU’RE SAYING YOU
EARLIER SAID, ALMOST EVERYBODY
WILL BE WORKING FOR —
I’M WORRIED. BECAUSE THE SYSTEM
IS GETTING MUCH MORE COMPLEX.
IT USED TO BE YOU WOULD SEE A
PATIENT. YOU WOULD WRITE
THEIR NOTE. YOU WOULD BILL
THEIR INSURANCE. NOW, YOU SEE A
PATIENT. AND YOU HAVE TO
FIGHT TO NOT HAVE TO TURN AWAY FROM
THEM AND GO ON THE COMPUTER AND
DOCUMENT STUFF. THEN YOU HAVE TO
CLICK A WHOLE BUNCH OF BOXES
ABOUT WHETHER YOU CHECKED THIS OR
THAT OR DID THIS WITH THEM, REPORT
ON THIS FACTOR AND THAT FACTOR AND
LABS YOU ORDERED. HAVE TO REPORT
EVERYTHING. YOU HAVE TO DEATH
BY A THOUSAND CLICKS.
YOU HAVE TO CLICK ALL KINDS OF
STUFF.>>Daryl: MILLION
DROP DOWNS.>>THERE YOU GO.
SO IT’S MORE ABOUT THE COMPUTER NOW
THAN THE ACTUAL PATIENT.
SO THAT’S JUST BEGINNING OF IT.
THEN THERE’S PRIOR AUTHORIZATIONS.
SO HAVE YOU HAD TO GONE TO THE DOCTOR
AND HAD TO GET AN X-RAY OF SOME
KIND?>>Daryl: SURE.
I’M 63 YEARS OLD.>>NOW, MY FATHER
WENT TO THE DOCTOR.
I’VE HAD THE WORST HEADACHE OF MY
LIFE. NEUROLOGIST.
NEUROLOGIST COULD NOT ORDER A SCAN
OF HIS HEAD. NEUROLOGIST SAID,
IT WILL TAKE ME A WEEK OR TWO WITH
THE PRIOR AUTHORIZATION JUST
GO EMERGENCY ROOM. JUST GO SEE HIM.
THAT’S THE ONLY WAY HE COULD —
YOU HAVE TO FILL OUT PAPERS.
THEN WE’RE NOT DONE.
YOU HAVE TO BILL. AND THEN YOU HAVE
TO FILL OUT THESE EXTRA THINGS.
THEN WE WERE TALKING TONIGHT,
THEN YOU HAVE TO CHECK YOUR LIST OF
PATIENTS MAKE SURE ALL OF YOUR
PATIENTS ARE ON THE LIST.
SO YOU GET PAID. VERY COMPLEX.
>>Daryl: ANOTHER QUESTION FROM
VIEWER ON THIS TOPIC.
I’M CONVINCED INSURANCE, HEALTH
INSURANCE, AND PROFESSIONAL
INSURANCE, PROBABLY MEANS
LIKE MALPRACTICE AND STUFF, BIGGEST
REASONS THAT DOCTORS ARE ALL
FORCED TO WORK FOR LARGER EMPLOYERS.
OPTIONS TO LARGER METROPOLITAN
AREAS. SELF-EMPLOYMENT IS
NOT AN OPTION FOR DOCTORS THESE DAY.
COUPLE OF QUESTIONS IN
THERE. HOW BIG A PROBLEM
IS IT? MULTIPLE INSURANCE
CARRIERS AND IS THE INSURANCE
ENVIRONMENT CHANGING A LOT?
IS THAT KIND OF ONE OF THE BIG
THINGS THAT’S HAPPENING?
>>I THINK AT LEAST FROM THE
PERSPECTIVE OF QUEEN’S, WE’RE
ACTUALLY TRYING TO PARTNER MORE WITH
HEALTH INSURERS AND TRYING TO TAKE
CARE OF POPULATIONS OF
PATIENTS. SO AGAIN, NEED —
>>Daryl: WHAT DOES THAT LOOK LIKE?
>>I THINK THE IN THE PAST, QUESTION
WAS WHEN YOU NEGOTIATE WITH THE
INSURANCE COMPANY, WHO ENDS UP WITH
THE BETTER PIECE OF THE PIE?
I THINK AT LEAST LOCALLY, WITH BIG
INSURERS, REALIZED THAT IT’S IN THE
INTEREST OF BOTH THE HEALTH
DEPARTMENT SYSTEM AND THE INSURERS
TO WORK TOGETHER. HEALTH SYSTEM.
POSITIVE EXPERIENCE.
>>YOU JUST SAID WHEN NEGOTIATE
WITH THE HEALTH INSURANCE.
SHE DOESN’T HAVE ANY POWER.
NEGOTIATING WITH THE HEALTH
INSURER. MOST OF THE
DOCTORS PRIVATE PRACTICE HAVE,
THEY’RE GIVEN A CONTRACT.
YOU CAN SIGN TO IT OR NOT.
IF YOU DON’T SIGN IT, YOU’RE GOING
TO HAVE DIFFICULT TIME OF IT.
BECAUSE YOU HAVE TO GO YOUR OWN
WAY. THAT’S BEEN THE
ISSUE. PAYMENT MODEL FOR
PRIMARY CARE, FAMILY MEDICINE,
INTERNAL MEDICINE AND PEDIATRICS
CHANGED IN 2017. ACROSS THE BOARD.
WE KNOW LONGER GET THE FEE FOR
SERVICE THAT THE DOCTOR WAS JUST
EXPLAINING. WHICH FEE FOR
SERVICE IS DIRECT EXCHANGE
MONETARILY FOR SERVICE.
WHICH HOPEFULLY, IN MEDICINE,
EXCHANGE OF MONEY FOR BRAIN POWER.
YOU GET TO UNDERSTAND WHAT IS
HAPPENING WITH YOU MEDICALLY.
AND HOPEFULLY, GET SOME RELIEF AND
TREATMENT FOR THAT.
BUT NO LOANER IS THAT THE CASE.
AND HERE IN HAWAIʻI, MAJOR
HEALTH INSURER CALLED PAYMENT
TRANSFORMATION. I PHYSICIANS IN
PRIMARY CARE GETS A FLAT FEE PER
MONTH OR CAPITATE THE PAYMENT FOR
EACH PATIENT. PER MEMBER PER
MONTH. THAT CAPITATED
PAYMENT IS THE SAME NO MATTER
WHAT SERVICE WE OFFER THE PATIENT.
SO IN PRIMARY CARE, IN HILO,
WHERE I TRY TO OFFER A LARGE
NUMBER OF SERVICES DUE TO THE LACK OF
OTHER CLINICIANS IN MY AREA, I
DON’T GET PAID ANY MORE THAN SOMEONE
WHO REFERS THOSE SERVICES OUT.
>>Daryl: IS THAT AMOUNT PER PATIENT
DIFFERENT DEPENDING ON THE
PARTICULAR NEEDS OF THE PATIENT AT
ALL? LIKE IS IT SAY,
THIS IS A PATIENT HISTORY OF
DIABETES, AND OBESITY, AND MAYBE
MENTAL ILLNESS, DO YOU GET MORE FOR
THAT PERSON THAN YOU WOULD FOR
HEALTHY, 35-YEAR-OLD GUY?
>>YOU’RE SUPPOSED TO.
WHEN I PARTICIPATED,
WHICH I NO LONGER PARTICIPATE IN
THIS PAYMENT MODEL BECAUSE IT WAS NOT
VIABLE AND PHYSICIANS ARE
GETTING RUN OUT OF PRACTICE.
WHERE I WAS. SO BUT WHEN I WAS
DOING THAT, THAT MODEL DID NOT PAN
OUT. THEY PAY A FLAT
FEE BASED ON THE INSURANCE.
SO MEDICAID GETS A CERTAIN RATE.
COMMERCIAL GETS I CERTAIN RATE.
AND THE MEDICARE GETS A CERTAIN
RATE. THAT’S MY
UNDERSTANDING HOW IT IS ACROSS THE
BOARD. AVERAGE RATE PER
MEMBER PER MONTH IS $24.
THAT IS AVERAGE WHAT WE GET AS A
CLINICIAN TO TAKE CARE OF ALL THE
PREVENTATIVE ACUTE AND CHRONIC
ILLNESSES FOR YOU AS A PATIENT.
>>Daryl: WHAT EFFECT HAS THAT
HAD ON YOUR PATIENTS?
>>WELL, UNFORTUNATELY, FOR
A LOT OF THE PATIENTS, WHAT WE
SEE IS THAT THE CLINICIAN IS NO
LONGER ABLE TO PROVIDE AS MANY
SERVICES. CLINICIAN NO
LONGER WANTS TO FRONT THE MONEY
FOR THINGS LIKE A STREP TEST, WE
HAVE TO PAY MONEY FOR OR PREGNANCY
TEST OR FLU SWAB. WHAT HAPPENS IS
THE CLINICIAN NO LONGER PURCHASES
THOSE AND INSTEAD, REFERS THOSE
THINGS OUT OR TELLS THE PATIENT,
I DON’T HAVE IN A CUTE APPOINTMENTS
AVAILABLE. GO TO URGENT CARE.
ACROSS THE BOARD, IT’S NOT REALLY
SAVING ANY MONEY. IN TERM OF MEDICAL
DOLLARS.>>Daryl: NOT
SAVING MONEY IN THE BIG PICTURE.
>>THAT’S CORRECT.>>Daryl: ABOUT BUT
IT IS FOR INSURANCE COMPANY?
>>NO.>>Daryl: YOU DON’T
THINK IT’S SAVING THEM MONEY?
>>NO. RELEASED STUDY
PUBLISHED IN MAJOR MEDICAL JOURNAL
SHOWED NO SAVINGS. IT SHOWED NO
INCREASE COSTS BUT IF YOU READ THE
STUDY, IT SHOWED PAYMENTS TO
PRIMARY CARE DECREASED.
COST OF PRIMARY CARE WENT DOWN.
COST OF ANCILLARY CARE WENT DOWN.
>>Daryl: WHOEVER WANTS TO BITE ON A
QUESTION.>>WHERE’S THE
BUTTON.>>Daryl: CALLER
PHYSICAL THERAPY ON MAUI.
PATIENT APPROVALS SO HARD TO GET,
DIFFICULT TO RN A BUSINESS.
REIMBURSEMENT 30% LOWER IN HAWAIʻI
THAN ON THE MAINLAND.
CARDIOLOGIST LOSING $230 PER
PACE MAKER. DOES THAT MAKE
SENSE? DOES THIS ALL LINE
UP.>>OF COURSE, IT
DOESN’T MAKE SENSE, BUT YES,
IT’S ALL TRUE. THAT’S THE
PROBLEM. EXACTLY WHAT HE
WAS TRYING TO DEMONSTRATE.
WHEN WE DON’T GET REIMBURSED HERE,
WE CAN’T ATTRACT PHYSICIANS.
ALL OF PHYSICIANS HERE ARE
PRACTICING HERE BECAUSE THEY WANT
TO BE HERE. CLARA WANTS TO BE
HERE. IF SHE CAN’T
AFFORD TO PAY STUDENT LOANS,
CAN’T FOR TO HAVE A PLACE TO LIVE
AND EAT ONCE IN A WHILE, EVERY OTHER
DAY, CAN’T BE HERE.
>>WE WANT TO BE HERE.
WE’RE HERE BECAUSE WE LOVE IT HERE.
EVERYBODY PRACTICING
MEDICINE IN HAWAIʻI RIGHT NOW
IS ON A MEDICAL MISSION.
NOBODY IS HERE GETTING RICH.
MOST OF US ARE ACTUALLY LOSING
MONEY.>>Daryl: LET ME
ASK THIS QUESTION. MAYBE YOU CAN
ANSWER THIS. REIMBURSEMENT IS
30% LOWER THAN HAWAIʻI THAN ON
THE MAINLAND.>>YES.
>>Daryl: HOW CAN THAT BE POSSIBLE
IS THIS EVERYTHING COSTS MORE HERE.
>>THAT’S TRUE.>>Daryl: WHY IS
IT?>>HISTORY OF OUR
HEALTH INSURANCE IS DIFFERENT.
IN SOME WAYS, OUR MEDICAID PAID
BETTER THAN OTHER STATE.
IT’S OUR COMMERCIAL PAYS
LOWER THAN OTHER STATE.
>>FUNCTION OF HMSA HAVING NEAR
MONOPOLY FOR SO LONG?
>>I CAN’T HONESTLY SAY.
>>Daryl: YOU’RE IN THE MEDICAL
SCHOOL. YOU CAN SAY
ANYTHING YOU WANT.>>I CAN’T SAY
ANYTHING. I WANT.
PROBABLY ALREADY GOT MYSELF IN
TROUBLE. IF YOU ASK ME WHAT
IS THE ONE THING WE CAN DO TO GET
THE DOCTORS WE NEED, I WOULD SAY
PAY MORE.>>Daryl: WHERE IS
THAT NONE I COMING FROM.
INSURANCE REIMBURSEMENT.
INSURANCE REIMBURSEMENT IN
HAWAIʻI TOO LOW. NO MATTER WHAT WE
DO TO BRING IN NEW PHYSICIANS, NO
MATTER WHAT INITIATIVES,
MEDICAL SCHOOL IS TO GO, STATE IS
DOING, IF WE DON’T STOP THE EXIT OF
CURRENT PHYSICIANS WE HAVE SERVING SO
WELL RIGHT NOW, WE ARE GOING TO
CONTINUE TO HAVE A CRISIS.
>>Daryl: OKAY, CLAIR?
YOU STILL WANT TO BE A DOCTOR?
>>YES. SHE IS THE
SOLUTION.>>YEAH.
>>Daryl: EARLY CALLERS WE GOT,
SORT THROUGH THIS. BOTH OF THEM ASKED
ABOUT SATELLITE MEDICAL SCHOOLS.
WHAT IS GOING ON WITH THAT IN THE
MEDICAL SCHOOLS? IT SAYS, WHY CAN’T
PROGRAMS BE INITIATED IN BOTH
HILO AND MAUI, NEED IS GREATER ON
BIG ISLAND. PROGRAM BE STARTED
IN HILO. ?
I THINK THAT’S FIRST ONE IS
SUPPOSED TO BE IN MAUI.
RIGHT?>>YES.
I KNOW JABSOM WORKING HARD TO
EXPAND OUR MEDICAL CAMPUS TO MAUI.
TO BOTH RECRUIT MORE AND DOCTORS
THERE IN MAUI AND ALSO TO GIVE LOCAL
KIDS THERE SOME VISIBILITY TO
MEDICAL SCHOOL AND MAKE HEALTH CARE
PROFESSION SEEM POSSIBLE FOR THOSE
KIDS. AND SO CURRENTLY,
I THINK THE REASON WHY I THINK IT IS
BEING PLACED ON MAUI INITIALLY IS
THERE IS GREAT INTEREST FROM
PARTNERS THERE IS MY UNDERSTANDING.
I’M SURE DOCTOR CAN SPEAK MORE WHY
MAUI IS THE LOCATION.
EVEN IF THE NEED IS GREATER ON BIG
ISLAND, MAUI ALSO NEEDS HELP.
AND I THINK IN TIME, THE GOAL IS
TO EXPAND TO ALL OUR NEIGHBOR
ISLANDS, NOT JUST MAUI.
I THINK THAT’S JUST ONE TINY
STEPPING STONE. AND THERE IS
HOPEFULLY GOING TO BE MANY MORE.
>>Daryl: DO YOU FIND THAT YOU
MENTIONED ALREADY THAT YOUR
CLASSMATES ARE ALL VERY COMMITTED TO
HAWAIʻI. WHAT ARE YOU
HEARING ABOUT WHAT LIFE IS LIKE ON
THE MAINLAND? HAVE YOU HEARD
FROM MEDICAL STUDENTS WHO SAY,
YOU’RE CRAZY FOR STAYING OUT THERE?
MORE MONEY TO BE MADE SOMEWHERE
ELSE. YOU SHOULD DO
SPECIALTY, MAKE A LOT OF MONEY
INSTEAD OF PRIMARY CARE.
>>I HAVEN’T. I KNOW IT’S A
REALITY FOR SOME PEOPLE.
I THINK A LOT OF PEOPLE HAVE A TRUE
PASSING FOR PRIMARY CARE AND
SERVING THIS POPULATION.
SO MAYBE THE GRASS SEEMS GREENER ON
THE MAINLAND, BUT I THINK EVERYONE
IS PRETTY DEDICATED TO
PURSUING THEIR PASSION HERE.
GREAT TO REMEMBER, THAT THESE PEOPLE
HAVE A PASSION. WE SHOULD REALLY
CULTIVATE IT AND HAVING MEDICAL
SCHOOL EXPAND TO THE ISLANDS IS A
GREAT IDEA. BUT IT STILL TAKES
7 YEARS TO TRAIN A PHYSICIAN.
EVEN INITIATING MEDICAL SCHOOLS
WILL TAKE 7 YEARS TO GET THESE
PEOPLE TO GRADUATE.
I DON’T WANT TO CALL THEM KIDS UP
GUYS ARE AWESOME AND ADULTS BUT YOU
KNOW, IT’S STILL GOING TO TAKE 7
YEARS TO GRADUATE A PRACTICING
PHYSICIAN. ON TOP OF THAT,
THAT DOESN’T GUARANTEE A
FOUR-YEAR GRADUATING MEDICAL
STUDENT A RESIDENCY SLOVMENT
WHICH WE HAVE NOT INCREASED OUR
RESIDENCY FUNDING NATIONALLY SINCE
1997. THAT’S A NATIONAL
ISSUE. THAT’S NOT A
HAWAIʻI ISSUE. EVEN THOUGH WE’VE
INCREASED OUR MEDICAL SCHOOL,
NATIONALLY, WE HAVE NOT INCREASED
OUR RESIDENCY SLOTS.
WHICH MEAN WE MAY NOT HAVE ALL THE
SPACE NEEDED TO GENERATE FULLY
TRAINED PHYSICIANS.
>>Daryl: I HAVE TO KEEP GOING.
>>IS HAVE TO HAVE US BACK.
>>Daryl: JUST DO IT FOR ANOTHER
HOUR. WHAT THE HECK.
I REMEMBER HEARING THIS DEBATE A LOT
REFORM MALPRACTICE INSURANCE.
IS THAT A BIG LIMITING FACTOR OR
BIG PROBLEM HERE IN HAWAIʻI IN
PARTICULAR?>>I DON’T THINK
RELATIVE WILL TO THE REIMBURSEMENT.
I THINK TORT REFORM, TEN YEARS
AGO, 15 YEARS AGO, WAS THE BIG
SUBJECT. BUT OUR COST FOR
MALPRACTICE IS SIGNIFICANTLY
LOWER THAN OUR HEALTH INSURANCE.
AT LEAST IN MY SPECIALTY.
I THINK IT’S TORT REFORM, VERSUS
REIMBURSEMENT, REIMBURSEMENTS ARE
A BIGGER ISSUE.>>Daryl: I THINK
THEY DID A LOT OF TORT REFORM A
NUMBER OF YEARS AGO.
>>LITTLE BIT.>>Daryl: I
REMEMBER SEEING ALL KINDS OF RULES
ABOUT HOW YOU CAN’T BRING
MALPRACTICE TILL YOU’VE GONE
THROUGH THIS CLAIMS PANEL AND
ALL OF THIS OTHER RIGAMAROLE.
>>YOU’RE INVOLVED WITH THAT, RIGHT?
>>YES. TELL YOU ALL ABOUT
IT. I DON’T THINK YOU
WANT ME TO. I THINK YOU’RE
RIGHT. NOTHING PERSONAL
ABOUT THAT. OKAY.
WHAT KIND OF INCENTIVES ARE
BEING USED TO ATTRACT
SPECIALISTS TO HAWAIʻI?
IS THAT PART OF YOUR KULEANA?
ARE YOU TRYING TO —
>>REACTIVE. WHAT HAPPENS WHEN
YOU RECRUIT SPECIALISTS FROM
THE MAINLAND? WHAT DO THEY TELL
YOU? DO THEY TELL YOU
KNOW?>>WE HAVE TO
COMPENSATE THEM FAIRLY.
CLEARLY, HOW MUCH YOU PAY THEM IS AN
ISSUE. MAKING SURE THEY
ARE THE RIGHT PRACTICE
ENVIRONMENT. THEY HAVE THE
SUPPLIES, CAPITAL THEY NEED.
BUT WE SPEND A LOT OF TIME TO ENSURE
THAT WE HAVE THE RIGHT
SPECIALISTS. ON CALL AT
QUEEN’S, 22 DIFFERENT
SPECIALTIES. ONE OF OUR COMMITMENTS
TO MAKE SURE WE GET THOSE CALLS,
I’M SORRY.>>CALL PANELS AT
THE VERY MINIMUM COVERED.
SO IT’S SIGNIFICANT ISSUE
TO RECRUIT A SPECIALIST.
NEUROSURGEON, HIRED THREE
NEUROSURGEONS IN THE LAST YEAR AT
QUEEN’S. SIGNIFICANT
INVESTMENT.>>Daryl: IS
PRIMARY CARE STILL OUR BIGGEST
SHORTAGE AREA? IN TERMS OF, MOST
CRITICAL SHORTAGE AREA?
>>SO IT IS BIGGEST SHORTAGE
AREA BECAUSE IT IS THE BIGGEST NEED.
BECAUSE EVERYBODY NEED AS I PRIMARY
CARE PROVIDER. NOT EVERYBODY
HOPEFULLY NEEDS A NEUROSURGEON.
>>Daryl: I HOPE NOT.
>>IF YOU HAVE A SHORTAGE OF A
NEUROSURGEON, THAT IS CRITICAL IN THE
TIME IF YOU NEED BRAIN SURGERY.
YOU MUST HAVE THAT NEUROSURGEON.
HOW DOWN IF YOU DON’T NEED BRAIN
SURGERY IF YOU DON’T HAVE A
PRIMARY CARE? END UP GOING TO
THE EMERGENCY ROOM FOR PRIMARY CARE.
HE DOESN’T WANT TO FOLLOW YOU ALL THE
TIME. SHE WANTS TO
FOLLOW YOU ALL THE TIME AND KNOW ALL
ABOUT YOU. NO OFFENSE, NOT
THE BEST CARE.>>Daryl: HOW DID
GET PEOPLE GO INTO PRIMARY CARE
INSTEAD OF BECOMING
SPECIALIST.>>
>>IT’S DIFFICULT. YOU HAVE TO HAVE
THE PASSION.>>Daryl: REALLY?
IT’S LOVE.>>IT IS.
WANTING TO KNOW EVERYTHING ABOUT
YOUR PATIENT. AND WANT WANTING
TO TAKE CARE OF THEM FROM BIRTH
TILL DEATH. DO THE PROCEDURES
THAT SHE’S ADMITTEDLY SAYING
SHE CAN’T DO FOR THEM.
>>Daryl: REMINDS ME OF SOMETHING.
ISN’T OUR FINANCING SYSTEM
SCREWED UP?>>YES.
SOMEONE SAYS WELL, FINANCIALS AREN’T
LINED UP WITH THE TRUE NEEDS MUCH
YOU MENTIONED I WANT TO BE A
DOCTOR TAKES CARE OF MY PATIENT FROM
BIRTH TO DEATH. WELL, FOR THE
FIRST 65 YEARS OR, ONE HEALTH CARE
SYSTEM. FOR THE —
>>OH, NO. CHANGED AT LAST
TEN TIMES PROBABLY.
>>Daryl: NO INCENTIVE FOR THE
INSURANCE COMPANY PAYING YOU WHEN
YOU’RE AN ADULT FOR PREVENTATIVE
CARE BECAUSE MEDICARE IS GOING
TO PAY FOR THE CHRONIC ILLNESS
WHEN YOU PASS 65. FINANCIAL
INCENTIVES AREN’T LINED UP WITH THE
NEED. OKAY.
WHAT’S STOPPING US FROM HAVING A
SYSTEM LIKE FRANCE?
ARE THEY SINGLE PAYOR?
PHYSICIAN CAN DO MEDICAL
RECORDKEEPING FOR OWN COMPUTER
SYSTEM. FRENCH DOCTORS HAVE
MINIMAL BUSINESS OVERHEAD.
WHY IS THAT?>>PROBABLY ALL
HAVE THE SAME ELECTRONIC HEALTH
RECORD. WE DON’T.
OURS DON’T COMMUNICATE WITH
EACH OTHER. THAT’S A BIG
PROBLEM. MINE DOESN’T TALK
TO HIS. MINE DOESN’T TALK
TO ANY OF THEIRS? WHY NOT?
>>NO NATIONAL STANDARD.
WE’RE CAPITALISTS. EACH OF COMPANY IS
PROPRIETARY SOFTWARE.
>>Daryl: ONE INSURANCE COMPANY
OR ONE MEDICAL SYSTEM WILL BUY
ONE SYSTEM, ANOTHER BUY
ANOTHER SYSTEM.>>FORTUNATE IN
HAWAIʻI, THREE OF THE BIG HEALTH
SYSTEMS ARE ON THE SAME.
SO WE CAN SHARE RECORDS.
PRIMARY CARE DOCTORS DON’T GET
TO SEE WHAT THEY DO.
>>Daryl: IS THE SOLUTION SINGLE
PAYOR?>>DEPENDS WHICH
SINGLE PAYOR.>>Daryl: OKAY.
SO GOVERNMENT?>>WELL IT WOULD
HAVE TO BE.>>Daryl: AT THE
CORE OF IT. GOVERNMENT WOULD
HAVE TO COLLECT THE MONEY, THEN
PASS OUT THE MONEY.
IN TERMS OF THEY MIGHT HAVE
INSURANCE COMPANY THAT MANAGES THE
SYSTEM. RIGHT?
SO GETTING REALLY QUIET.
>>I THINK THE PROBLEM WITH THE
PEOPLE, PHYSICIANS IN PARTICULAR,
HAVE A SINGLE PAYOR.
THINK AT THE CORE, PHYSICIANS ALL
WANT SINGLE PAYOR IN TERMS OF
SIMPLICITY. WANT TO TAKE CARE
OF OUR PATIENTS. WANT THAT PART OF
SINGLE PAYOR. BECAUSE THEN WE
WON’T HAVE THE HUGE
ADMINISTRATIVE BURDEN OF
UNDERSTANDING EACH DIFFERENT
REQUIREMENT FOR EACH DIFFERENT
INSURANCE. WHICH MAY BE YOU
DON’T HAVE TO DEAL WITH, BUT I HAVE
TO DEAL WITH KNOWING DIFFERENT
FORMULARY, EACH DIFFERENT PRIOR
AUTHORIZATION FORM, ALL OF THESE
DIFFERENT THINGS. SIMPLICITY WE
LIKE. THE TROUBLE IS
THAT WE HAVE REALIZED AS
PHYSICIANS THAT WHAT IS HAPPENED
RIGHT NOW IS THE GOVERNMENT IS
REGULATING OUR MEDICAL SYSTEM.
AND WHAT IS HAPPENED WITH THAT
THEY’RE DOING SO WITHOUT PHYSICIAN
INPUT. IN TERMS OF
PHYSICIANS ACTUALLY
PRACTICING THE REAL MEDICINE.
SO BY DOING SO, ALL THE
REGULATIONS ARE NOT WORKING FOR
PEOPLE WHO ARE ACTUALLY ON THE
GROUND. IN FACT, TWO
MEMBERS OF THE PTAC COMMITTEE WHO
ADVISED CMS HAVE RESIGNED IN
PROTEST OF THAT ADVISORY COMMITTEE
WHO TRIES TO GIVE C MS ADVICE.
>>GOVERNMENT, MEDICAID AND
MEDICARE. THE ONES ACTUALLY
IN CHARGE OF MEDICARE,
GOVERNMENT CONTROLLED SYSTEM.
AND THEY LISTEN TO NONE OF THE
RECOMMENDATIONS. I BELIEVE THAT
PTAC HAS GIVEN THEM 15 DIFFERENT
RECOMMENDATIONS OVER 2 YEARS.
AND TWO OF THE SMALL COMMITTEES
HAVE RESIGNED IN PROTEST OF THIS.
>>Daryl: RESULT OF THAT IS YOU’VE GOT
GOVERNMENT REGULATIONS THAT
ARE USUALLY PLACE THE ON THE PAYORS.
RIGHT? INSURANCE
COMPANIES AND THE.>>AND ON
PHYSICIANS.>>Daryl: AND ON
PHYSICIANS THAT DON’T MESH WITH
REALITY.>>EXACTLY.
LAY THIS OUT. IF WE WERE TO
HAVE ONE PAYOR, PROBABLY BE
MEDICARE. THAT IS NATIONAL.
MEDICARE FOR ALL. LET’S SAY WE HAVE
MEDICARE. MEDICARE IS
TESTING OUT DIFFERENT PAYMENT
METHODOLOGIES RIGHT NOW.
WITH PRIMARY CARE. THERE’S TWO OR
THREE DIFFERENT ONES GOING ON.
SO THEY DON’T EVEN KNOW.
>>MINIMUM FIVE TO SEVEN.
FIVE SO SEVEN DIFFERENT PAYMENT
MODALITIES GOING ON RIGHT NOW.
WE, I THINK IT WOULD BENEFIT TO
HAVE ONE FOR ALL THEN WE WOULD CUT
OUT A LOT OF THE COSTS WHICH WOULD
BE ALL THE DIFFERENT
INSURANCE COMPANIES.
ONCE I DID A STUDY OF HOW MANY PRIOR
AUTHORIZATIONS FORMS THERE ARE,
HOW MANY FORMS THAT NEUROLOGIST
WOULD HAVE HAD TO FILL OUT FOR MY
FATHER’S MRI, A THOUSAND.
JUST HERE. WITH OUR LIMITED
NUMBER OF INSURANCE
COMPANIES. SO.
>>Daryl: WE’VE GOT LIKE FIVE OR SIX?
>>KIND OF EIGHT. KIND OF?
THERE’S A THOUSAND DIFFERENT PRIOR
AUTHORIZATION FORMS?
>>YEAH. THAT INCLUDES
DIFFERENT MEDICATIONS.
DIFFERENT STUDIES. DIFFERENT LAB
TESTS. ORDERING PHYSICAL
THERAPY.>>Daryl: DO YOU
HAVE DIFFERENT COMPUTERS THAT
YOU’RE TALKING TO AS WELL?
FROM YOUR, LIKE DOES ONE INSURANCE
COMPANY HAVE ONE COMPUTER SYSTEM,
ANOTHER ONE HAS ANOTHER ONE?
>>NO. SO I USE ONE HR.
ELECTRONIC CHART SYSTEM.
WHAT I CHART EVERYTHING ON.
I HAVE TO LOG IN REMOTELY TO OUR
LOCAL HOSPITAL, HILO MEDICAL
CENTER, WHERE I DO HAVE ACCESS TO SEE
MY PATIENTS WHILE THEY’RE IN THE
HOSPITAL. AND SEE THEIR
RECORDS. NOW, IF I WANT TO
LOG ON TO ONE OF THE INSURANCE
HEALTH SYSTEMS, TO SEE WHETHER MY
PATIENTS HAVE MET ALL OF THEIR
QUALITY METRICS, I HAVE TO LOG ON
REMOTELY TO THEIR SYSTEM.
EACH INSURANCE HAS THEIR OWN SYSTEM
FOR THAT.>>I WANT TO COME
BACK. TOUCH BASE.
YOU’RE EXCITED ABOUT ALL OF THIS.
HOW IS IT THAT YOU FIGURE ON COPING
WITH THIS? I MEAN, ARE YOU
JUST SUPREMELY CONFIDENT, AT
LEAST HAVE SOME ANXIETY ABOUT WHAT
YOU’RE WALKING INTO?
>>YEAH, I THINK THERE’S DEFINITELY
SOME APPREHENSION. ALL PRETTY ANXIOUS
AS IT IS BEING IN THE MEDICAL
SCHOOL, WORRIED ABOUT EXAMS AND
EVERYTHING LIKE THAT.
BUT I THINK WE ARE THINKING ABOUT IT
BECAUSE WE ARE VERY AWARE OF THE
PHYSICIAN SHORTAGE AND ALL OF THESE
CHALLENGES THAT THEY BRING UP.
SO I THINK IT’S SOMETHING WE’RE
THINKING ABOUT AND HOPEFULLY, WE CAN
CONTRIBUTE IN A POSITIVE WAY.
IN THE FUTURE.>>DO YOU HAVE
HOPE?>>DUI.
FOR THE WHOLE SYSTEM?
>>YEAH. I DO.
WHAT GIVES YOU THAT HOPE?
>>I THINK IT’S SEEING MY
CLASSMATES AND SEEING LIKE THE
TRUE GENUINE PASSION THAT THEY
HAVE, EVERY SINGLE DAY IN CLASS.
SO MANY OF THEM ARE DEDICATED TO
BEING A DOCTOR AND BEING THE BEST
THEY CAN BE AND PROVIDING BEST
CARE. A LOT OF MY
CLASSMATES ARE SUPERINVOLVED WITH
THE COMMUNITY. JABSOM IS A VERY
COMMUNITY-BASED SCHOOL.
WE HAVE PROGRAMS IN MANY
COMMUNITIES HERE ON OAHU, NEIGHBOR
ISLANDS, SO MY CLASSMATES ARE
WORKING ON MAKING CONNECTIONS AND
HOPEFULLY, IN THE FUTURE, THINGS
LIKE ELECTRONIC HEALTH RECORDS,
CAN CONNECT IN THE SAME WAY.
>>Daryl: FIGURE IT OUT.
IN MY BUSINESS, JOURNALISM
BUSINESS, BROADCASTING
BUSINESS, ONE OF THE THINGS THAT WE
DO WELL ANY TARING TO, SOMEONE WILL
LEAVE HAWAIʻI TO GO OFF TO SCHOOL
ON THE MAINLAND. MAYBE DO TWO OR
THREE YEARS IN ANOTHER TELEVISION
STATION. SOMEWHERE ELSE.
THOSE ARE THE ONES WITH REALLY WANT
BECAUSE THEY GONE, CUT THEIR TEETH
AND READY TO BEPROFESSIONAL ON
AIR. LOOK AT DOCTOR,
MEDICAL SCHOOL DEGREE ON THE
MAINLAND, DONE A RESIDENCY ON THE
MAINLAND, BUT THEY’RE ORIGINALLY
FROM HAWAIʻI, DO YOU FIND MANY OF
THEM WILLING TO COME BACK OR DO
THEY JUST, IS IT HARD POSSIBLY FOR
THEM TO MOVE BACK, OR ARE THEY PRETTY
MUCH LOCKED INTO THEIR PRACTICES
AND UNABLE TO COME BACK SNMPLEGHTS I
THINK LIKE MOST THINGS IN HAWAIʻI,
WHEN WE RECRUIT, IT’S VERY
RELATIONSHIP BASED.
WE DEFINITELY LOOK FOR TIE TO
HAWAIʻI. THE JABSOM
STUDENTS WE WOULD LIKE EVERY JABSOM
STUDENT TO COME BACK.
WE DON’T OFFER RESIDENCIES IN ANY
OF THE SURGICAL SUBSPECIALTIES.
GOING TO TRAIN, NEUROSURGERY, YOU
HAVE TO GO TO THE MAINLAND.
OUR IDEAL CANDIDATE SOMEONE
WHO GOINGS TO JABSOM, GETS
TRAINED WELL, COMES BACK, AND
TAKES CARE OF THE PEOPLE.
SO WE DEFINITELY LOOK FOR FOLKS WHO
HAVE A HAWAIʻI TIE.
>>Daryl: SOMEBODY NAMED GIL.
YOU NEED TO TALK ABOUT.
HE SAYS, I’M A JABSOM ALUMNI.
WORKING, ON MAINLAND.
MY WIFE IS ALSO PHYSICIAN.
LOVE TO COME BACK TO HAWAIʻI TO
WORK. DIFFERENCE IN PAY
IS JUST TOO GREAT. ADD THAT TO THE
HIGHER COST OF LIVING.
. YEP.
COME BACK, GIL.>>PLEASE.
>>THAT’S EXACTLY WHAT WE’VE BEEN
SAYING. YOU CAN’T NO
MATTER WHAT ALOHA WE OFFER, WE CAN’T
COMPENSATE PEOPLE FAIRLY HERE IN
HAWAIʻI AT THE RATES WE’RE BEING
REIMBURSED. THAT MEANS THAT
PEOPLE WON’T COME BACK.
THAT DOESN’T MEAN PEOPLE ARE TRYING
TO GET RICH. DOCTORS HERE
AREN’T GETTING RICH.
DOCTORS ARE JUST TRYING TO MAKE A
LIVING. WE’RE NOT EVEN
GETTING COMPENSATED ENOUGH
TO PAY FOR OUR PRACTICE.
WHAT’S HAPPENING IS PRACTICES ARE
CLOSING AND PEOPLE AREN’T ABLE TO
STAY IN BUSINESS. AND THEY’RE BEING
BOUGHT OUT BY LARGER COMPANIES.
IF THERE’S NOT A LARGER COMPANY
AVAILABLE TO PURCHASE THAT
PRACTICE, THAT PRACTICE IS FORCED
TO CLOSE, HAPPENING ON THE
NEIGHBOR ISLANDS IN PARTICULAR.
THAT COMMUNITY IS LOSING PHYSICIAN.
NO MATTER HOW MUCH CLAIR WANTS TO DO
TO NEIGHBOR ISLAND, IF SHE
CAN’T PAY TO LIVE, SHE NEEDS TO EAT.
SHE NEEDS TO PAY HER STUDENT DEBT.
ALL OF THOSE THINGS NEED TO
HAPPEN FOR HER TO STAY THERE.
ALL OF THOSE THINGS NEED TO
HAPPEN FOR GIL AND WIFE TO ARRIVE
HERE. AS LONG AS WE
DON’T HAVE THE APPROPRIATE
COMPENSATION AND GET PAID ONE-THIRD
TO ONE-HALF WHAT A PHYSICIAN CAN GET
PAID ON THE MAINLAND.
PEOPLE WILL NOT COME HERE.
>>Daryl: IT’S THAT DRAMATIC.
WHY IS IT SO MUCH — TALKED
EARLIER ABOUT BASICALLY THE
INSURANCE REIMBURSEMENTS
BEING LOWER. WHICH DOESN’T SEEM
TO MAKE ANY LOGICAL SENSE.
OTHER THAN MONOPOLISTIC KIND
OF THING. WHAT IS THE
SOLUTION TO THAT ARE IN TERMS OF,
IS THERE A ROLE FOR THE LOCAL
GOVERNMENT TO PLAY?
OR THE STATE GOVERNMENT TO
PLAY? IS THERE ANYTHING
IT CAN BE DONE ABOUT THAT IN.
>>WELL, I THINK IT’S HISTORIC.
SO IN HAWAIʻI, WE HAVE THE PREPAID
HEALTH CARE ACT. GIVES US VERY HIGH
LEVEL OF INSURANCE.
YOU PROBABLY HEARD ABOUT OBAMA BRONZE
LEVEL. SILVER LEVEL.
OURS IS LIKE DOUBLE PLATINUM.
IT’S DIAMOND. WAY UP THERE.
WE HAVE AMAZING INSURANCE.
AND WE KEPT THE COSTS DOWN OVER
TIME. SO I THINK IT HAS
DO WITH THAT RELATIONSHIP.
THE INSURANCE COMPANIES HAVE TO
PROVIDE A LOT OF SERVICE FOR
PROBABLY A LOWER PREMIUM DEFINITELY
LOWER PREMIUM THAN WOULD BE FOR THAT
LEVEL OF SERVICE. HOWEVER, AS
MICHELLE SAID, IF SOMEONE, SHE’S
ONLY PAID $24 A MONTH FOR SEEING A
PATIENT. BUT HOW MUCH DOES
THAT PATIENT PAY IN INSURANCE?
500? YOU KNOW, WHERE IS
THE RESTS ABOUT? IT GOES TO
MEDICATIONS. PHENOMENALLY
EXPENSIVE. PROCEDURES.
TO THE INSURANCE COMPANY.
GOES TO MANAGING ALL OF THOSE FORMS
THAT HAD TO BE FILLED OUT.
>>Daryl: ALSO, JUST SO PEOPLE GET
IT, INSURANCE COMPANIES HAVE TO
PLAN FOR THE RISK OF ALL OF THEIR
CLIENTS.>>RIGHT.
>>Daryl: THEY DO NEED TO KEEP MONEY
ASIDE SO THAT THAT PERSON WHO DOESN’T
GET SICK, IS GOING TO SUBSIDIZED THE
PERSON.>>$500 A MONTH,
YOU MIGHT COST THEM 10,000.
>>OKAY. ANOTHER BIG ISSUE
THAT WE HAVEN’T TALKED ABOUT IS
ASKING ABOUT, WHAT’S THE TERM?
I THINK IT’S CALLED SCOPE OF
PRACTICE, SCOPE OF PRACTICE DEBATE.
WHICH IS ALTERNATIVES TO
MD’S. COUPLE OF
QUESTION. WHY ARE RN’S NOT
BEING USED FOR PRIMARY INTERVIEWS
WITH PATIENTS? NOTICED A LOT OF
CLINICS FAILED TO HIRE MORE ADVANCED
PRACTICE NURSES. I PREFER TO HAVE
MY MEDICAL FOLLOW UP WITH APRN.
I KNOW THAT’S BIG ISSUE WAS THE
NURSE PRACTITIONERS.
HOW ARE WE IN THIS STATE WITH
ALLOWING NURSE PRACTITIONERS AND
OTHER FOLKS NOT MD’S SUPPORT THE
MEDICAL SYSTEM?>>THEY HAVE FULL
SCOPE OF PRACTICE HERE.
>>Daryl: HAWAIʻI IS ONE OF THE
STATES WHERE THEY HAVE FULL SCOPE OF
PRACTICE?>>KEEP IN MIND,
THEY ONLY HAVE 500 STUPID SURPRISED
CLINICAL HOURS.>>Daryl: WHAT DOES
THAT MEAN?>>THEY DO 500
HOURS WITH PATIENTS WITH
SUPERVISOR TEACHING.
>>Daryl: THIS IS THE TRAINING
PERIOD?>>TRAINING
PERIOD. YES.
SO PROBABLY THE SHORTEST TRAINING
PERIOD FOR A PHYSICIAN IS ABOUT
20,000 HOURS. SO THE DIFFERENCE
IS IN TRAINING ARE SIGNIFICANT.
BUT ALSO THE PHYSICIANS ARE
TRAINED TO DO THE PROCEDURES, TAKE
OFF A MOLE, EVEN IN THE OFFICE, YOU
CAN DO GYNECOLOGICAL
PROCEDURES. A LOT OF
PROCEDURES THAT DOCTORS ARE
TRAINED TO DO THAT NURSE
PRACTITIONERS AREN’T TRAINED TO
DO. EARLIER, DOCTOR
SAID SHE’S IS NOT GOING TO — NOT
YOU PERSONALLY, BUT THE DOCTORS
WILL PROBABLY NOT TAKE THE TIME TO
THOSE PROCEDURES BECAUSE THEY’RE
PAID ONE PAYMENT FOR THE PATIENT
PER MONTH. SO WE’RE LOSING
THOSE. BUT IN HAWAIʻI, I
THINK WE HAVE A FAIRLY
COLLABORATIVE RELATIONSHIP AND
WE HAVE A LOT OF PRACTICES, I DON’T
WANT TO SAY A LOT. WE HAVE VERY WELL
RUN PRACTICES THAT INCORPORATE THE
APRNS AND PHYSICIANS AND
COMMUNITY HEALTH WORK, RN’S,
PSYCHOLOGISTS, AND REALLY WORK WELL
TOGETHER. THAT IS THE BEAUTY
OF MEDICINE. IF EVERYBODY IS
WORKING UP TO THE FULL SCOPE OF
PRACTICE, HIGHEST LEVEL OF THEIR
TRAINING, THEN THE DOCTORS WOULDN’T
BE PUSHING ALL THE BUTTONS.
>>THERE WOULD BE HELP BY SOMEBODY
WHO KNOWS HOW TO PERHAPS TAKE NOTES
FOR THEM. WHICH IS HAPPENING
A LOT.>>Daryl: INVOLVE
ACE BUNCH OF PEOPLE THAT AREN’T
EVEN IN HILO.>>RIGHT.
THAT’S TRUE. I ACTUALLY DO USE
REGISTERED NURSES IN MY PRACTICE TO
HELP ME SEE PATIENTS.
WE DO EXCEPTIONAL JOB.
PATIENTS LOVE IT. THEY DO A LOT OF
PATIENT EDUCATION. LIKE DOCTOR SAID,
EVERYBODY SHOULD BE WORKING AS A
PART OF A PHYSICIAN LED
TEAM. IT’S VERY
IMPORTANT THAT WE ALL WORK AS A
TEAM. THE EDUCATION
TRACKS ARE DIFFERENT.
WE LEARN, WE’RE IN MEDICAL SCHOOL,
THEY’RE IN NURSING SCHOOL.
AND WE DO LEARN DIFFERENTLY.
AND WE SHOULD ALL WORK TOGETHER FOR
THE PATIENT. AND THAT IS REALLY
IMPORTANT.>>JUST TO JUMP
IN. TEAM BASED CARE,
100%. WE ACTUALLY
STRUGGLE FINDING APP’S.
ADVANCE PRACTICE PROVIDERS.
OTHER PA OR APRN. SAME PEOPLE
TROUBLE WITH DOCTORS.
ADVANCED PRACTICE PROVIDER.
APRN, ADVANCE PRACTICE NURSED OR
PA, PHYSICIAN ASSISTANTS.
WE DON’T HAVE A PHYSICIAN
ASSISTANT PROGRAM IN IN HAWAIʻI.
>>WE DO NOW.>>I’M SORRY.
YOU’RE RIGHT. IN KONA.
STARTED ONE. UNIVERSITY OF
WASHINGTON.>>Daryl:
UNIVERSITY OF WASHINGTON CAME TO
HAWAIʻI TO TRAIN PEOPLE HERE?
>>YES. WE NEED THESE
FOLKS. WE JUST DON’T HAVE
ENOUGH OF THEM. SO THE SAME ISSUE
WITH PHYSICIANS.>>POSTINGS FOR
OVER A YEAR FOR ADVANCED PRACTICE
PROVIDERS.>>Daryl: IT’S NOT
A MAGIC BULLET.>>NOT A MAGIC
BULLET BECAUSE WE DON’T HAVE ENOUGH
OF THEM.>>I WAS GO TO
SAY, I THINK ONE OF OUR STUDENT
GROUPS ON CAMPUS, FAMILY MEDICINE
INTEREST GROUP, IS PUTING ON A HUGE
STUDY RIGHT NOW, AND ASSESSMENT,
INTERVIEWING STUDENTS,
EDUCATORS, AND PROGRAMS THAT
EXIST ON EVERY SINGLE NEIGHBOR
ISLAND. A ASSESSING WHAT
WORKING WELL AND RECRUITING
STUDENTS INTO HEALTH CARE
PROFESSIONS. AS WELL AS WHAT
ARE SOME CHALLENGES.
I JUST, I THINK IT’S A GREAT
RESPONSE FOR THEM TO NOT SAY, THIS
IS HOW YOU CAN GO INTO MEDICINE.
THE WHOLE PURPOSE OF THE PROGRAM IS
TO GIVE VISIBILITY TO ALL HEALTH CARE
PROFESSIONS INCLUDING
MEDICINE, ALSO NURSES.
>>Daryl: GOOD POINT.
ONE OF THE THINGS YOU REFLECTED IN
YOUR REPORT IS WAS THE IDEA OF HAVING
HEALTH ACADEMIES IN THE HIGH
SCHOOLS. SO CAN START
GETTING SENSE OF WHAT’S AVAILABLE.
INTERESTING TO ME THAT YOU’RE
TALKING ABOUT THESE ADVANCED
PRACTICE FOLKS, PROBABLY COULD BE
WORKING A LOT QUICKER THROUGH
THE TRAINING THAN SOMEONE BECOMING
FULL MD.>>YEAH.
TEAM BASED MODEL. .
PROBABLY A PRETTY GOOD JOB.
>>PRETTY GOOD JOB.
PRETTY GOOD JOB.>>PEOPLE SHOULD,
WHO ARE OUT THERE, THINKING ABOUT
MEDICINE, DON’T THINK THEY CAN
BECOME A DOCTOR,.>>SO MANY OPTIONS
FOR THEM.>>Daryl: COOL.
VERY NICE COMMENT FROM SOMEONE.
IT SAYS, THERE’S CLEARLY A
PHYSICIAN SHORTAGE IN HAWAIʻI,
INCORRECT IF THE IMPRESSION IS
GIVEN THAT HEALTH CARE IS POOR IN
HAWAIʻI. SHOWED HAWAIʻI IS
SINGULAR IN ITSABLE TO PROVIDE
HIGHER QUALITY CARE WITH LONGER
LIFE EXPECTANCY, LOWER COST THAN
EVERY OTHER STATE IN THE UNION.
>>THAT IS TRUE. A LOT SHORTER.
>>Daryl: HOW ARE WE DOING THAT?
WHAT IS GREAT ABOUT OUR SYSTEM
HERE?>>WE’RE HEALTHY
PEOPLE. TO START WITH.
SO HE WITH DO LIVE LONGER.
WHAT WE DOING? LOWER COSTS ARE
REIMBURSEMENTS ARE LOW.
>>Daryl: DOCTORS —
>>RIGHT THERE. REIMBURSEMENT
ACROSS THE BOARD ARE LOW.
LOCALLY AND FEDERALLY.
OUR MEDICARE REIMBURSEMENTS ARE
ACTUALLY LOWEST. WHICH RIGHT NOW,
WE’RE PUSHING TO INCREASE OUR
MEDICARE REIMBURSEMENTS
BECAUSE WHEN OUR MEDICARE
REIMBURSEMENTS ARE AT BASE, HIGHEST
COST OF LIVING, IF NOT THE, WE’RE ONE
OF IF NOT THE HIGHEST COST OF
LIVING THE NATION THAT’S A BIG DEAL.
>>Daryl: CLAIR, KIND OF RUNNING
OUT OF TIME. I WOULD LIKE YOU
TO FINISH, ANSWER THIS QUESTION.
WHAT PERCENTAGE OF THE STUDENTS
PASSING THROUGH JABSOM ARE FROM
HAWAIʻI AND LIKELY TO PRACTICE IN
HAWAIʻI, BASE OF THE QUESTION.
HOW EXCITED ARE YOU ABOUT THE IDEA
OF THESE FRIENDS YOU’RE WITH,
BECOMING DOCTORS WITH YOU AND
MOVING INTO THIS COMMUNITY?
>>REALLY EXCITED. THERE’S SO MANY
PROGRAMS JABSOM HAS ALLOWING
STOWNTS TO TRAIN LIKE I TRAINED ON
THE BIG ISLAND. HOPING TO TRAIN ON
BIG ISLAND OR MAUI.
SPEAKING TO CLASSMATES.
SOME FROM NEIGHBOR ISLANDS FOLLOWING
THESE PROGRAMS. TO THEY SAY, I
CAN’T WAIT TO WORK HERE AND REFER TO
MY PATIENTS HERE ON THE BIG ISLAND
TO YOU ON MOLOKAI. ALREADY KIND OF
DREAMING ABOUT SOMETHING LIKE
THAT. AND I THINK I JUST
FIND A LOT OF HOPE IN MY CLASSMATES
WHO SAY THEY WANT TO PRACTICE ON
NEIGHBOR ISLANDS BECAUSE OF THE
VISIBILITY THAT JABSOMPROVIDED
THEM TO NEIGHBOR ISLANDS.
>>Daryl: WHAT IS THE CORE VALUE
YOU’RE EXPRESSING BY CHOOSING THAT?
>>RURAL?>>Daryl: WHY DO
YOU WANT TO DO THAT?
>>BECAUSE ALL OF US HERE IN
HAWAIʻI, IS UP A SMALL PLACE, I
THINK WE ALL HAVE TIES TO A RURAL
PLACE. WE HAVE FAMILY.
FRIENDS. GROWN UP THERE.
>>Daryl: THANK YOU SO MUCH.
THANK YOU ALL OF YOU FOR JOINING US
TONIGHT. DR. KELLEY WITHY,
PROFESSOR OF FAMILY MEDICINE
AND COMMUNITY HEALTH AT THE UH
MED SCHOOL. DR. MICHELLE
MITCHELL, WHO PRACTICES FAMILY
MEDICINE ON THE BIG ISLAND.
DR. RICK BRUNO, EMERGENCY DOCTOR
AT THE QUEEN’S MEDICAL CENTER.
AND. CLARE-MARIE
ANDERSON, 2ND-YEAR UH MEDICAL
STUDENT. NEXT WEEK ON
INSIGHTS, THE MINIMUM WAGE. IS
THE LEGISLATURE GOING TO INCREASE
IT THIS YEAR? PLEASE JOIN US
THEN. I’M DARYL HUFF FOR
INSIGHTS ON PBS HAWAIʻI, ALOHA!


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