by Edwin Quinabo
Throughout the U.S., healthcare demand is growing due to an aging population, overall population increase, and a greater insured population made possible through the Affordable Care Act. While demand is up, supply of physicians has not been keeping pace, resulting in a health care model for potentially compromised patient care and inadequate staff availability to address patient needs, experts say.
In some cases, the current supply-demand shortfall of physician-to-patient is a matter of life and death – that has medically underserved communities and some health care professionals calling the current situation a public health crisis.
Hawaii’s physician shortage is deep, complex, as it is in states across the country. But health experts say Hawaii’s shortage would take additional initiatives (relative to other parts of the U.S.) to correct due to unique conditions such as the state’s extremely high cost of living that’s disincentivizing doctors to practice medicine on the islands.
At the same time, Hawaii’s uniqueness is also opening the door to innovative ways to deal with its physician shortage that other states are not positioned to do. One is the state’s entrenched ethnic diversity is ideal for attracting international medical graduates (IMGs) to practice medicine in the state.
Dr. Charlie Sonido, Hawaii physician, Asst. Clinical Professor of Medicine at the University of Hawaii John A Burns School of Medicine (JABSOM) and IMG-scholar from the Philippines, founded Hawaii Physicians Preceptorship Program decades ago. Now called the Primary Care Clinic of Hawaii Preceptorship Program, it was originally established to provide clinical experience for IMGs (or preceptees) to enhance their opportunities to land a medical residency in the U.S. But today the program — that had over a hundred preceptee-physicians spanning decades — has also become an invaluable reservoir of highly trained alumni-doctors (of the program) to tap to help with the state’s physician shortage.
Alumni-doctors of the program often return to Hawaii after completing their medical residencies on the mainland. Some of them now work for Hawaii hospitals and medical groups. A few have chosen to return to work at Dr Sonido’s Primary Care Clinic of Hawaii (PCCH), one of the largest private medical practices in the state with clinics on Oahu, Kauai and the Big Island. These doctors through PCCH are working in medically underserved communities on Oahu and the neighbor islands.
But even with creative projects like PCCH’s Preceptorship Program, the dearth in physicians in the state remains dire.
“There is an acute shortage of physicians in the state of Hawaii in all specialties, especially among Filipinos,” Dr. Sonido said. “Our clinic at the Primary Care Clinic of Hawaii has been trying hard to recruit doctors who understand the language and culture of Filipinos to add to our 11-member providers across the state with little success. The acute shortage leads to physician overload and subsequently burnout.”
He adds, “The insurance companies keep decreasing reimbursement and the overhead keeps going up. As a result, independent solo practice has been dwindling, physicians are retiring early or moving to the mainland. We have tried many ways to reverse the process by increased efficiency, constant innovation and working hours. But you can only do so much, it is near the breaking point.”
By the numbers, areas of shortage
How short is Hawaii of physicians? Dr. Rainier Dennis Bautista, primary care physician at PCCH and mentor of the clinic’s Preceptorship Program (himself having gone through the program over a decade ago), said “We are lacking both primary care physicians and specialists. Per the Hawaii Physician Workforce Report, compared to last year, the doctor shortage went up from 820 to 1,008. The greatest shortage was within Primary Care, which was 412.”
The statewide physician shortage from 2019 to the present is estimated to be between 710 and 1,008. The higher number (1,008) is projected when researchers accounted for specialty specific needs.
The proportional need is greatest on the neighbor islands, with both Maui and Hawaii County experiencing a physician shortage of 40%.
Primary care in the report includes Family Medicine, Internal Medicine, Pediatrics and Geriatrics. The largest subspecialty shortages are with Colorectal Surgery, Pathology, Pulmonary, Infectious Disease, Allergy/Immunology and Hematology/Oncology.
On possible reasons why there is a greater shortage within Primary Care versus specialties, Seiji Yamada, JABSOM family medicine faculty told the Filipino Chronicle, “Over a lifetime career, proceduralist specialty physicians can expect to earn at least $1 million more than primary care physicians. This is largely a function of how CMS [Centers for Medicare and Medicaid], and the insurance corporations following CMS, set their scales for how physicians are paid for the care they provide.”
He said, “Because of the competition for coveted postgraduate training (residency) slots in proceduralist specialties – those who are successful in gaining admission often view themselves as the best and the brightest. They look down upon those physicians who enter primary care. Medical students are often told by their specialist teachers to not choose primary care.”
Dr. Yamada said medical students are typically graduating with educational debts of a quarter or a half million dollars. “The prospect of being in debt for longer dissuades many medical students from choosing careers in primary care.”
Primary care physicians (PCPs) are traditionally the focal providers of health services. During the period between 1980 and 1999, a time of rapidly increasing aggregate physician numbers in the United States, primary care was still the only practice area to show a steady decline in practitioners.
Overall Hawaii has more than 10,000 licensed physicians but only about 3,484 are active, and of that number 2,974 Full Time Equivalents (FTEs).
Covid exacerbates problem
Health experts say the physician shortage has deepened since the pandemic and could get worse. Even before COVID-19 hit, the state was experiencing a physician shortfall. In the same Physician Workforce Report that is put out by JABSOM, more than 400 Hawaii doctors say the pandemic forced them to close their practices, reduce their hours, or switch to telehealth.
JABSOM Director of the Hawaiʻi/Pacific Basin Area Health Education Center Dr. Kelley Withy told the Filipino Chronicle, “While many of our oldest physicians retired during the pandemic, 21% of our physicians are already age 65 or older.”
The report says Hawaii is expected to increase relative shortages of physicians for the next several years as older physicians leave their practices. It estimates Hawaii needs to add as many as 820 doctors to a pool of 3,484 physicians actively providing care to satisfy the need for services, the report said.
At least 110 physicians retired in 2020, 139 left the state, 120 decreased their work hours and 8 passed away. The number of physicians went down in all Hawaii counties which experts say is particularly problematic for the neighbor islands and rural areas of Hawaii where many communities had already been medically underserved.
Hawaii’s underserved rural communities follow a national trend. Less than 8% of the nation’s physicians are practicing medicine in rural areas.
Within rural sections of the country, there is a higher prevalence of poverty and chronic disease, the population is typically older, and a greater proportion of residents are without health insurance or receive Medicaid or Medicare.
Dr. Jon Avery Go, Internal Medicine, PCCH, said “Nationally, there is an anticipated shortage of up to 124,000 physicians within the next decade.” He says the shortage is felt by both patients and physicians, and the entire community.
How the physician shortage affects quality of healthcare?
“So what it [physician shortage] means is that if you need a doctor urgently, you might die because you might not be able to access that,” says Dr. Withy. “And if you need a specialist chronically to help you manage your condition, you may have to travel to get to that specialist and it may be by air travel, which of course, is difficult.”
Shortage means longer wait times for appointments. In some situations, wait times across the state can be more than six months, according to the Hawaii State Rural Health Association.
For physicians, shortage could require seeing patients past normal office hours at 6 p.m. But after seeing patients, doctors still have other work such as charting, checking labs and making phone calls that could go well into late evening. Shortage can lead to physician burnout, or at worse, affect patient care when physicians must see too many patients in a day.
What happens then? Dr. Go said, “due to the number of patients that need to be seen, visits become shorter and only specific issues may be addressed during each encounter which may lead to the patient needing more visits to address multiple or recurring problems.” He said, “Physician shortage leads to poor patient outcomes and decreased quality of care via many ways.”
Other examples Dr. Go gives: 1) Patients may not get seen in a timely manner to address issues early enough to avoid hospitalizations and ER visits. 2) Outpatient procedures may not get scheduled or done in a timely manner which may lead to adverse outcomes. The window of opportunity for early intervention and proper management could be missed.
Shortage, “simply put,” Dr. Withy says, “people will not be able to access healthcare. We will have to travel or skip healthcare and that leads to late diagnoses and higher death rates.”
Main driver of physician shortage, possible solutions
*DRIVER: LOW PAY/HIGH COST OF LIVING. Besides aging doctors, challenges to retention (keeping doctors in the state) and inadequate recruitment to replace those retiring, Dr. Withy said a major cause of the shortage is low pay in Hawaii paired with high cost of living, which makes it difficult for physicians to make a living.
For this same reason – low pay in a high cost of living state – Dr. Go says both physician retention and recruitment have been challenging for Hawaii. “Many who come to Hawaii soon realize that vacationing and living/working in Hawaii are completely different.”
*SOLUTION: BETTER COMPENSATION/MANAGEABLE WORKLOAD. To improve both retention and recruitment, Dr. Go suggests employers/medical groups can offer a more competitive and attractive compensation package and benefits. But before that can happen, he acknowledges that more net revenues must be brought into medical practices in order for employers/medical groups to be able to provide better compensation packages for their physicians.
Also, of importance to have in Hawaii, he says, is more opportunities and higher pay in other sectors besides the medical field. This can be attractive for a physician’s spouse or family member to encourage the entire family to either stay or move to Hawaii.
Besides pay, Dr. Go says having a balanced work and home-family life situation is also a draw for doctors. “This plays a major role in preventing physician burnout, and the more physicians there are, the more manageable are the workload and hours for physicians — which will also mean better patient care and patient satisfaction.”
*SOLUTION: INCREASE MEDICARE REIMBURSEMENT RATES. This is one of the focal areas that Hawaii doctors want changed to raise revenues for private practices and physician’s salaries to be more competitive with other mainland states and to help offset Hawaii’s high cost of living.
At the current Medicare Reimbursement Rate, Hawaii is included with rural areas such as Louisiana and other small states. The Medicare Reimbursement Rate is gauged by population. But Hawaii’s high cost of living is more typical of larger states such like California. Changes to the Medicare Reimbursement Rate must be done at the federal level.
GET on medical services
Health experts say another major area that would improve Hawaii physician’s net income is changing the State’s GET (General Excise Tax). Currently, Hawaii hospitals and their employed physicians are exempt from the GET. But the GET applies to health care services provided by group and private practice physicians. And it is against the law for doctors to pass this tax onto patients, which means the GET must be paid by doctors. Hawaii is one of only a few states that has this set up.
But there is increasing support at the Hawaii State Legislature to change this law, to get passed a bill that would exempt GET on medical services.
Backed by physicians and community groups, a GET exemption on medical services could reduce the cost of healthcare for private practice physicians which could lure new doctors to the islands and keep doctors from leaving.
Keli‘i Akina, president and CEO of the Grassroot Institute of Hawaii, whose organization supports the GET exemption on medical services, said “If we exempted medical care from the general excise tax, it would save doctors and patients more than $200 million [a year]. And that would help keep doctors in our state, rather than having to flee the state to earn money elsewhere. And that’s why we started the petition.”
Private practice doctors in Hawaii must pay at least 4% of their gross receipts in taxes to the state, and three of the counties add surcharges beyond that.
Other initiatives favorable to recruiting and retaining doctors
Typical points largely supported by the medical community in attracting more physicians to local communities, and areas that Dr. Bautista says he supports include:
– an educational loan repayment program to attract younger doctors straight out of medical schools and their residency
– additional funding for residency programs to have additional spots for local applicants
– establish new residency and fellowship programs especially in the neighbor islands
– more support for independent practitioners.
“There seems to be a great focus on building up the already large health organizations in the state (like Queens, HPH, and Castle), while independent practitioners are faced with decreasing reimbursements, and increasing administrative requirements,” Dr. Bautista said.
Other initiatives typically mentioned by the medical community that could improve Hawaii’s physician shortage include:
-Reduce administrative requirements
-Establish a housing stipend for doctors
– Institute a national licensing program for doctors and nurses. Streamline and reduce licensing tests for doctors. Have reciprocity for medical licensing with other states.
– Forgive student loan debt for doctors
-Extend interest-free loans that would help doctors on their mortgages
Expand hawaii’s medical school and post-graduate residency programs
Healthcare experts say one of the most effective ways to get new doctors to practice in Hawaii is to increase the number of students at JABSOM. Currently there are 77 medical students enrolled at JABSOM; and more than 225 participate in JABSOM’s Accreditation Council of Graduate Medical Education (ACGME)-accredited residency and fellowship programs.
Dr. Withy says expanding Hawaii’s medical school and post-graduate residency programs are ideal solutions, but the impacts wouldn’t kick in for another seven to 10 years.
The long-term goal is to train 100 students and have medical school branches on all islands. The challenge is that these goals are expensive. More faculty would be needed to teach additional students.
There is data to support the idea that increasing student numbers at JABSOM would most likely lead to more physicians practicing in Hawaii.
JABSOM Dean Jerris Hedges said more than 80% of physicians who graduate from both JABSOM and its residency programs tend to stay in Hawaii to practice—that is one of the highest retention rates in the country.
Dr. Withy said, “the medical school can only increase in size if we conduct more training on neighboring islands, because the training sites on Oahu are saturated. This is better for everyone, because if more students train on neighboring islands, more doctors will stay on neighboring islands to practice.”
She adds, “There is a new program supported by Chan-Zuckerberg Initiative where six medical students with ties to Kauai have been admitted and get full scholarships to medical school. They do many of their educational experiences on Kauai, then have to spend four years practicing there after residency. We hope this kind of program can be introduced on all islands.”
Recent state intiatives
This year Gov. David Ige signed two bills relating to the state’s physician shortage: Senate Bill 2657 (now Act 262: Relating to Medical Education Training) and Senate Bill 2597 (now Act 263: Relating to loan repayment for health care professionals).
Senate Bill 2657 funds JABSOM’s expansion of medical residency and medical student training opportunities on the neighbor islands, and in areas where healthcare is most needed.
Senate Bill 2597 allows for more loans to be given in the Hawaiʻi State Loan Repayment Program, which helps graduates of JABSOM and other health professions reduce their educational debt in exchange for remaining in Hawaiʻi to practice.
“My administration is committed to supporting the development and expansion of high-quality educational and training sites, especially on the neighbor islands where we face the greatest challenge,” said Gov. Ige.
by Edwin Quinabo