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How Healthy is Healthcare in Hawaii? - Extended Version

Leading doctors and other experts discuss major trends and problems in Hawaii healthcare

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Jerris Hedges (Dean, John Burns School of Medicine): This is an exciting time even though we are all facing some significant challenges. The fact that people come together for these forums gives me great enthusiasm. In keeping with the last panel, we were asked to come up with a word to symbolize what we’re going to speak on, and my word is transform. I’m hoping that we will inspire you and others to transform what we’re doing. I’m going to talk a little bit about the role of the medical school and a significant opportunity that we have that has added simplicity in terms of concept that I think will play into what you heard from Sen. Green. But we cannot continue doing what we’re currently doing. We don’t have enough funding and we don’t have enough providers to implement care in the way that it should be delivered. So how do we get there? What can we do collectively around that? You’ve heard a little bit about the shortage of providers here in Hawaii but it’s not just here in Hawaii. It’s a national shortage.

In 2025, it’s anticipated that there’ll be 120,000 fewer providers than what the demographics in the U.S. will require. So we cannot simply pull from other states to meet the needs of Hawaii. We need to be able to build programs here that will help us train, recruit, and retain physicians for our needs and other healthcare providers to help us deliver the healthcare that we need for the future.

What can we do here through the medical school? We can incrementally increase the class and the size for the medical school and we’ve been working at that. However, that’s challenging because our model needs to be addressed and we also need to look at supplemental models that will help us leverage what we do have. It’s an expensive proposition to train additional physicians and there’s a limit to how much we can do that.

Can we create a more efficient model of training? I think we can and if we look at this from a revolutionary standpoint, I think what’s needed is to work with both the legislature and Hawaii Medical Board to develop a new category of physician that is not constrained by some of the processes that we have now in national accreditation requirements, but will allow us to supplement what we’re doing in our medical education and it can be tailored to our needs on the neighbor islands and other rural sites.

It should be primary-care based and ambulatory-focused. It should be one that is more economical to implement and one that will result in trainees with both less educational debt at the completion of their training and with anticipation for a more modest salary. I would like to outline a concept that was proposed by Daniel Hunt who is the Executive Director for the accrediting body for medical schools in the U.S. He proposed a Doctor of Clinical Practice degree, to be done in conjunction with current medical schools — essentially a streamlined path into becoming licensed, so instead of the four years of medical school training, there will be three years.

The three years would be based on the clinical knowledge set that we now provide but would be focused more on application and less on the basic science elements. The anticipation is that the in-hospital subsequent training would be more attenuated and would focus on what one needs to do for continuity of care. The bottom line is it would complete your training and become ready for license in four years rather than the four years in medical school plus the three or four additional years in residency training. I think this is something we can do in Hawaii.

This has another tremendous benefit if we can do this in conjunction with our current medical school and residency training. The one great benefit is the trainees that come out of such a program would be targeted specifically for Hawaii. Hawaii would be the site in which they could be licensed and we wouldn’t be losing physician trainees to other parts of the nation. I have other things that we can talk about — more specifics related to such a proposal — but the foundation for this has already been built. The medical school has a problem-based learning integrated curriculum that can be adopted with minor modifications to allow this sort of program to develop. I’ll stop there.

Green: Dean, stay for one question. How many students graduate a year from the medical school? If you have all the financing you needed, how many could you possibly expand to in five years, and does it make any sense to start including mid-level providers in some of the training — physician assistants, nurse practitioners, and so on — at the medical schools?

Hedges: Under the current system, 66 students enter a four-year program each year. Anywhere from 62 to the full 66 complete the training. We could expand with supplemental funding to at least 75, if not 80, students. I think we could do better with expansion if we do this supplemental program, and have two tracks for people to enter, and with such a program I think we could have closer to 100 trainees per year in Hawaii, which would get us closer to what we need to maintain a steady state. Could we do this in conjunction with other professions? Absolutely, in fact, I think the pathway into such a program would be one that would normally welcome those who came from either advanced nurse practice programs or pharmacy into such a program as a conjoined effort. So, I think it is something that we could implement and more broadly include other disciplines in the program itself.

Hilton Raethel (Senior Vice-President, Hawaii Medical Service Association): You’ve heard a lot about the issues in healthcare and you’ve heard a lot about what could be done and what maybe should be done. I’m going to spend a few minutes today talking about some of the things that are being done right now. Specifically, I want to talk about the issues of cost and quality that everyone has talked about, the increasing costs and the issues with quality.

We recognize that at HMSA. We’ve been serving the community as a nonprofit mutual benefit society for 73 years. I’m proud to be part of HMSA and we have embarked in a new direction to help solve these problems, including a new program across our hospital network.

Historically, healthcare in Hawaii has been paid predominantly on a fee-for-service basis and what that means is it’s basically a piece-meal program. In other words, the more you do, the more you get paid, and you get paid based on volume, not value, and on quantity, not quality. Now, that is a terrible set of incentives for healthcare, but that’s the way healthcare has been reimbursed in Hawaii and across the United States for many decades.

We’re going in the process of transforming that and you didn’t ask me about my word, Josh, but my word is transformation, so which is not quite transformed but it is transformation. We’re in the process of transforming healthcare and if you want to change behavior, you have to change incentives. So, we’re changing incentives. What I mean by that is that we are paying hospitals and doctors now for how well they treat patients. We’re paying them for taking care of a patient population. We’re paying them for quality, safety, efficiency, reducing harm.

This is not something you change overnight. You can’t change a whole system of care in just a few months or a couple of years. We started last year working with every hospital in our provider network across the state, setting a goal of having 15 percent of their reimbursement tied to these outcomes for quality, safety, and efficiency.

That’s one of the initiatives. I also want to talk about primary care. We believe that as a nation, we have underinvested in primary care, and we’re working actively to fix that. We have two programs in place. One of them is a pay-for-quality program where we are looking at what is the best evidence-based care for patients with chronic diseases such as diabetes, asthma, heart disease — what does the best evidence say about what those members should be getting every year. We’re putting those metrics out there. We’re saying to the doctors, here’s the metrics, here’s the threshold, here’s your population. This is how many diabetic members you have. This is the scoring on those metrics and we’re going to pay you to take care of those members, to bring those patients in, to make sure they get their eye exams, to make sure they get their foot exams, etc. We’re paying them to take care of their patients.

In addition to that, we have another program for primary care physicians, who are dealing with patients in a medical home. That program runs in concert with the pay-for-quality program and helps physicians support or develop the infrastructure needed to take care of their patients. So that’s another revenue stream in addition to our pay-for-quality, so we are putting double-digit increases into our budget, year-over-year increases for primary care. We believe we need to emphasize more primary care. We believe we need to strengthen the relationship between the patient and the member, especially patients with chronic disease. We’re working with the employer groups across the state to get the employers and employees engaged because that’s a huge issue. We have to get patients connected with their doctors, especially patients with chronic disease.

So again, HMSA has already embarked on these initiatives statewide. We’re proud of these initiatives. We’re proud of what we’re doing. We’re proud of our partnerships with organizations such as Queen’s, Hawaii Pacific Health, HHSC, Kuakini, and Castle. They are all involved and we’re proud of that partnership with our primary care physicians to help transform the healthcare delivery system in Hawaii.

Green: One question that comes to mind is as you try to realize savings and move money towards primary care, what’s the prospect of sharing savings with businesses, the business community, or the providers themselves should you realize those achievements?

Raethel: We absolutely believe that we can bend the cost to it. In other words, we can reduce the rate of healthcare inflation in the country. In terms of cost saving, you are talking about two particular groups. One is employers; the other is providers. With employers, the cost savings come from the reduction in healthcare premiums, so the rate of inflation comes down and we believe we’re already starting to see evidence of that. Employers get the benefit because they end up paying less year-over-year in terms of rate increases.

Now, in terms of sharing savings with providers, this is a huge issue. Because every time a provider prevents a re-admission, that’s a loss of revenue. Every time they reduce a complication or eliminate a complication that is reduced revenue. So we are working with our providers to come up with mechanisms to make sure that as they go through the transition from a volume-based model to a value-based model that they have the revenue to support that transition.

Hawaii Business magazine invites you to comment on our articles and the issues they raise. Comments are moderated for offensive language, commercial messages and off-topic posts and may be deleted. Some comments may be chosen for inclusion in the magazine on the Feedback page.

Old to new | New to old
Jan 27, 2013 11:08 pm
 Posted by  julieanderson

I think now a days Hawaii is the best state which provides many features quality and more user friendly!

Mar 1, 2013 02:56 am
 Posted by  catherinalucy

Hawaii has huge ethnic and socioeconomic disparities when we start peeling away the onion and you do not just aggregate the statistics.

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